Jean-Benoît Falisse. What sparked off your interest in community accountability in health? Could you tell me a bit more about the KEMRI-WT research activities on this issue?
Sassy Molyneux. I’ve been interested in the interactions between communities and health systems for years, beginning with initial PhD research in the Coast of Kenya in the late 1990s. Community participation and empowerment has long been emphasised as an important approach to ensuring affordable, locally responsive, health prevention and treatment services. However achieving this is clearly far from straightforward. An approach to involving communities that had been promoted in Kenya as in many other countries was the Bamako initiative, which in Kenya included the establishment of community run pharmacies, but unfortunately these pharmacies were struggling by the time of my PhD fieldwork. There have also been many efforts over the years to promote community participation in health care in Kenya through village and facility level committees. These committees were being discussed at the time of my PhD by health managers as a huge success, as ‘gold standards’ but it appeared that when user fees were reduced in Kenya in the early 2000s, their role was weakened through having less resources over which they had a say. I could see then that there was great potential but also challenges in selecting and working with ‘representatives’ of such complex communities in very hierarchically organised health systems.
I increasingly began to hear about ‘community accountability’ which was and is being promoted for a whole range of instrumental and intrinsic purposes. I was intrigued as to what ‘it’ really was, and if and how it differs from community participation. I was also interested in learning more about how to feasibly involve communities given the difficulty in defining them, the technical nature of many aspects of health service delivery, and the complex power relations within communities and health systems, and between health providers and community members. Working in a large multi-disciplinary research programme, I was also interested in learning from theoretical and practical insights and ideas from health system community accountability, to inform community involvement in the programme’s biomedical research activities.
Today most authors and public health practitioners talk about community ‘accountability’ rather than community ‘participation’ (as people did at the time of the Bamako Initiative). Is it really a different concept?
My understanding is that in community accountability, individuals or their representatives influence elements of health systems through voicing views and opinions, which are then responded to; therefore there is an element of answerability. This requires action and response through challenges and systems that support this. I think that community participation is a broader term, which might well include this too. But both terms are used differently and in overlapping ways. Perhaps most important, regardless of the term or across both terms, is to consider the depth of community involvement, or the levels of genuine empowerment, because many writers have argued that community involvement can range from simple information giving to communities at one end of the spectrum, through consultation, to community influence and control at the other end. This is important in highlighting that setting up opportunities of interacting with community members does not necessarily lead to community influence and control. Moreover, there is the potential for ‘manipulation’ or ‘tokenism’ in community involvement initiatives; for paying simple lip service to a fashionable idea. It was my recognition of both the potential but also the challenges and even possibly perverse outcomes associated with community accountability that led me to be inquisitive about this area.
In a recent literature review (2012), you point out that there are actually not that many studies on the impact of community accountability mechanisms. What do you think is the reason? Do we know what actually works?
There is a slight caveat to that finding in that we were focusing very specifically on accountability mechanisms linked to peripheral health facilities. So there will be a body (probably several bodies) of literature that we did not consider that deal with community accountability without specific mechanisms linked to facilities. Also there is likely to be research that has been conducted that’s not written up formally in reports that are (easily) publically accessible.
Part of the gap is I think related to accountability strengthening initiatives often being part of quite complex interventions being conducted in complex health and social systems. When this is combined with the difficulties in defining and measuring many aspects of community accountability (for example depth of involvement or engagement, levels of empowerment, and subtle shifts in power relationships), designing and conducting convincing and relevant evaluation strategies becomes very challenging. There is therefore a need for more innovative methodological approaches; of moving far beyond the simple RCTs or relatively standard qualitative methodologies. This is a challenge that’s recognised in health systems research more broadly, with growing promotion for example of (participatory) action research, and interest in incorporating reflexive and deliberative approaches into evaluations to ensure that the tacit knowledge of the range of actors involved is adequately drawn upon.
You also point out that most of the literature has focused on health facility committees. Why is it so? What are the other existing mechanisms? Any you think is particularly promising?
As I mentioned above, we were focusing very specifically on accountability mechanisms linked to peripheral health facilities so that might in part explain this. Of course there are many other forms of community groups that advocate for health improvement, that are not specifically linked to facilities, including those that have been more spontaneously initiated and established by community members themselves. And at facilities there are other interventions such as patients’ rights charters (to promote awareness of rights and interest in demanding change) and information sharing and suggestion boxes (to reduce information asymmetries and encourage ideas and opinions to be voiced), and other mechanisms which can be loosely termed community monitoring. The latter often involve community members and health providers deciding together on priority areas for action/change, implementation of change, community monitoring of progress, and information sharing with the public about health facility progress along the lines of the indicators learned. These are potentially very exciting initiatives, and the challenge then becomes sharing the lessons across different contexts and levels of the health system, and encouraging spread and adaption of successful initiatives to other places.
About external validity. What can we learn from necessarily local experiences of community accountability? How strong are the contextual and cultural factors in explaining the success of mechanisms of community accountability?
I think we saw from our review that while although of course community accountability initiatives have to be locally appropriate and responsive, there are cross cutting ideas that emerge that are relevant across all sites; a form of theoretical generalizability that is helpful for initiatives in other settings. So for example in our work the importance of: clarity in community members’ roles and responsibilities; and information availability and access. Also the need to carefully consider remuneration and other forms of incentives for community representatives, the challenges of asymmetries between health staff and community representatives in resources and power, and the importance of building trustful relationships. Many of these aspects are in turn linked to how much real interest and value there is from the health system in community inputs.
You advocate for mixed-methods research on community accountability mechanisms. Could you explain how the qualitative and quantitative approaches reinforce/complement each other when exploring questions of community accountability? Would a single method necessary be incomplete or weaker?
I think good quality qualitative approaches can be in themselves appropriate for exploring the complexities I’ve described above. A challenge is to be given enough space in write ups and particularly in peer- reviewed journals to convince readers of the methodological and analytical depth of studies. Some qualitative studies appear to be relatively superficial group discussions and individual interviews through which it is very hard to give justice to the topic. To complement these approaches with quantitative methodologies – where possible and relevant to the specific question – can assist to give an overall picture of scale of issues/impacts, and can be helpful also in research uptake; in framing the importance of initiatives to particular audiences. As noted above, incorporating more ‘novel’ approaches into qualitative or mixed method evaluations – for example participatory approaches, deliberative activities and key actor reflections could strengthen studies further. Here, I think there is a need to continue to share ideas about how to strengthen the trustworthiness and transferability of the data gathered through such methodological approaches, and to convince others of this quality in order to inform policy and practice. There are numerous community accountability initiatives being implemented all of the time – either initiated and sustained by communities or representatives themselves, or by governments and other actors. Finding new ways to document and evaluate such activities convincingly to key audiences would be helpful. This would require unpacking not only of the successes but also of the challenges and failures, and the reasons behind the outcomes.
It seems there is a recent renewal of research on community participation/accountability. Would you agree? What do you think are the main remaining areas of research on community accountability (in health)?
I think community participation/accountability is (re)emerging as an area of focus and attention in policy and practice and therefore in research also. This is possibly assisted by the new terminology! My area of interest now, building on from past research, is how forms of external or community accountability such as committees and community monitoring, interact with and are affected by organisational culture and internal accountability systems ie answerability of health providers and managers to their bosses up the bureaucratic system and to other funders. And I’m interested in drawing on both traditional and less traditional methodological approaches, as I’ve mentioned above, to doing this. Some of these thoughts and ideas are being taken up through governance work co-led with Professor Lucy Gilson, and funded by DFID as part of a research consortium (RESYST).