Improving the Linkages between Social Accountability and Social and Behavior Change: A Preliminary Report of Country Data Collection for Côte d'Ivoire, Ghana, and Guinea

"...a springboard for bringing government, health sector, and citizen actors together to identify and address health system challenges..." - Susan Pietrzyk

Literature and programming priorities suggest that work on social accountability (SA) and social and behaviour change (SBC) tends to ignore opportunities for overlap and synergy between the two. SA approaches revolve around the interactions between government, health system, and citizens - actors who play a role in SBC. However, the defining objective of SBC programming is to facilitate individuals changing their behaviours and shifting to optimal health choices and actions, not the relationship of the various actors and the context of the system. Conducted as part of the Health Systems Strengthening Accelerator (Accelerator) global health system strengthening (HSS) initiative, funded by the United States Agency for International Development (USAID) and the Bill & Melinda Gates Foundation, this study aims to identify and support promising opportunities for SA-SBC linkages to increase equity and efficiency through universal health coverage (UHC), with a focus on Côte d'Ivoire, Ghana, and Guinea.

Accelerator leaders - Results for Development (R4D), with support from Health Strategy and Delivery Foundation (HSDF) and ICF - began by conducting a series of literature reviews to explore SA-SBC linkages. They note that SA is widely understood to be a way for citizens to hold state actors accountable for their actions. In a 2005 working paper, the World Bank Institute defined SA as "an approach toward building accountability that relies on civic engagement, that is, in which ordinary citizens and/or civil society organizations participate directly or indirectly in exacting accountability from government" (World Bank Institute 2005). In that same paper, the World Bank Institute posited six elements of SA by which systems and interventions can be classified:

1. The spectrum of punishment versus reward
2. The spectrum of rule following versus performance-based evaluation
3. Level of institutionalisation (i.e., ad hoc activism or institutionalisation into law)
4. Level of involvement of citizens versus external actors
5. Inclusiveness of participation (i.e., whether elitist or more inclusive)
6. Branches of government that are targeted

The SA-SBC linkages study is advocating that a seventh dimension - the degree to which the SA system catalyses behaviour changes on either the side of the citizenry or state actors - should also be considered. To that end, studies have suggested mechanisms to create behaviour change by political leaders by shifting the incentives for these leaders to act in the public interest and to legally enforce that they do, and to form wider partnerships of international, national, and local bodies for monitoring behaviour.

Strengthening SA implies impacting governance in two ways: (i) Communities themselves become more aware or educated of the impact their collective voices can have on influencing health policies and services through targeted behaviour change, and (ii) government itself changes its behaviour or approach to policy making and service provision based on received preferences from its constituents (Wibbels 2014). In the latter, a strong process of SA provides opportunities for citizens to provide feedback or evaluate the quality of government behaviour so that polices and services are responsive and adaptive to changing contexts.

Here are some country-specific findings/examples from the literature review:

• Côte d'Ivoire: The West Africa Breakthrough ACTION family planning (FP) project has used community inputs to designate health facilities as good quality as they relate to FP services (Johns Hopkins Center for Communication Programs [CCP] 2019). Quality is defined by community members themselves, which supports the development of an accreditation system, building on a similar programme creating "Gold Circle" clinics from the 1990s. Johns Hopkins CCP is using findings from community focus groups that are part of this programme to develop strategic messages to promote improved quality of care that communities can receive, encouraging even more community members to use available FP and strengthening the feedback loop between SA and behaviour change (Johns Hopkins CCP 2019).
• Ghana: Examples of recent SA interventions include scorecards to improve maternal and newborn health services at health facilities, the availability and accessibility of information and data products to citizens, and citizen awareness of and participation in the national budget process. One intervention used existing community groups to pinpoint service delivery gaps in facilities using a systematic community engagement process. This bottom-up approach resulted in several improved outcomes, including an increase in spontaneous vaginal deliveries, an increase in female condom distribution, positive impacts on HIV testing for pregnant women, an improved number of clients testing for malaria before treatment, and overall enhancement of knowledge levels of mothers on the importance of antenatal and postnatal services (Alhassan et al. 2019).
• Guinea: The government developed a Post-Ebola Priority Action Plan in 2015 and a National Economic and Social Development Plan to restart economic growth and be more responsive to citizen needs in the post-Ebola period. Health facilities in Guinea, as in many other West and Central African countries as a result of the Bamako Initiative, are meant to be run by a management committee that includes community members. These committees are intended to provide an opportunity for SA in two ways: first, by engaging in community outreach and co-managing resources, and second, by engaging in the integration of community concerns and preferences into service delivery. Creating a "safe space" for government officials to interact with civil society without fear of being confronted was found to be a successful way to create behaviour change around SA (Poli et al. 2020).

From May 2020 to October 2020, the Accelerator project held 21 key informant interviews and conducted an online survey, which was completed by 179 stakeholders in Côte d'Ivoire, Ghana, and Guinea. Across the three countries, 31.8% of survey respondents reported they work for a government ministry, and 28.5% reported that they work for a non-governmental organisation (NGO). Selected findings include:

• Across the 179 respondents, 92.7% indicated there is an active effort to advance UHC in their country, though they were largely split about whether SA activities are being used to advance UHC. The challenges that respondents reported in relation to SA in support of UHC included a top-down approach in developing and rolling out UHC, few if any processes for involving citizens, a lack of a culture or of understanding of SA, and poor citizen organisation and mobilisation. Further, many respondents indicated that UHC is not a priority for the government and that there is weak mobilisation for UHC and for SA.
• 68.7% of survey respondents indicated that SA is prioritised in their country. Challenges with implementing SA activities centred on the need for more transparency, communication, good governance, collaboration, and community engagement. The respondents perceived partnership-defined quality, public hearings, and community radio as the most successful SA activities. Other SA activities suggested included information-sharing, healthcare facility forums, exchange and feedback mechanisms, quality assessments, and performance monitoring tools.
• Across the three countries, the percentage of respondents replying strongly agree or agree that specific groups are well represented in efforts to advance UHC are relatively low. As reported here, greater representativeness can be achieved by changing behaviours to adopt more inclusive processes with collaborative work between government, healthcare providers, healthcare institutions, and citizens.
• Respondents appeared to view behaviour change from the government and citizens as linked in asserting that the government must change its behaviour and better inform citizens of their rights, and citizens must change their behaviour to exercise their rights.
• In terms of lessons learned around how to foster productive alliances and common goals between citizens and government, including behaviour-change-related lessons, respondents cited the following types of stakeholder collaboration, among others:
  • Improve communication and coordination of activities related to HSS and UHC.
  • Strengthen community-level implementation and participation.
  • Strengthen use and dissemination of media and information.
  • Improve data collection and analysis for evidence-based decision-making.
  • Increase participation of civil society organisations and the private sector.
  • Strengthen policies, governance, and leadership.

  Respondents in all three countries agreed that citizens are engaged in demanding quality and affordable health care. However, fewer than a third of the respondents felt that facility providers or administrators were accountable to patients, and fewer than half agreed that the government was accountable to citizens for providing quality services, information about health services, and equitable allocation of financial resources. Most respondents, particularly in Côte d'Ivoire, emphasised the need for behaviour change from healthcare service providers and healthcare facilities as key for improving patient satisfaction and quality of care.

Following the publication of the SA-SBC linkages study, the Accelerator held events to discuss the findings. The discussion has been wide-ranging and included, for example, the role of behaviour change in health financing, recognition of distinguishing between individual behaviours and systemic behaviours, measurement of SA, the role of performance-based financing, and engaging civil society in SA when they depend on government funding. Participants have also noted:

• The importance of having confidence in leaders and organisers, which can occur through more open communication and transparency, to facilitate behaviour change;
• The importance of creating frameworks for inclusive discussions of community health challenges and integrating community voices to improve community health outcomes to support UHC; and
• The need to create trust in health institutions and to advocate for the increased engagement of civil society.

In moving stakeholder engagement from discussion to research utilisation, the Accelerator has launched two country-level efforts to apply a behaviour change lens, as follows:

• Budget Advocacy and the Community Health Strategy in Guinea: The Accelerator is engaging the Community Health Multisectoral Technical Platform to develop a tool that applies an SBC lens to budget advocacy-related social accountability activities. The tool will include strategies for increasing citizen and civil society participation in budgeting prioritisation and oversight processes and improving leaders' receptiveness toward involving citizens and addressing their priorities. It is hoped that a behaviour-change-focused budgeting process can increase dialogue between citizens and civil society with national and subnational decision-makers.
• Citizen Mobilization around UHC in Togo: The Accelerator is facilitating two virtual workshops with the UHC Task Force to identify individual citizen and civil society engagement barriers. Participants in the workshop sessions are asked to apply a behaviour change lens to assess the various roles and interactions of government, health sector, and civil society actors in mobilising around UHC and increasing SA across the health sector more broadly. As demonstrated in the SA-SBC linkages study, citizen engagement is widely viewed as an important aspect of efforts to advance UHC, with increasing demand for greater representation in decision-making around UHC. Applying this evidence in the workshops will inform a behaviour-change-focused strategy for increasing dialogue between citizens and civil society with decision-makers.