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Transcript of Social Accountability
- More responsive and transparent states
- More democratic resource allocation
Community-level monitoring of service delivery:
At community level, where frontline workers and patients live side by side, organizations tend to choose more collaborative strategies to engage with frontline workers. Exposing gaps in the delivery of health care services may create tensions between service users and providers. This tension, while unavoidable and necessary to change power dynamics between community members and the state, can be addressed by identifying spaces for dialogue and negotiation, for instance by:
a) creating local committees or informal groups
b)'revamping' existing democratic structures (e.g.Village Health Nutrition and Sanitation committee, Gram Sabha ...) that have a mandate to improve service delivery yet are often non-functioning. Using existing platforms may help on the long-run with 'institutionalizing' community monitoring, however may run the risk of it becoming a 'cosmetic' process.
Local-level negotiation may lead to the development of plans of action to improve service delivery, or to commitments by local authorities, which needs to be in turn monitored by community members.
Social accountability processes begin with creating a ‘culture of questioning’ which is crucial to mobilize communities around issues of healthcare and basic services. The rights-based framework provide a framework for social action and awareness building.
In this phase, organizations working on the ground focus on: A) raising awareness and informing community members over rights and entitlements and B) awareness on wider social and policy structures, the role of democracy, and the way state functions.
1- Awareness Raising
Once community members gained awareness over rights and entitlements, they are engaged into monitoring the delivery of health and nutrition services at community level. Beyond more ‘traditional’ tools (Scorecards), organizations facilitating the monitroing process may also use ICTs and pictorial materials/flashcards (to ensure inclusion of illiterate individuals). At times the choice is also influenced by funders’ requirements.
However the effectiveness of social accountability tools does not depend on the type of tool chosen, but on the strategy built around it. The leverage points that a specific tool can open up for communities is context-specific.
Iterative process of information exchange
- Empowered citizens
- Better service delivery (quality and availability)
- Reduced social inequalities
(3) ...and with social movements.
Because social accountability is ultimately about shifting unbalanced power dynamics, local actions can be more effective if synced up with wider social movements, campaigns or policy-level advocacy.
A process of 'negotiation' follows wherein community members use data collected to formulate specific demands to improve service delivery.
This process of negotiation is usually easier at community level, but more challenging at higher levels (district/state). As a result, organizations may choose to strategically mix collaborative and confrontational approaches when dealing with service providers.
Regulation of the private health sector is indeed a very critical and urgent task. Lack of regulation means lack of an effective framework for claiming accountability in service delivery. Moreover, the relations patients-private providers is of an economic nature that doesn’t follow the paradigm of rights and duties. As a result, the leverage points community members have are virtually non-existent.
Participants feel that Governments should affirm their role as main responsible for healthcare provision and regulation by urgently regulating the private sector and introducing accountability safeguards. However this task is particularly challenging because key decision-making spaces and processes, especially at policy-level, are neither transparent nor accountable to the principle of ensuring access to quality healthcare for all.
2 - Monitoring & data collection
Using data to negotiate
with service providers:
(1) Platforms for negotiation at
(2) ...Linked with platforms at
District/State level ...
Data collected at community level, is aggregated and submitted at District or Province/State level discussion forums (mirroring community-level structures) between civil society and government representatives. Plans of actions developed at local level may also be brought to higher authorities to seek better allocation of resources.
Experience shows that when locally-collected data is used to push for better service delivery at ‘higher’ levels community members are seen as legitimate sources of information, and their voice becomes more legitimate.
"Monitoring data that is generated through systematic enquiry and review of secondary data holds up women's and girls' reality in front of the government authorities. When the MSAM [Women collective]'s leaders approach government functionaries the pressure of the collective is strengthened with the power of 'evidence. The authorities cannot negate the facts and data coming out of these real-life case stories. "
The power of data
The use of ICTs
When adequately tailored to the needs of community members, the use of technology for data collection can be particularly beneficial because:
- it can increase participation of community members, especially women, because it protects anonymity. For instance, patients feel comfortable with reporting corruption in health facilities through the use of SMSs or IVR (interactive voice recording) because they don’t fear retaliation from health staff.
- government authorities tend to attribute higher validity to data collected though the use of technology.
- organizations are able to collect data more systematically.
Key elements for sustaining community participation over time are:
A) Focus on collective process: awareness raising and community monitoring are carried out collectively
B) Social recognition from fellow community members is key to encourage participation and increase accountability within the community.
C) Setting clear and reachable goals helps manage expectations from community members.
Addressing intra-community inequality
Social accountability processes can be useful to resist oppression and ensure representation of vulnerable groups. In contexts where gender, caste and religion hinder people’s participation, raising women’s voices, especially with regards to sexual and reproductive health, is particularly challenging. Women face different levels of opposition at family and society level which prevents them from attending meetings and participating meaningfully in discussions.
Some organizations address these barriers by ensuring each group within the community can participate to community monitoring and agenda-setting. This may require holding multiple conversations and then coming together to discuss each group's perspective. The role of practitioners and organizations is to facilitate these discussions and ensuring inclusion of all voices.
Participation and inclusion:
Iterative processes of data exchange between communities and government is particularly effective. Solid examples come from organizations using participatory processes to unpack government budgets and increase citizens' decision-making power. In a case emerged during the consultation, community members reviewed budget allocations proposed by the government and through a participatory process formulated ‘key asks’ for the government. In turn, the State has initiated more structured consultations with communities through District level groups during the formulation of yearly budgets. This has ensured budget allocations are grounded on local needs.
'If communities can demand accountability from the state, they also have to look within and address gender inequality in that domain - this requires giving up privilege which is no doubt a challenge, but necessary. In interventions like these (...) we always lay the foundation with an understanding of gender/caste/class inequalities, before speaking about entitlements.' [a participant]
'Local CBOs work with groups of rural women from marginalized communities (called Mahila Swasthya Adhikar Manch – MSMA) on issues of land rights, livelihood rights, health rights, violence against women, right to information, etc. (...) Women support each other in the group meetings... they listen each others' problems, emotions, etc. and show solidarity. Then they identify reasons behind these problems and make a collective plan of action against the issues... Thus they become active claimants from passive beneficiaries.' [a participant]
"Primary Care Management Committees attached to basic health units, and supported by a group of local activists, were influential in shaping joint action plans. Joint citizen monitoring committees are vibrant forums that provided ample opportunities to both facility staff and community activists to interact with district decision maker. Continuous feedback to the district officials resulted in implementation of local plans at higher level."
"In the context where we work, it is impossible to address issues related to maternal health without tackling other factors causing socioeconomic marginalization, such as labor exploitation. So while we initially focused on community-level monitoring of maternal health services, our efforts have then included supporting a State-level campaign calling for a living, decent wage, along with improvements in health services. We have partnered with other local groups and supported the campaign at district/state level (workers mobilization and advocacy with the government) as well as international level (advocacy with UN bodies, INGOs and media)." [a participant]
Organizations face crucial questions when defining and measuring change: what does impact mean, and who defines it? Who drives evaluation processes?
Evaluations are usually conducted for funders, and and thereby try to abide to project commitments and narrow indicators that focus largely only services uptake. However, this 'technocratic' approach often fails to grasp complexities surrounding community’s choices over service access and usage. Indeed, service uptake depends from a number of other factors, such as quality and acceptability of the service, and the capacity of service providers to deliver healthcare. Overall, mainstream approaches to evaluations tend to overlook the many declinations of social change that result from social accountability processes, such as empowerment. Organizations identified emerging approaches, such as the 'stories of change’ method, more promising to document ‘how’ and ‘why’ change is created.
"Tools are just medium to create environment in the community so that people can sit together and start talking about the issues." [a participant]
“Often times, implementers of social accountability as well as those who study them, tend to look at improvement in services and increase in uptake as indicators of effectiveness of SA. But is this really sufficient? The dynamics illustrated [in the consultation] show an empowered community constantly negotiating and asserting its rights, while services per se may not be improving. Is this not a marker of change?” [a participant]
This is a summary of the online discussion
'Mutual-learning at accountability’s cutting edge – a practitioners’ consultation on improving Health and Nutrition services in South Asia'
hosted by IDS and
in March 2016.
The consultation engaged 49 participants, including activists, consultants and academics working in/on Bangladesh, India
From the consultation 'Social Accountability for Health and
Nutrition in South Asia' - March 2016