Over the past decade, social accountability for health has coalesced into a distinct field of research and practice. Yet evaluations of social accountability programs frequently fail to assess important power dynamics. In this commentary, we argue that we must include an examination of power in research and evaluation of social accountability in sexual and reproductive health, and suggest ways to do this.
Power dynamics affect many areas of sexual and reproductive health, such as decision-making power within families, patient treatment in clinical settings, and professional relationships among health providers. The role of power in shaping health status and disparities, access to health care, the quality of care that communities receive, and social hierarchies (e.g., relating to caste, race, gender, ability, or class) has been theorised in many disciplines – ranging from social psychology to anthropology and political science [1, 2]. Failure to assess power dynamics can mean failure to identify crucial contextual characteristics that must change to improve sexual and reproductive health. Relevant characteristics include those that the program directly seeks to change, such as power relations between patients and health providers, or power dynamics that influence implementation and success of social accountability efforts more indirectly, such as government commitment to funding family planning programs, or societal gender norms. For example, one midwifery program failed in part because the community midwives could not undertake the required travel because of prevailing gender and class norms which prevented them moving around freely . In that case, understanding wider social hierarchies was crucial to understanding programme failure.
Non-governmental organizations, international organizations, government agencies, and grassroots actors employ social accountability strategies to effect change in sexual and reproductive health. Common tactics include sharing data on health system performance, and community engagement and dialogue with decision-makers . These tactics have been deployed to address a broad range of sexual and reproductive health priorities, such as ensuring contraceptives are available, ensuring clinic hours are convenient, respectful patient care, and reducing health provider absenteeism. However, community engagement and data sharing do not necessarily ensure that the intervention affects power dynamics to benefit communities. For this reason, evaluations should assess power dynamics, making explicit whether and how the intervention addresses power. Collective action has the potential to transform power relations, including relations within communities, between communities and health system actors, and within health systems . Collective action (as opposed to isolated individual efforts) can generate countervailing power, which can foster change by, for example, impelling formalised sanctions processes, shaming health providers, or raising provider awareness of community dissatisfaction. Whether explicitly stated or not, changed power relations are at the heart of what social accountability practitioners seek, particularly in the context of sexual and reproductive health. For example, social accountability efforts have resulted in historically oppressed groups gaining greater voice in articulating maternal health priorities, local health providers no longer treating patients rudely with impunity, and health care workers at the bottom of the professional hierarchy being able to successfully negotiate to receive the supplies they need [6,7,8].
The authors of this commentary are part of the community of practice on measuring social accountability and health outcomes convened by the Department of Sexual and Reproductive Health and Research, World Health Organization. Measurement and evaluation of social accountability is an evolving area; this evolution relates to broader discussions within the social accountability field about the importance of the political and social setting; the degree and depth of change possible with locally bounded, time limited efforts; and the importance of understanding social accountability programs and tactics in the context of long-term, iterative social change strategies [9,10,11]. In a systematic review of methods to measure the impacts of social accountability on reproductive, maternal, newborn, child and adolescent health, presented to the community of practice in 2018, Marston et al. concluded that qualitative data are crucial to exposing mechanisms and processes of change, as well as to elucidating the broader social, political, and historical context . The authors also found that no studies took an explicit systems approach and the analyses generally did not examine the extent to which programs influenced or were influenced by power dynamics within the health system and broader social structures .
Understanding whether, how, and at what levels power relations are shifted can help us to understand program success, and, particularly if evaluations are theory-based, build the evidence base in the field of social accountability [1, 9]. Recognizing that there are no ‘off the shelf’ solutions to very complex research and evaluation challenges, we share key lessons from our efforts to conduct power-sensitive research and evaluation using different methodological approaches. We seek dialogue with others who have used these approaches, as well as with those who have used alternative approaches, as we build the evidence base on how to assess power in research and evaluation on social accountability for sexual and reproductive health.