How can greater voice and accountability for citizens bring about improved health services? This Technical Brief from the Partnerships for Transforming Health Systems Programme (PATHS) reviews several voice and accountability initiatives supported by PATHS in selected states in Nigeria. It concludes that the creation of formal mechanisms of voice and accountability can be effective in opening space for citizen-state accountability and improving service responsiveness. Further work is however needed from the government on strengthening accountability mechanisms for these initiatives to be fully successful.
Voice and accountability really matter if health services are to be improved. Citizens need to be able to claim improvements in services; providers and policy-makers need to be accountable for their decisions and actions; and services need to respond to the ideas, concerns and suggestions of clients. Knowing how, when and where to intervene to strengthen citizen voice and accountability within the health sector, however, is challenging in contexts where health systems are very weak and many issues require urgent attention.
In Nigeria, prior to 2002, awareness of rights was almost universally low among the general public. Mechanisms that would allow clients to challenge poor quality health services were largely absent, and health providers and policy-makers lacked incentives to respond appropriately to client needs. The result was very low utilisation of public health facilities and a breakdown in the relationship between health facilities and communities. PATHS initiatives were designed to create opportunities to begin to strengthen citizen voices on health and to address accountability failures. Five years on, a review found that:
- Involving clients and community representatives in the assessment and monitoring of service delivery not only helped to open up space for citizen voices to be heard in the health sector, but also strengthened provider responsiveness to client needs.
- Involving members of the community in the governance of health facilities through Facility Health Committees led to communities challenging a variety of accountability failures, either at the health facility or ‘higher up the system’.
Although in the PATHS states implementation of systems strengthening and service delivery improvement initiatives resulted in improved accountability of health providers to local communities, for various reasons efforts to strengthen accountability between policy-makers and communities proved more challenging. These attempts to strengthen voice and accountability were prone to failure in the absence of parallel efforts to strengthen public accountability at local government level. To translate the success of PATHS to other states in Nigeria and elsewhere and to sidestep some of the challenges encountered in this first phase, donors should incorporate the lessons below into their programme design:
- Clients and communities need to be supported so that they can participate in processes in ways that extend beyond token involvement.
- Initiatives through which citizen voices could reach health providers and policy makers proved more effective than informal routes for improving voice and accountability. These formal mechanisms not only placed an obligation on different parts of government to listen to the voice of the people, but also introduced incentives to respond.
- Such initiatives need to be widely publicised so that service users and communities are better informed and better able to use the standards as a reference point for claiming their entitlements
- Civil society organisations, such as NGOs and CBOs, have a potentially important role to play in creating space for voice and catalysing changes in accountability between providers, policy-makers and communities.
