Authored by: Susan Pietrzyk, PhD, International Health and Development Team, ICF

As a project, the Accelerator’s focus on health system strengthening (HSS) is pursued in various ways. Analysis and use of evidence and tools along with original research provide important insights. Investments such as these build an understanding of complex dynamics and provide a springboard for bringing government, health sector, and citizen actors together to identify and address health system challenges. 

A recent study—Improving Linkages between Social Accountability and Social and Behavior Changeand subsequent engagements with stakeholders in Côte d’Ivoire, Ghana, Guinea, and Togo is one example of the Accelerator’s commitment to aligning research and facilitative work to the needs of country-based health system experts.

This blog highlights key findings from the SA-SBC linkages study and outlines the types of stakeholder engagement and research utilization efforts we are pursuing.

Key Findings

Literature and programming priorities suggest that social accountability and social and behavior change tend to operate in isolation of each other. In comparison, the former works to cultivate change at governance, institutional, procedural, and systemic levels, whereas the latter centers on specific health areas and associated behaviors at individual, family, and community levels. Further, social accountability approaches revolve around the interactions between government, health system, citizen actors. These actors play a role in social and behavior change strategies; however, the defining objective of social and behavior change programming is to facilitate individuals changing their behaviors and shifting to optimal health choices and actions, not the relationship of the various actors and the context of the system. Working in the overlap of these two practices areas opens space to map what behaviors must change, including within social accountability activities, which are often central to HSS work and efforts to advance universal health coverage (UHC).

Côte d’Ivoire, Ghana, and Guinea were selected for virtual data collection. One hundred seventy-nine stakeholders completed an online survey, and 21 key informant interviews were conducted. The study aimed to investigate social accountability work, the successes and challenges, and the extent that certain actions and behavior facilitate or impede success. Key findings include:

  • Across the 179 respondents, 68.7% indicated that social accountability is prioritized in their country. Government support and citizen advocacy were noted as key to the success of social accountability.
  • Fewer than a third of the respondents felt that facility providers or administrators were accountable to patients. Fewer than half agreed that the government was accountable to citizens for providing quality services, information about health services, and equitable allocation of financial resources.
  • Respondents appeared to view behavior change from the government and citizens as linked in asserting that the government must change its behavior and better inform citizens of their rights. And citizens must change their behavior to exercise their rights.
  • The challenges that respondents reported concerning social accountability in support of UHC included a top-down approach in developing and rolling out UHC, few if any processes for involving citizens, a lack of a culture or understanding of social accountability, and poor citizen organization and mobilization. 
  • As presented in the table below, the percentage of respondents who strongly agree that specific groups are well represented in advancing UHC are relatively low. These findings suggest that UHC efforts are perceived to struggle with representativeness. Striving for greater representation is an important strategy that can be achieved by changing behaviors to adopt more inclusive processes with collaborative work between government, health, and citizen actors.

Percent of Respondents Agreeing Specific Population Groups Represented in Universal Health Coverage Efforts

Discussing the Findings and their Implications

During the first half of 2021, the Accelerator held 12 events to discuss the findings from the SA-SBC linkages study, with an additional six events planned during the second half of 2021. The discussion has been wide-ranging and included, for example, the role of behavior change in health financing, recognition of distinguishing between individual behaviors and systemic behaviors, measurement of social accountability, the role of performance-based financing, engaging civil society in social accountability when they depend on government funding as well as other topics. Other highlights include:

  • Participants noted the importance of having confidence in leaders and organizers, which can occur through more open communication and transparency, to facilitate behavior change.
  • Participants noted the importance of creating frameworks for inclusive discussions of community health challenges and integrating community voices to improve community health outcomes to support UHC.
  • The need to create trust in health institutions was emphasized, along with the importance of advocating for the increased engagement of civil society.

Research Utilization and Applying a Behavior Change Lens

In moving stakeholder engagement from discussion to research utilization, the Accelerator has launched two country-level efforts to apply a behavior change lens, as follows:

Budget Advocacy and the Community Health Strategy in Guinea: The Accelerator will engage the Community Health Multisectoral Technical Platform to develop a tool that applies a social and behavior change lens to budget advocacy-related social accountability activities. The tool will include strategies for increasing citizen and civil society participation in budgeting prioritization and oversight processes and improving leaders’ receptiveness towards involving citizens and addressing their priorities. As demonstrated in the SA-SBC linkages study, there are mixed views about the extent social accountability efforts are successfully used, including participatory budget efforts. Applying this knowledge to the tool will inform a behavior change-focused budgeting process to increase dialogue between citizens and civil society with national and subnational decision-makers.

Citizen Mobilization around Universal Health Coverage (UHC) in Togo: The Accelerator will facilitate two virtual workshops with the UHC Task Force to identify individual citizen and civil society engagement barriers. Participants in the workshop sessions will apply a behavior change lens to assess the various roles and interactions of government, health sector, and civil society actors in mobilizing around UHC and increasing social accountability across the health sector more broadly. As demonstrated in the SA-SBC linkages study, citizen engagement is widely viewed as an important aspect of efforts to advance UHC with increasing demand for greater representation in decision-making around UHC. Applying this evidence in the workshops will inform building a behavior change-focused strategy for increasing dialogue between citizens and civil society with decision-makers.