This technical brief focuses on how seven different systems strengthening and service delivery improvement initiatives helped strengthen citizen participation and voice, and enhanced accountability in the PATHS states over the period 2003 to 2008. The initiatives were:
- Patient Focused Quality Assurance (PFQA)
- Peer Participatory Rapid Health Appraisal for Action (PPRHAA)
- Integrated Supportive Supervision (ISS)
- Facility Health Committees (FHCs)
- Standards of care and Patient Charters
- Safe motherhood demand-side initiative (SMI-D)
- Community Action Cycle (CAC)
Some general conclusions and lessons learned from implementation of the seven initiatives described in this technical brief are highlighted below:
- Involving clients and community representatives in the assessment and monitoring of service delivery opened up space for citizen voices to be heard in the health sector and helped strengthen provider responsiveness to client needs.
- Clients and communities need to be supported so that they can participate in processes such as PPRHAA and ISS in ways that extend beyond token involvement.
- Involving members of the community in the governance of health facilities through facility health committees proved an effective way to progress a V&A agenda.
- Initiatives that provided formal mechanisms through which citizen voices could reach health providers and policy makers appeared to offer the most potential from a voice and accountability perspective.
- In contrast, initiatives that relied on citizens trying to influence policy-makers via informal routes (e.g. safe motherhood demand-side initiative and facility health committees) could not guarantee that citizens would get an audience with a policy-maker, while getting a response appeared to depend on a policy-maker’s personal initiative or whim.
- Government-led V&A initiatives, such as defining standards of care and introducing patient charters can help create an enabling environment for voice and accountability.
- Citizens’ willingness to challenge policy-makers about poor quality health services in some instances opened up a space for providers to manoeuvre for improved resources or working conditions.
- Civil society organisations, such as NGOs and CBOs, have a potentially important role to play in creating space for voice and catalysing changes in accountability between providers, policymakers and communities.