Social Accountability: Evidence on Pro-equity Interventions to Improve Immunization Coverage for Zero-dose Children and Missed Communities

"Social accountability approaches can shift power and alter relationship dynamics between rights holders and duty bearers, thus potentially allowing citizens in missed communities to exercise more agency."

This evidence brief, published by FHI 360, presents results from a rapid literature review to understand the effectiveness and implementation of social accountability interventions for advocating for essential health services, including immunisation activities, within communities in vulnerable contexts and especially among zero-dose children (those who have not received a single vaccine to prevent disease) and missed communities (population groups that face multiple deprivations, such as socio-economic inequities and gender-related barriers). 

The brief forms part of a series of rapid literature reviews (involving peer-reviewed and grey literature published between January 2010 through November 2022) conducted by FHI 360, and supported by the Vaccine Alliance (Gavi). The purpose of the reviews is to synthesise existing evidence on the effectiveness and implementation considerations for selected interventions that could help achieve more equitable immunisation coverage, specifically helping to reach zero-dose children and missed communities. Results of syntheses are presented through evidence briefs (see Related Summaries below for others in this series with implications for social change communication) and an online Evidence Map. The objectives of the evidence briefs are to understand which strategies are effective, identify implementation considerations, and assess gaps in knowledge and understanding. Overall, they are meant to help programme planners assess whether an intervention, such as social accountability programmes, should be considered for reaching zero-dose children and missed communities. For this reason, the mapping and the briefs use a categorisation scheme to rate interventions as: potentially ineffective, inconclusive, promising, or proven.

As explained in the brief, "Social accountability involves strategies rooted in citizen engagement and collective action used to hold governments and service providers accountable for their actions. This review focuses on social accountability within the context of public health and health care delivery systems. Community-led, evidence informed advocacy that elicits a response from service providers, governments, or other relevant actors can play a critical role in social accountability."

The rapid review sought to answer the following questions:
 

1. Are social accountability interventions effective in advocating for essential health services, particularly immunisation services, for communities in vulnerable contexts, including those who are marginalised or underserved?
2. What types of social accountability activities are occurring among communities in vulnerable contexts regarding health, and which models and/or key components work better than others to advocate for health services, particularly immunisation services?
3. What are the implementation considerations for social accountability activities among communities in vulnerable contexts, including those who are marginalised or underserved?

The following is a summary of the findings as highlighted in the brief:  

Effectiveness of social accountability interventions to advocate for zero-dose children and missed communities: Despite a proliferation of descriptive reports on social accountability, few empirical studies have been conducted to assess its effectiveness in improving aspects of health service provision. This limitation is likely due to the highly context-dependent, dynamic, and complex nature of these approaches. Nonetheless, this rapid review identified several existing reviews and more recent primary research studies suggesting that social accountability can positively impact healthcare service delivery across a range of contexts and populations, in part through advocacy efforts. It can also impact intermediate outcomes, such as community empowerment and self-efficacy, which may contribute to communities' ability to advocate for better health services. Based on these findings, social accountability was categorised as a "promising" approach to address inequities in immunisation approaches. 

The review also found that social accountability approaches, specifically community score card (CSC) approaches, have most frequently occurred in rural settings aimed to effect change within local healthcare facilities. At more macro-levels, social accountability approaches have been used in contexts where governments have mandated or formalised mechanisms to increase citizen participation in health care. Rights-based approaches have frequently involved marginalised groups. Few social accountability approaches have occurred in fragile/conflict-affected settings or have sought to address gender-related barriers through taking gender-responsive or gender-transformative approaches. 

Main facilitators and barriers to implementation: 
 

• Facilitators include mobilising communities to foster cohesion, purpose, and collective action; building coalitions and leveraging partnerships; having responsive governments and enabling policy and legislative environments; and creating effective forums for communities and decision-makers to share information and engage in bi-directional dialogue.
• Barriers include lack of resources and funding, weak citizen participation, potential for excluding the most marginalised groups, difficulties scaling-up or sustaining without external support, and existing health system barriers.

Key gaps: Key gaps include lack of a clear theoretical understanding of the relationship between advocacy and social accountability, and lack of evidence to support the mechanisms through which social accountability is hypothesised to effect change. More distinction is also needed on the types of social accountability approaches and when, where, and how they are most effectively deployed. 

Based on findings, the brief highlights several steps programmes can take to tailor social accountability interventions to help achieve equity:
 

• Identify characteristics of zero-dose children and missed communities, such as understanding whether geographic areas are most affected (e.g., remote rural areas) or whether certain groups that share similar characteristics are most affected (e.g., those of lower socio-economic status, ethnic or religious minorities), as the most effective social accountability approach might differ depending on who is affected. CSC approaches have been used most frequently when entire geographically defined communities are targeted, whereas rights-based approaches have been used more frequently to address challenges faced by marginalised or disadvantaged sub-populations.
• When social accountability approaches involve marginalised groups, designate specific roles for members of these groups within social accountability initiatives to ensure their voices are heard, and sensitise leaders and health system actors regarding their needs.
• Ensure that critical ingredients for a successful social accountability approach are in place, including confirming which community members are willing to participate and whether health systems are motivated to be responsive to issues raised. Understanding the policy and legislative environment and developing a platform for information gathering, such as through community-based monitoring (CBM), are also critical. 
• Understand what current partnerships exist and how coalitions could be formed and leveraged to develop an effective social accountability approach. Also understand if there are existing forums for community stakeholder dialogue and whether these forums could be enhanced for social accountability purposes (e.g., enhanced networking, building social capital). Developing a theory of change and considering involvement of multi-level activities and/or multi-sectoral actors are also important.