Health provider responsiveness to social accountability initiatives in low- and middle-income countries: a realist review

Abstract

Social accountability in the health sector has been promoted as a strategy to improve the quality and performance of health providers in low- and middle-income countries. Whether improvements occur, however, depends on the willingness and ability of health providers to respond to societal pressure for better care. This article uses a realist approach to review cases of collective citizen action and advocacy with the aim to identify key mechanisms of provider responsiveness. Purposeful searches for cases were combined with a systematic search in four databases. To be included in the review, the initiatives needed to describe at least one outcome at the level of frontline service provision. Some 37 social accountability initiatives in 15 countries met these criteria. Using a realist approach, retroductive analysis and triangulation of methods and sources were performed to construct Context-Mechanism-Outcome configurations that explain potential pathways to provider responsiveness. The findings suggest that health provider receptivity to citizens' demands for better health care is mediated by health providers' perceptions of the legitimacy of citizen groups and by the extent to which citizen groups provide personal and professional support to health providers. Some citizen groups activated political or formal bureaucratic accountability channels but the effect on provider responsiveness of such strategies was more mixed. Favourable contexts for health provider responsiveness comprise socio-political contexts in which providers self-identify as activists, health system contexts in which health providers depend on citizens' expertise and capacities, and health system contexts where providers have the self-perceived ability to change the system in which they operate. Rather than providing recipes for successful social accountability initiatives, the synthesis proposes a programme theory that can support reflections on the theories of change underpinning social accountability initiatives and interventions to improve the quality of primary health care in different settings.

Implementation of free maternal and child healthcare policies: assessment of influence of context and institutional capacity of health facilities in South-east Nigeria

“…These gaps in the roles of HFCs provide insights into the potential of citizen participation for the improvement of free health services as has been argued in a previous study [49]. It would be imperative to train and mentor HFCs and health care providers on the mandate of HFCs within the FMCHP policy to ensure that health facilities implement changes to the free care programme based on concerns raised by citizens [53]. …”

Rights-Based Training Enhancing Engagement of Health Providers With Communities, Cape Metropole, South Africa

“…A programme theory was used to frame the interpretive analysis of themes. This facilitated the assessment of the extent and nature to which HPs' post-training responsiveness outcomes, as defined by Lodenstein et al (2017a), can contribute to the three interconnected principles of community participation, PHC and people-centred health systems as described in the introduction.…”

“…The evaluated HP training cross-cuts the six key mechanisms to HP responsiveness identified in Lodenstein et al (2017a) realist review of social accountability initiatives in LMICs. In their proposed programme theory, the authors suggest that HP responsiveness outcomes are influenced by (i) HPs' perceptions on the legitimacy of the social accountability initiative, (ii) their feelings of support, safety, appreciation, and (iii) of moral responsibilities and obligations, (iv) their fear for public or professional reprisal, (v) their self-identification with the initiative's claims or ideals and perceived self-capacity to act, and (vi) their perceptions on health care users.…”

An ethical imperative: Safety and specialization as nursing priorities of WHO Global Initiative for Childhood Cancer

“…There has been a strong focus on standards of accountability for health care in LMIC, but historically, a lack of prioritization, or even neglect, of protective measures for nurses and others has been evident. We must promote standards, identify incentives, and provide a solid rationale to institutions and governments to prioritize access to PPE for all those handling hazardous drugs, and, in parallel, advance specialized nursing roles and education to develop proficiency in pediatric oncology nursing care and optimize patient outcomes …”

“…It is a duty to do no harm and to protect health professionals, as well as patients/families, from avoidable and preventable harm by providing nurses and pharmacists with adequate training and proper protective equipment. There has been a strong focus on standards of accountability for health care in LMIC, 9,41 but historically, a lack of prioritization, or even neglect, of protective measures for nurses and others has been evident.…”