Social accountability has been emphasised as an important strategy to increase the quality, equity, and responsiveness of health services. In many countries, health facility committees (HFCs) provide the accountability interface between health providers and citizens or users of health services. This article explores the social accountability practices facilitated by HFCs in Benin, Guinea and the Democratic Republic of Congo. The paper is based on a cross-case comparison of 11 HFCs across the three countries. The HFCs were purposefully selected based on the (past) presence of community participation support programs. The cases were derived from qualitative research involving document analysis as well as interviews and focus group discussions with health workers, citizens, committee members, and local authorities. Most HFCs facilitate social accountability by engaging with health providers in person or through meetings to discuss service failures, leading to changes in the quality of services, such as improved health worker presence, the availability of night shifts, the display of drug prices and replacement of poorly functioning health workers. Social accountability practices are however often individualised and not systematic, and their success depends on HFC leadership and synergy with other community structures. The absence of remuneration for HFC members does not seem to affect HFC engagement in social accountability. Most HFCs in this study offer a social accountability forum, but the informal and non-systematic character and limited community consultation leave opportunities for the exclusion of voices of marginalised groups. More inclusive, coherent and authoritative social accountability practices can be developed by making explicit the mandate of HFC in the planning, monitoring, and supervision of health services; providing instruments for organising local accountability processes; strengthening opportunities for community input and feedback; and strengthening links to formal administrative accountability mechanisms in the health system.

The Democratic Republic of the Congo is one of the countries in Sub-Saharan Africa with the highest maternal mortality ratio estimated at 846 deaths per 100,000 live births. Innovative strategies such as social accountability are needed to improve both health service delivery and utilization. Indeed, social accountability is a form of citizen engagement defined as the ‘extent and capability of citizens to hold politicians, policy makers and providers accountable and make them responsive to their needs.’ This study explores existing social accountability mechanisms through which women’s concerns are expressed and responded to by health providers in local settings. An exploratory study was conducted in two health zones with purposively sampled respondents including twenty-five women, five men, five health providers, two health zone officers and eleven community stakeholders. Data on women’s voice and oversight and health providers’ responsiveness were collected using semi-structured interviews and analysed using thematic analysis. In the two health zones, women rarely voiced their concerns and expectations about health services. This reluctance was due to: the absence of procedures to express them, to the lack of knowledge thereof, fear of reprisals, of being misunderstood as well as factors such as age-related power, ethnicity backgrounds, and women’s status. The means most often mentioned by women for expressing their concerns were as individuals rather than as a collective. They did not use them instead; instead they looked to intermediaries, mostly, trusted health providers, community health workers and local leaders. Their perceptions of health providers’ responsiveness varied. For women, there were no mechanisms for oversight in place. Individual discontent with malpractice was not shown to health providers. In contrast, health providers mentioned community health workers, health committee, and community based organizations as formal oversight mechanisms. All respondents recognized the lack of coalition around maternal health despite the many local associations and groups. Social accountability is relatively inexistent in the maternal health services in the two health zones. For social accountability to be promoted, efforts need to be made to create its mechanisms and to open the local context settings to dialogue, which appears structurally absent.

Background: The importance of immunization for child survival underscores the need to eliminate immunization inequalities. Few existing studies of inequalities use approaches that view the challenges and potential solutions from the perspective of caregivers. This study aimed to identify barriers and context-appropriate solutions by engaging deeply with caregivers, community members, health workers, and other health system actors through participatory action research, intersectionality, and human-centered design lenses. Methods: This study was conducted in the Demographic Republic of Congo, Mozambique and Nigeria. Rapid qualitative research was followed by co-creation workshops with study participants to identify solutions. We analyzed the data using the UNICEF Journey to Health and Immunization Framework. Results: Caregivers of zero-dose and under-immunized children faced multiple intersecting and interacting barriers related to gender, poverty, geographic access, and service experience. Immunization programs were not aligned with needs of the most vulnerable due to the sub-optimal implementation of pro-equity strategies, such as outreach vaccination. Caregivers and communities identified feasible solutions through co-creation workshops and this approach should be used whenever possible to inform local planning. Conclusions: Policymakers and managers can integrate HCD and intersectionality mindsets into existing planning and assessment processes, and focus on overcoming root causes of sub-optimal implementation.

Social accountability (SA) comprises a set of mechanisms aiming to, on the one hand, enable users to raise their concerns about the health services provided to them (voice), and to hold health providers (HPs) accountable for actions and decisions related to the health service provision. On the other hand, they aim to facilitate HPs to take into account users’ needs and expectations in providing care. This article describes the development of a SA intervention that aims to improve health services responsiveness in two health zones in the Democratic Republic of the Congo. Beneficiaries including men, women, community health workers (CHWs), representatives of the health sector and local authorities were purposively selected and involved in an advisory process using the Dialogue Model in the two health zones: (1) Eight focus group discussions (FGDs) were organized separately during consultation aimed at sharing and discussing results from the situation analysis, and collecting suggestions for improvement, (2) Representatives of participants in previous FGDs were involved in dialogue meetings for prioritizing and integrating suggestions from FGDs, and (3) the integrated suggestions were discussed by research partners and set as intervention components. All the processes were audio-taped, transcribed and analysed using inductive content analysis. Overall there were 121 participants involved in the process, 51 were female. They provided 48 suggestions. Their suggestions were integrated into six intervention components during dialogue meetings: (1) use CHWs and a health committee for collecting and transmitting community concerns about health services, (2) build the capacity of the community in terms of knowledge and information, (3) involve community leaders through dialogue meetings, (4) improve the attitude of HPs towards voice and the management of voice at health facility level, (5) involve the health service supervisors in community participation and; (6) use other existing interventions. These components were then articulated into three intervention components during programming to: create a formal voice system, introduce dialogue meetings improving enforceability and answerability, and enhance the health providers’ responsiveness. The use of the Dialogue Model, a participatory process, allowed beneficiaries to be involved with other community stakeholders having different perspectives and types of knowledge in an advisory process and to articulate their suggestions on a combination of SA intervention components, specific for the two health zones contexts.

Social accountability has to be configured according to the context in which it operates. This paper aimed to identify local contextual factors in two health zones in the Democratic Republic of the Congo and discuss their possible influences on shaping, implementing and running social accountability initiatives. Data on local socio-cultural characteristics, the governance context, and socio-economic conditions related to social accountability enabling factors were collected in the two health zones using semi-structured interviews and document reviews, and were analyzed using thematic analysis. The contexts of the two health zones were similar and characterized by the existence of several community groups, similarly structured and using similar decision-making processes. They were not involved in the health sector’s activities and had no link with the health committee, even though they acknowledged its existence. They were not networked as they focused on their own activities and did not have enough capacity in terms of social mobilization or exerting pressure on public authorities or providers. Women were not perceived as marginalized as they often occupied other positions in the community besides carrying out domestic tasks and participated in community groups. However, they were still subject to the local male dominance culture, which restrains their involvement in decision-making, as they tend to be less educated, unemployed and suffer from a lack of resources or specific skills. The socio-economic context is characterized by subsistence activities and a low employment rate, which limits the community members’ incomes and increases their dependence on external support. The governance context was characterized by imperfect implementation of political decentralization. Community groups advocating community rights are identified as “political” and are not welcomed. The community groups seemed not to be interested in the health center’s information and had no access to media as it is non-existent. The local contexts in the two health zones seemed not to be supportive of the operation of social accountability initiatives. However, they offer starting points for social accountability initiatives if better use is made of existing contextual factors, for instance by making community groups work together and improving their capacities in terms of knowledge and information.

This paper aims to identify factors that influence the capacity of women to voice their concerns regarding maternal health services at the local level. A secondary analysis was conducted of the data from three studies carried out between 2013 and 2015 in the Democratic Republic of the Congo (DRC) in the context of a WOTRO initiative to improve maternal health services through social accountability mechanisms in the DRC. The data processing and analysis focused on data related to factors that influence the capacity of women to voice their concerns and on the characteristics of women that influence their ability to identify, and address specific problems. Data from 21 interviews and 12 focus group discussions (n = 92) were analysed using an inductive content analysis, and those from one household survey (n = 517) were summarized. The women living in the rural setting were mostly farmers/fisher-women (39.7%) or worked at odd jobs (20.3%). They had not completed secondary school (94.6%). Around one-fifth was younger than 20 years old (21.9%). The majority of women could describe the health service they received but were not able to describe what they should receive as care. They had insufficient knowledge of the health services before their first visit. They were not able to explain the mandate of the health providers. The information they received concerned the types of healthcare they could receive but not the real content of those services, nor their rights and entitlements. They were unaware of their entitlements and rights. They believed that they were laypersons and therefore unable to judge health providers, but when provided with some tools such as a checklist, they reported some abusive and disrespectful treatments. However, community members asserted that the reported actions were not reprehensible acts but actions to encourage a woman and to make her understand the risk of delivery. Factors influencing the capacity of women to voice their concerns in DRC rural settings are mainly associated with insufficient knowledge and socio-cultural context. These findings suggest that initiatives to implement social accountability have to address community capacity-building, health providers’ responsiveness and the socio-cultural norms issues.