Community accountability at peripheral health facilities: a review of the empirical literature and development of a conceptual framework

Abstract

Public accountability has re-emerged as a top priority for health systems all over the world, and particularly in developing countries where governments have often failed to provide adequate public sector services for their citizens. One approach to strengthening public accountability is through direct involvement of clients, users or the general public in health delivery, here termed 'community accountability'. The potential benefits of community accountability, both as an end in itself and as a means of improving health services, have led to significant resources being invested by governments and non-governmental organizations. Data are now needed on the implementation and impact of these initiatives on the ground. A search of PubMed using a systematic approach, supplemented by a hand search of key websites, identified 21 papers from low- or middle-income countries describing at least one measure to enhance community accountability that was linked with peripheral facilities. Mechanisms covered included committees and groups (n = 19), public report cards (n = 1) and patients' rights charters (n = 1). In this paper we summarize the data presented in these papers, including impact, and factors influencing impact, and conclude by commenting on the methods used, and the issues they raise. We highlight that the international interest in community accountability mechanisms linked to peripheral facilities has not been matched by empirical data, and present a conceptual framework and a set of ideas that might contribute to future studies.

Figure 1

Spider diagrams to describe and assess community participation Note: In Rifkin's approach level of community involvement in each of five factors considered to influence the breadth or depth of community participation in a community health programme is considered by the assessment team on the basis of data collection and discussion. The five factors are needs assessment, leadership, organization, resource mobilization, and management. To show visually levels of community participation, a spider diagram is drawn (see Figure). For each factor, the breadth of community involvement is based on a consensus reached by the assessment team, with widest participation being marked furthest from the central point, and narrowest closest to the central point. The points on each line are then linked with each other, allowing the breadth of community participation to be visualized.

Figure 2

Factors influencing the functioning and impact of community accountability mechanisms