Community and Provider-driven Social Accountability Intervention for Family Planning and Contraceptive Service Provision: Experiences from the Field

"...changes in both self-perception and in the relationship between the communities and health workers lead to greater mutual understanding and local prioritization, along with changes in service delivery..."

In recent years, social accountability initiatives led by community members and civil society organisations (CSOs) have been brought to bear on issues such as limited uptake in use of family planning and contraceptive (FP/C) services, which is often a result of poor-quality services. A social accountability process brings about a series of interrelated changes that can shift the attitudes and behaviours of stakeholders and improve the quality of services. Published by the World Health Organization (WHO), this document outlines the key principles used in the Community and Provider-driven Social Accountability Intervention (CaPSAI) Project study, which was a 24-month, mixed-methods, quasi-experimental study across 16 sites in Ghana and Tanzania.

As outlined here, social accountability is a participatory process that creates social change, rather than a set of tools or activities. It works best when the efforts of two sets of actors are coordinated: those with decision-making power in combination with regular members of the community. In collaboration, the two groups ensure that actions, decisions, and resources for primary health care are effective and equitable. In addition, community members and civil society can monitor and advocate for better services, given that patients engaging frontline services play a critical role in identifying local challenges in primary health care that require attention. Accountability is likely to be most effective when it brings in the voices and experiences of both actors.

Using an interrupted time series analysis with a control group and a cohort study, CaPSAI evaluated the role of social accountability interventions on contraceptive uptake and use in settings with low modern contraceptive uptake. It also examined how social accountability processes are implemented and operationalised, focusing on behaviours, decision-making processes, and the barriers and facilitators of change. The intervention was co-designed and implemented by the study implementation leads and two CSOs: Ghana Integrity Initiative (GII) in Ghana and Sikika in Tanzania.

The CaPSAI theory of change is based on the idea that change is dynamic, interconnected, and nonlinear:



Each of document's sections of the document focuses on one of the nine steps in the social accountability process, which are expected contribute to changes in the attitudes and behaviours between and among stakeholders (service users, social groups, and service providers) - and, ultimately, to service-level reforms. In brief, the steps include:

1. Preparatory work: Prepare the necessary institutional and social permissions and approvals required to implement the social accountability process.
2. Introduction to authorities and gatekeepers: Ensure that local authorities and gatekeepers are both aware and supportive of the process.
3. Mobilisation and introduction of the project to the community: Spread awareness of the project among the local community, ensuring participation from a wide range of community members.
4. Health, rights, and civic education with community members: Share information about sexual and reproductive health and rights (SRHR) and entitlements with community members, working together to explore any perceived gaps or shortcomings in the services they receive.
5. Health, rights, and standards of care sensitisation with health actors: Share information about SRHR and entitlements with health providers, generating discussion on key issues faced by local people.
6. Prioritisation meeting with the community: Ensure that a diverse range of community members identify and rank the most pressing issues related to FP/C information and services in their community.
7. Prioritisation with health actors: Ensure that healthcare providers (HCPs) identify and rank the most pressing issues related to FP/C information and services in their community.
8. Interface meeting and joint action planning: Share the assessments separately generated by community and health actors and then jointly identify areas for improvement and develop an action plan to ensure concrete measures are taken to improve services and/or maintain good practices.
9. Regular ongoing monitoring and follow-up: Track if progress has been made in the jointly-agreed action plan, perhaps involving high-level duty bearers or third parties in addressing any unresolved issues.

Within each step's section of the document, there are two parts. The first part provides information to support design, including what is included in each step and questions to be considered at the time of designing this step. The second part provides information to support implementation, including what kind of resources are required, learnings based on the CaPSAI implementation experience, and a practical account of implementing the step based on the CaPSAI implementation experience.

Some of the main lessons to emerge from CaPSAI are:

• Learn from and adapt to the local context. For example, the capacity of civil society and health system responsiveness are often influenced by wider state-society relationships. The context also comprises the norms, values and attitudes that surround sex, reproduction, gender, and contraception.
• Be aware that the use and provision of FP/C services is influenced by local values and attitudes, which can either constrain or facilitate change. Therefore, sensitisation around FP/C issues is central to the implementation of social accountability.
• Follow up on progress made on agreed action, as it can sustain pressure on decision-makers long after project funding has run out. Support local capacity.
• Manage expectations about what can be achieved within a given time frame, particularly in the case of potentially sensitive areas such as FP/C services and SRHR.

Annexes include the Sikika prioritisation tool, GII prioritisation tool, GII monitoring tool, and CaPSAI reporting templates. Also offered is a guide for completing the post-implementation report.