Supporting Integration of Social Accountability Processes in Family Planning and Contraceptive Service Provision

"As part of efforts to develop more people-centred health systems, community members participation in health policies and service delivery has received increasing attention...and is expected to lead to improved quality, accountability and equity of health services."



Accountability is central to ensuring that human rights are systematically and clearly integrated into the provision of contraceptive information and services. Ensuring that people have access to high-quality family planning/contraceptive (FP/C) information, services and commodities is fundamental to their right to health. This World Health Organization (WHO) manual is designed to support national- and local-level policymakers and programme managers in integrating social accountability (SA) processes in the provision of FP/C services. It details how to enable or implement SA programmes that stimulate active community member engagement and health system responsiveness and explains how to monitor interventions to ensure progress, sustainability, and scale-up.



Following the World Health Assembly resolution (WHA69.24) in 2016, this manual provides concrete technical support, geared toward Member States but applicable more broadly, to realise the Integrated People-Centred Health Services (IPCHS) framework - in particular, how to develop and implement programming that strengthens health systems to better promote and protect people's health rights and provide for their health.



SA is a participatory process that entails different health system actors, from community members, service users, and service providers to decision-makers, to interact and to collaborate in identifying service issues and developing an action plan for addressing them. It is a complex, socially embedded, and context-driven process that involves many different actors interacting in several ways: raising awareness around entitlements, jointly setting priorities, deliberating solutions and ways forward, and following up together to ensure these issues are addressed. These interactions take place over time to bring about changes in attitudes and behaviours, quality of health-seeking, and overall provision of services.



Though no single theory of change (ToC) works in all situations, there are 3 interrelated components of successful human-rights-based accountability. The 3 components should be included in a conceptual model that explains how a particular SA strategy is likely to work for a specific setting. The 3 components are:

1. Information (as relates to the right to information and is required for accountability actions) - Information can be about official standards, for example, the standards of care outlined in the national sexual and reproductive service delivery guidelines, and community members are expected to mobilise and demand performance up to the official standards. Information can also be about perceived differences in performance quality.
2. Collective action (as it relates to civil rights, such as the right to thought, to speech, to associate, and to assemble) - Collective action is action taken by a group of people based on a collective decision and can include community member demands for information from governments about budgets and spending, procedures, standards, and performance. Actions can generate information through community member data collection and monitor delivery of public goods, findinggaps between expected and delivered service levels. Actions can also include seeking redress and remedy.
3. State response (corresponding to the right to seek redress or a legal remedy) - Health system responsiveness is "the ability of the health system to meet the population's legitimate expectations regarding their interaction with the health system, apart from expectations for improvements in health or wealth" (WHO, 2021). Such response can include generating and releasing information, reforming processes, mobilising resources, advocating for reforms at higher levels, and changing behaviour.

The manual is divided into 3 sections:



Section 1 provides an introduction (Chapter 1) and familiarises readers with theoretical, practical, and contextual underpinnings of SA (Chapter 2). It outlines the importance of the interplay between the law and the accountability system in the context of FP/C, highlighting sexual and reproductive health and rights in legal and policy contexts (Chapter 3). This section provides examples of ToCs used in the context of research on SA applied to reproductive, maternal, newborn, child, and adolescent health (RMNCAH). It also identifies contextual factors that surround SA and those that need to be considered when applying it to RMNCAH - specifically, contraceptive service provision.



Section 2 focuses on how policymakers and programme managers can support social participation (Chapter 4) and enable responsiveness to SA demands (Chapter 5). Factors outlined here that enable or support functional and equitable participatory spaces include, in brief:

• Selecting members and who participates: Explicitly supporting the participation of marginalised or vulnerable groups can ensure diverse representation.
• Ensuring a level playing field: WHO has underlined several recommendations for social participation that related to the quality and type of participatory spaces: the use of a broad range of diverse dialogue techniques adapted to the different population groups and where there is transparency about the role and function of the participatory space (WHO, 2021).
• Building trust between health actors and community members: Ensuring trust and collaboration between the community and health actor groups is vital for social participation to work. Community input should be incorporated into the various stages of programme development to ensure that there is practical and not just symbolic collaboration.
• Making human and financial resources available for primary health care system and for (independent) participation: In different settings, social participation can only achieve goals of improving health facility service provision and responsiveness if they are given adequate resources and power to make decisions in practice, and where local and national governments are experienced in responding to community concerns.
• Supporting platforms in which community members can engage meaningfully with decision-makers and service providers: Multiplying opportunities for interactions between health actors and community members can reinforce enabling elements for social participation.
• Promoting transparency and access to information: Ensuring the availability and accessibility of information regarding the official standards and performance provides community members with information on what they can mobilise and demand action.

Section 3 supports monitoring and evaluation (M&E) of SA programmes (Chapter 6) and planning for sustainability and scale-up (Chapter 7). Example: Advocate at the subnational level to create interest and ownership, partnerships between civil society organisations and governments, concerted efforts to address community members' concerns, and recourse mechanisms to affirm people's faith in the public health system.