The Role of Social Accountability in Improving Respectful Care

"The existing research assessing ways to promote respectful care is somewhat limited, generally focusing on efforts at the facility level, as opposed to addressing social norms and other structural factors, such as stigma or national-level policy."

Evidence suggests that social accountability efforts - citizen-led, collective processes that seek to improve health care access and quality through community monitoring - can impact outcomes related to respectful reproductive, maternal, newborn, child, and adolescent health (RMNCAH) care. From the United States Agency for International Development (USAID) MOMENTUM Knowledge Accelerator (MKA), this package of materials (technical report, companion brief, and conceptual framework) aims to strengthen our understanding of the role of social accountability in enhancing respectful care across RMNCAH.

To inform this work, MKA conducted a rapid literature review (focused on low- and middle-income countries, or LMICs), conducted key informant interviews and focus group discussions, and held convenings of USAID and key external stakeholders in July 2022.

As this work highlighted, the term "respectful care" overlaps with other existing constructs whose definitions and measures vary significantly across contexts. However, MKA did develop a working definition of respectful care across the RMNCAH continuum: "Care is respectful if it maintains all individuals' dignity, privacy, and confidentiality; ensures that interactions with individuals or carers enhance informed decision-making, without inducement or coercion; promotes continuous support (as appropriate); is compassionate and responsive to their preferences, needs, and values; and is free from stigma, discrimination, mistreatment, and harm."

Policies and programmes to promote respectful care use a wide variety of approaches. The technical report summarises the limited evidence base on efforts to influence social norms and national policy to improve respectful care. For example, patients and communities can be engaged in designing tools and programmes to promote patient-centred care, including respectful care. Human-centred design takes participation a step further by involving stakeholders in identifying and describing the problem, designing and prototyping a solution, and putting the chosen solution into practice.

Along these lines, spaces created by social accountability efforts can provide an opportunity for health providers to learn about community priorities and concerns, as well as for communities to hear about health provider limitations, giving them more realistic expectations. Analyses find that social accountability efforts create new processes for state-society interaction, such as community/health facility interface meetings, or democratise existing processes, such as village health committee meetings. These programmes are premised on the assumption that information on rights, entitlements, and service quality among service users will lead them to make collective demands for improvement. In tandem, they assume that information on community priorities and health sector performance will spur action and responsiveness among service providers and policymakers.

Table 2 in the technical report provides a summary of studies assessing social accountability and respectful-care-related outcomes in RMNCAH. It presents relevant quantitative studies, including a brief description of the intervention/programme implemented, the measures of respectful care (or that are "respectful care adjacent") they used, study outcomes, and the domain of RMNCAH health the programme sought to address. This table is complemented by a narrative summary of the non-experimental (quantitative pre- and post-test, qualitative, etc.) research on respectful-care-related outcomes of social accountability. MKA then discusses what the literature reveals about the mechanisms of change and explores how these mechanisms might play out in respectful care in RMNCAH.

Based on current evidence, the technical report outlines ways in which respectful care in RMNCAH may be particularly well-suited as a specific outcome of interest to address in social accountability approaches. Table 5 maps attributes of social accountability and respectful RMNCAH care against key constructs in a social accountability conceptual framework, suggesting potential synergies and pitfalls. For instance, in brief:

• Social accountability programmes typically entail members of the community assessing health system performance. Respectful care can and should be monitored - at least in part - by communities themselves.
• Many elements of respectful care are within the control of local health providers, such as polite treatment, the provision of information, and compliance with consent processes. Thus, local-level efforts could realistically lead to short-term improvements in respectful care and build engagement among participants who see that the process bears fruit.
• Social accountability efforts aim to change the power dynamics between health systems and patients and their families; such power dynamics are especially pertinent to RMNCAH (e.g., in the case of norms regarding gender and sexuality). Most social accountability theories of change envision communities as becoming "empowered" and collectively mustering the countervailing power required to change the behaviour of providers and decision-makers.

Synthesising and building on existing empirical evidence and theory, the technical report presents a possible theoretical pathway from social accountability to respectful care in RMNCAH. In this conceptual framework, "social accountability is a process by which, first, information on rights and entitlements is either shared with community members or community members are supported in gathering this information themselves. Then, the intervention strengthens individuals' and community collective capacity to make claims based on the information shared or gathered. Finally, the process facilitates interface and dialogue between community members and health providers and institutional decision-makers about the community's desired changes in quality of health care received, including respectful care."

MKA explains how various participants - e.g., community members, healthcare providers, and non-health-sector actions - could benefit from such a multifaceted and iterative process, which often builds on existing community engagement platforms. Ultimately: "The increases in knowledge, conscientization, capacity, empathy, and feelings of pressure, along with the interaction of community members and health care providers and decision-makers with non-health sector actors, lead to mutual empowerment and a shared commitment among all parties to address power dynamics and the gaps in respectful care standards....Given the iterative nature of social accountability, the community remains attentive to the power dynamics between communities and health care providers/decision-makers and engaged in monitoring and advocacy activities throughout the entire process, leading to improved governance and democracy."

The technical report identifies several challenges and gaps related to social accountability and respectful care in RMNCAH, including limited evidence for social accountability as a strategy to promote respectful RMNCAH care, variation in the ways social accountability and respectful care are operationalised and measured, short implementation periods and a lack of flexibility in the way projects are structured, and challenges related to the scalability and sustainability of interventions.

The report concludes with a series of recommendations for: refining the conceptualisation of social accountability and respectful RMNCAH care; improving how key constructs (e.g., social accountability, respectful care, RMNCAH) are measured and operationalised; building a stronger evidence base for social accountability as a strategy to promote respectful care; developing consolidated tools and guidance for social accountability specific to respectful care and RMNCAH; and strengthening implementation of social accountability and respectful care interventions.

According to MKA, the conceptual framework that accompanies the technical report has implications for both implementers and researchers. Implementers can use the framework to design local-level social accountability interventions that engender improvements in respectful care. Researchers and evaluators can use it to assess how changes in context or moderating factors influence the success of social accountability and to evaluate the effectiveness of the conceptual framework itself.