Engaging and empowering communities to enhance accountability is a growing trend in the health sector. This guide aims to help policymakers and programme managers assess whether engaging communities makes sense in the context of the performance-based incentive (PBI) programmes they support, and to determine the best approach for such engagement and how to mitigate the risks. PBI aims to improve accountability relationships by providing fee-payers with tools to hold providers accountable through the provision of incentives for verified increases in the quantity and quality of health services. The guide draws on research conducted in three countries implementing very different PBI programmes: Burundi, Indonesia and Mexico.
Evidence showing the relatively weak links between public sector health spending and better health has highlighted the importance of health sector governance as a key intervening variable between inputs and outcomes. Because of this, mechanisms that aim to strengthen governance and improve accountability have gained new relevance for policymakers and programme managers. One such approach is performance-based incentives (PBI) – programmes that provide rewards to patients, health care providers, or managers, once agreed-upon actions have been take or results delivered. PBI is being implemented all over the world, and in some countries has become part of the national health financing strategy.
Within PBI there is growing interest in engaging communities in the design and implementation of PBI schemes. This interest seems to be driven mainly by two things: first, the idea that engaging communities may be a cost-effective approach to programme administration and verification; and second, that it might have additional positive spillover effects, such as enhancing social accountability and citizen empowerment. The guide focuses on community engagement (CE) in the sense of communities (whether individuals or organisations) playing an active role either in the design or implementation of schemes.
Among the challenges highlighted in this guide is the need to balance cost savings with ensuring that programme functions are robust. There are risks of elite capture and exclusion, and tensions between the goals of community engagement – for example, the desire for community engagement to be inclusive and representative – and the needs of the programmes, which require individuals and entities with skills, experience, and independence/objectivity. Principles that emerge include the following:
- Don’t cut costs. Engaging communities may result in some cost savings, but don’t cut corners on essential PBI functions.
- Get the programme functions right. The rigour of PBI functions should not be sacrificed in favour of empowerment.
- Establish checks and balances. For example, where CBOs are contracted to conduct verification, their results should be systematically counter-verified. To mitigate the risk of collusion with facilities, it may also be beneficial to contract CBOs on a per-district basis. There is a need to balance oversight – which costs money – with the desire in the first place to save money by engaging communities.
It is also important to recognise the limits of engaging communities in the design and/or implementation of PBI. Despite building up the capacity of CBOs, the programmes in Burundi and Mexico do not appear to be fomenting community-wide participation and empowerment to bring accountability to bear. Only Indonesia fosters CE in that way, because the programme was designed firstly with that in mind.
Furthermore, community monitoring and pressure is only likely to be effective if it is targeted at the right level. The accountability problems that many community mobilization programmes target occur at all levels – ministry/donor, regional, district, and local – but community groups in most cases target their oversight at the village or facility level.
If the goal is wider CE, feeding back performance data to communities could be built into programmes by, for example, leveraging and/or revitalizing the role of health committees. Giving communities an opportunity, a forum, for ongoing engagement with their health providers, and ongoing information about their performance, would go a long way towards creating long-lasting positive bottom-up pressure to hold providers accountable for results.