Skip to main content

At the interface between the formal and informal, the actual and the real: a realist study protocol for governance and accountability practices in urban settings focusing on adolescent sexual and reproductive health and rights



This paper presents the protocol of a study that aims at exploring how different multi-level governance arrangements impact on sexual and reproductive health of adolescents living in informal settlements. The overall objective of this study is to contribute to a better understanding of the causal chains underlying accountability in sexual and reproductive health for adolescent girls and young women living in urban informal settlements in low-and middle-income countries.


The overarching methodology is realist evaluation. The study adopts a case study design, through which governance and accountability practices in Mumbai, Delhi, Cotonou and Kampala will be examined. Different social science methods to develop and test a programme theory will be used. Heuristic tools for the analysis of the accountability ecosystem and mapping of governance arrangements, drawing from contextual political analysis and critical realism, will be developed in order to identify the intervention-context-actor-mechanism-outcome configurations.


The methodological approach is geared towards building robust case-based explanation with due attention to context and the roles of different actors. The combination of different social science methods will lead us to a better grasp of the inherently political nature of social accountability.


Two-thirds of the world’s population will live in urban settings by 2050. Nearly 90% of 2.5 billion ‘new’ urban residents will live in Africa and Asia. Sixty % of the global urban population will be under 18 by 2030 [1]. A considerable proportion of these urban adolescents live in insecure environments, exposing them to a number of sexual and reproductive health-related risks. Through overcrowding, hyper-mobility, entrenched poverty, an informal economy based on middlemen and bad infrastructure, informal urban settlements expose their vulnerable residents, including adolescent girls and young women, to health risks. Health system challenges include denial of access to a quality public health system. When services are available, residents of informal settlements often face poor quality of care, stigma, discrimination by providers, and lack of recognition of citizenship (or non-portability of health entitlements in the case of migrants). Unregulated private providers often overcharge users for care of poor quality. The privatization of public goods (such as hygiene facilities), the absence of specific adolescent sexual and reproductive health and rights (ASRHR) and sexual violence services, and delays in referral of emergencies due to traffic congestion present additional challenges for adolescent girls and women. Yet, the urban environment, including informal settlements, can be a site for adolescents’ empowerment, specifically of adolescent girls: it can provide opportunities for innovation through multi-actor engagement, self-organisation and emergent collective action, linking urban city authorities, NGOs and grassroots or community-based organisations. Cities are arenas where actors engage in consensus-building strategies but also in resistance and protest, to enforce accountability towards vulnerable groups.

There is a dearth of evidence regarding the macro- and meso-level context conditions that increase the vulnerabilities of adolescent girls in the informal settlements of cities and which lead to poor adolescent sexual and reproductive health and rights (ASRHR) outcomes. Research into the relationship between the physical environment, the (un)safety of public space in informal settlements and adolescents’ needs for protected space and privacy is a priority.

In this study, I focus on the sexual and reproductive health and rights of adolescent girls and young women living in informal settlements, and more specifically on life skills education, sexual health, sexually transmitted infections, sexual violence and rights to health. At the core is the examination of the causal chain between accountability practices, sanitation and sexual and reproductive health service delivery in informal settlements, and health outcomes of adolescent girls and young women in Kampala (Uganda), Cotonou (Benin), and New Delhi and Mumbai (India). I will look specifically into the intersections between gender, citizenship, poverty, ethnicity, caste and religion.

Adolescent girls in informal settlements: health, precarity and accountability

Since 2007, more than half of the world’s population lives in cities. Urbanization is only expected to increase during the next decades, with expansion or consolidation of informal settlements in many low- and middle-income countries (LMIC). Within informal settlements, adolescent girls are a vulnerable group. Besides the burden of disease related to the socio-economic and environmental conditions (overcrowding, extreme poverty, pollution and social exclusion related to caste, ethnicity or being a migrant), they experience specific disadvantages and risks related to their sexual and reproductive health (SRH) and rights, and prevailing gender norms. Levels of sexual violence in slums are high. Among 313 surveyed young adult women in Kampala, 32% said to have been raped [2]. Violence towards adolescent girls is associated with obtaining resources such as food and money, and the absence of trusted family members. In a cross-sectional study in Kampala, 73% of adolescent respondents reported that it was “common for strangers (but also relatives) to force young females to have sexual intercourse without consent”, likely resulting in unintended pregnancy [3]. Pommells et al. demonstrated the link between access to sanitation facilities and sexual violence [4]. The lack of access to sanitation facilities (‘sanitation insecurity’ [5]) does not only expose them to a range of infectious diseases, but also to multiple stressors, inadequate menstrual hygiene, sexual violence and adverse pregnancy outcomes [6, 7]. In India, not having a house toilet doubles the risk of sexual violence [8]. High levels of child marriage and childhood pregnancy contribute to the health risks. Adolescent girls often prefer living in groups in overcrowded rooms over living with family in rural areas, as a way to escape the lack of voice and the overburden of household work [9]. Others live with their family, but are married off and become pregnant at a precocious age with increased risks of birth complications. In Uganda, 40% of adolescent girls is married by the age of 18 and in in India and Benin, early marriage is not declining, despite it being illegal [10, 11].

A systemic analysis of upstream political determinants of health service delivery for vulnerable groups is neglected in current health research. Informal settlements are often illegal, which means that local authorities do not recognise their inhabitants as citizens with legal entitlements. Thus, their right to access to public services, including health services, waste management and sanitation, is ignored. Delhi has 750 slum clusters. The Indian government only recognises two types of slums: legally recognised or “notified” slums and illegal informal settlements [12]. People living in notified slums experience less deprivation because of better access to public services [13]. In Kampala, slums take up one quarter of the total city area, housing 60% of the population. Forced eviction has led to mistrust of the municipal authorities. The latter relies on NGOs to provide adequate sanitation [14].

The fact that circumstances are dire for many does not mean that residents are passive nor that they powerless [15]. If effectively supported, adolescent girls can emerge as a powerful force for change and agency. In informal settlements, they are often part of informal networks of grassroot organisations, community leaders and community-based organisations. Informal leaders act as power brokers and link up to formal actors, such as local authorities, politicians and (international) NGOs, to obtain public goods for the slum communities. Such de facto governance arrangements have been labelled ‘webs of informal governance’ [9], ‘hybrid’ [16] or ‘real’ governance [17]. These authors refer to the emergence of specific accountability relationships in marginalized communities, which are best considered as accountability ecosystems: “complex systems of informal and formal accountability arrangements involving multiple actors with a wide range of roles, responsibilities and interactions across levels, from the transnational to the local level” [18]. More recently, such accountability practices are described as ‘organic’ [19].

Accountability interventions in health in low- and middle-income countries

In the last ten years, accountability has risen high on the global health agenda, where it has been interpreted as holding those in power to account. This began with the UN Secretary General’s Every Woman Every Child Campaign that put the spotlight on accountability as a way to improve maternal, neonatal and child health and address the disappointing results related to MDG 5 (the reduction of maternal mortality and access to reproductive health). However, the concept is quite nebulous and its application in global health is influenced by specific disciplinary perspectives and trends, including New Public Management, human rights and ethics [20].

In recent years, social accountability interventions have proliferated in LMIC [21, 22]. To influence the accountability ecosystem, two main routes have been followed [18]. First, civil society organisations have been demanding accountability on behalf of vulnerable, underserved groups (such as adolescent girls and young women, but also other vulnerable groups) through social mobilization, protest and public interest litigation. These oppositional strategies can be contrasted with consensus-oriented approaches that are primarily driven from within the health system and seek to establish a better dialogue between the communities and upstream (local government or state government) or downstream (district health managers, health service providers) actors in the health system. Participatory audit processes or citizen participation structures (eg. village health committees) are used to seek redress for wrongdoing in a collaborative manner. For instance, NGOs working on accountability in SRH in Uganda prefer consensus-oriented strategies, referring to reduced civic space and governmental repression and the influence of external donors’ preferences, although NGOs have used strategic litigation to address maternal mortality [23, 24]. In India, a mix of oppositional (eg. public interest litigation) and consensus-oriented strategies are being used to hold government and increasingly, private sector actors accountable [24,25,26]. Benin has a high teenage pregnancy rate and a high maternal mortality ratio. Interventions therefore focus on, by way of NGOs, girls’ empowerment to strengthen their voice on the one hand, and, on the other hand, supply-side interventions, such as the improvement of the quality of care through maternal audits. Recently, also, a more progressive abortion law was adopted in Benin, for which NGOs advocated [27,28,29].

Both oppositional and consensus-oriented strategies of accountability share the underlying assumption that better accountability would improve health system governance and thus lead to improved quality of care and health outcomes [30]. However, they are grounded in competing Western political theories (Mouffe’s agonistics [31] and Habermas’ consensual deliberation [32] respectively). The causal chains of these accountability strategies have rarely been empirically explored and compared in urban informal settlements in LMIC. Moreover, it is not clear which strategy works best in which political context, at which stage of the policy process and how (in terms of processes, underlying mechanisms and outcomes).

Research objectives

The overall objective of this study is to contribute to a better understanding of the causal chains underlying accountability in sexual and reproductive health for adolescent girls and young women living in urban informal settlements in LMIC. In line with the steps of the realist research cycle, which I discuss in the next section, I define the specific objectives as follows:

  1. (1)

    To develop the initial programme theory on accountability in sexual and reproductive health towards adolescent girls and young women living in informal settlements

  2. (2)

    To empirically test and refine the initial programme theory in four settings

  3. (3)

    To refine the programme theory that specifies the mechanisms and context conditions driving accountability towards adolescent girls and young women in informal settlements

  4. (4)

    To develop methodological guidance regarding realist research for complex problems with specific attention to the impact of local (political) context on intervention strategies

This study will contribute to the knowledge management strategies of the World Health Organization’s (WHO) Community of Practice on Accountability in Reproductive Health and the COPASAH global network, the community of practitioners on accountability and social action in health. It will connect endeavours of decontextualizing, synthesising and disseminating knowledge from local practitioners and local collective action to policy-making levels and practitioners in other settings.


I will adopt realist evaluation (RE), a research methodology grounded in scientific realism. Originally developed by Pawson and Tilley [33], it aims at answering not only the effectiveness question ‘does it work?’, but also the causal questions ‘how, why, in which conditions and for whom’. Realist evaluation is an approach that fits complex topics well [34]. It combines a realist ontology with a weak constructivist epistemology. Focusing on mechanistic causal explanation, RE considers that outcomes or events result from generative or emergent causal mechanisms that are triggered in certain contexts. Realist evaluation provides not only a methodology to develop, test and refine theory, but also to bolster comparative case study design.

RE studies start and end with theories. Its research cycle is aimed at theory-building (Fig. 1). So-called programme theories (PT) spell out how outcomes are expected to be attained, in which conditions (context) and how (mechanisms). These programme theories are to be refined through repeated empirical testing. The ultimate aim is to build a theory of the middle range on a particular social phenomenon. The middle range theory, a notion developed by Robert K. Merton, lies between macro-level ‘grand’ theories and context-specific narratives [35, 36].

Fig. 1
figure 1

The realist theory-building cycle, adapted from Marchal et al. [37]

In any explanation of social and political determinants of health inequities, context matters. Any social phenomenon to be empirically observed and subsequently explained by means of political and social determinants is set in a specific loco-temporal (place/time) context and any action is to be situated at a particular level or scale [38]. These context conditions are often only in part open to empirical observation, as they occurred prior to the actual data collection in case of retrospective research. Some of these context features and their impact can only be understood if their processes are traced back to events and processes in the past, and thus, outside immediate empirical observation [39, 40]. For example, if one wants to explain the social exclusion of current Muslim youth in urban India, one needs to go back to historical events and processes of formation of citizenship and state-Muslim community relations. Similarly, women’s protest for better care can only be adequately understood within the context of the emergence of the women’s rights movement in India in the 1970s. Social determinants research rarely focuses on these processes of social change and transformation, and if not explained, such studies can appear deterministic [40, 41].

In contrast with ‘traditional’ variable-based successionist causal explanation, dominant in research on determinants of health inequities, RE offers a case-based approach to examine causal relationships, exposing the generative mechanisms that explain how in specific conditions an intervention brings about an outcome (or not) [42]. By means of its emphasis on causal pathways or chains, in which actors’ agency and social structures interact to produce outcomes, RE is well-equipped to explore the intersecting vulnerabilities and the impact of context in this study. Intersecting vulnerabilities can indeed only be partially uncovered by the variable-based explanation in health determinants research [43].

My analytical strategy is inspired by the work of critical realist Margaret Archer. One of the key theoretical premises of realist research is that it analyses a stratified social reality, which consists of three layers: the empirical, which is observable and can be studied, the actual and the real [44]. In contrast to constructivist approaches, it distinguishes what is knowable (epistemology) from what really exists (ontology). Realism positions itself between positivism and constructivism. It has in common with constructivism that we can only gain partial knowledge of social phenomena (the empirical) from our own perspective or vantage point. Our position in the social world determines how we derive knowledge from it. Hence, we need to use a range of methodologies and tools from different disciplines to build theories on social phenomena and understand what is happening (ie. ‘the actual’), which is a reality outside of how we perceive people’s actual practices. To understand why a certain social phenomenon in a given context emerges, we need to refer to the ‘real’ layer. The ‘real’ is the domain where the interplay between social structures and human agency leads to causal mechanisms or powers generating the social practices in the actual realm [45].

To capture social practices in a given context and their effect on change, Archer developed an analytical framework [45] that fits our study approach well. The Structure-Culture-Agency (SAC) nexus is the core tenet of Archer’s frame, where “full significance is accorded to the timescale through which structure, culture and agency themselves emerge, intertwine and redefine one another, since this is the bedrock of the explanatory format employed in accounting for any substantive change in social form.” Archer uses a temporal analytical sequence to analyze the emergence of social change. In my study, I consider accountability as inherently relational and dynamic, with the potential to transform social reality or to perpetuate the status quo [46]. The interaction between social structure and agency is central to understanding what drives actors’ accountability practices. Formal governance arrangements as well as informal norms (Time 1—T1) are indicative of structure and culture and predate emergent accountability practices that are grounded in actors’ agency and collective agency (T2-T3) and are potentially transformative. T4 is the phase when social change occurs, improving responsiveness towards adolescent SRH needs in informal settlements, or not, when the governance system reverts to the status quo. Following Archer’s analytical framework, governance can be considered as embedded in structure and culture, predating the accountability practices we empirically observe. We thus need to apply a historical lens to the analysis of governance relations and accountability practices. These do not happen in a temporal vacuum: relationships and practices are dynamic and co-evolve with changes in context. For example, a grassroot organisation’s accountability strategy may have evolved from protest actions towards seeking consensus and collaboration with local authorities, dependent on the broader state-citizen context, the relationship with local authorities, changes in local political power and professionalization of the organisation or changes in the leadership of the organisation itself.

In realist research, context matters a lot. In applied research domains, such as health, outbreak control, education and implementation science overall, we are experiencing the “contextual” turn, a shift from context-aware to context-driven research that pays more attention to local contingencies. [47,48,49,50]. However, health researchers seem to have been grappling with ways to define context, and to use methods that go beyond the mere enumeration of political, social or cultural context factors [51]. Some research articles analysing contextual drivers or ‘macro-level factors’ in relation to tuberculosis and diabetes are a case in point [52,53,54]. Many, if not most such studies struggle to explain exactly why and how ‘context’ impacts on the study outcomes or results.

Health inequities research has focused on exposing the determinants of inequity, following the influential 2005 WHO Commission on the Social Determinants of Health. The focus on determinants, drivers or root causes remains highly influential and has been transposed to research zooming in on political determinants and drivers within the context of the Sustainable Development Goals and of reaching Universal Health Coverage [55, 56]. Also in this field, research that focuses on determinants, macro-factors or context drivers has been criticized for giving way to overtly deterministic thinking and not going much beyond stating that context conditions matter [51]. Such studies often present correlations between a context condition and a disease – for example the correlation between countries in conflict and leishmaniasis [57]. From a realist perspective, constant conjunction is no substitute for causation. Furthermore, such studies frequently do not provide the means to adjudicate why a certain context condition matters more than another, nor do they consider the complex interplay between structural conditions and agency. Even if the political context is mentioned as a structural determinant—collective action and agency, for example in the form of actions performed by civil society, grassroots- or community-based organisations, are often left out of the explanatory equation [45].

Next to the temporal dimension, one of the important dimensions of ‘context’ is evidently the geographical location, with ‘place’ often conveying a sense of meaning (including negative meanings) [58]. ‘Slums’, or, informal settlements as a study context illustrate this very well. For a long time, the term ‘slum’ was indicative of a negative urban planning discourse, with informal settlements considered solely in a pejorative sense as a ‘negative space’ in terms of governance and urban planning. In such discourse, there was nothing else one could do but to eradicate slums. Slum eradication, however, has nowadays, at least on paper, been replaced by a discourse of slum upgrading and urban informality and creativity [59,60,61]. Moreover, with the Covid-19 pandemic, authors have noted that the relative absence of local authorities in informal settlements or poor marginalised city areas does not mean that there is no health governance, as people tend to self-organise to access health services, installing handwashing stations or getting supplies delivered in the local hospital in the favela in Rio de Janeiro [62]. Governance in informal settlements does not automatically equate with a negative or empty space. To the contrary, it acts as an essential corollary to the ‘formal’ sphere: it is the informal governance relationships on which the formal world depends, and there are fluid boundaries between both spheres [63].

Below, I present the methods in relation to each step of the realist research cycle (Fig. 1), which starts and ends with theory [37]. Initial programme theories are refined through a process of accumulation of insights and evidence and specification of the findings. The end result is a programme theory which tells us how in certain context conditions, actors’ strategies might work or not work and why. I refer the reader to [64] for a succinct overview of the main principles and definition of terms used in RE. It should be noted that while I developed the study in response to a call for individual post-doctoral fellowships of the Flemish Fund for Scientific research (FWO), in each study country, one main researcher will lead a team of 2 to 3 junior researchers. They will be involved in data collection, data analysis and writing up of the findings.

Formulating the initial programme theory

The initial programme theory that is the starting point of this study builds upon previous research on accountability towards vulnerable groups in an urban and a rural local health system in Ghana [65]. That study concluded that public accountability towards the most vulnerable groups in urban and rural health systems needs to be enforced by the groups themselves through voice and collective action. Table 1 presents the narrative version of the resulting programme theory.

Table 1 The programme theory of the Ghana study [66]

In practice, the above programme theory will be refined on the basis of a review of accountability in sexual and reproductive health and rights [18], an ongoing realist review on adolescent digital empowerment strategies and accountability, and a review of the literature on access to adolescent-friendly services in informal settlements in LMIC.

The study design

Realist research is method-neutral, and the study design needs to enable testing of the initial programme theory. Understanding the context conditions for improved accountability towards adolescents living in poor urban neighbourhoods or informal settlements requires an in-depth understanding of the mechanisms underlying the observed practices and agency. A causal case study design allows for the study of social interaction and actors’ practices and the analysis of the underlying causal mechanisms and context conditions [67]. Causal case study methods have emerged in comparative politics, which has grown into a full sub-discipline [68,69,70].

In this study, the case is defined as accountability practices to enhance vulnerable adolescents’ sexual and reproductive health and overall well-being and empowerment. The study sites are informal settlements in Kampala (Uganda), Cotonou (Benin), and New Delhi and Mumbai (India), and more specifically urban poor neighbourhoods, where marginalised communities or groups reside. A layer of context that may be relevant at the meso-level is local urban governance, local political context and the history of grassroots organisations working with adolescents in urban poor neighbourhoods. In India, I included two different mega-cities, New Delhi and Mumbai, where different political parties are in power at the city- and state-level. Elements of the macro-political context, including the political system, and issues of democratic space, social inclusion and citizenship, will be captured through the differentiation between countries.

In each city, a grassroot organisation is selected as an entry point for fieldwork. These organisations work with and for adolescent girls and young women with intersecting vulnerabilities, such as belonging to a religious minority, gender, caste or poverty. They are active in poor urban neighbourhoods or informal settlements where these vulnerable groups reside.

This overall set-up represents different layers of context conditions, at the micro- (adolescents’ intersecting vulnerabilities), meso- (grassroot organisation) and macro- (political) level, as we assume that these play a role in accountability strategies and practices.

Data collection

Realist evaluation is method-neutral: any data collection method that yields data required to test the initial programme theory can be used.

The governance ecosystem

The governance ecosystem can be defined as the governance actors and the relationships that inform the actual governance arrangements and practices as they are operating in informal settlements. I will map both the formal and informal governance spheres.

To map the formal governance sphere, we will collect data through in-depth interviews with city- and local (health) authorities and representatives of local community-based organisations. We will also conduct a review of policy documents, with the aim of analysing relevant policy documents originating at different levels relevant to adolescent health and well-being, including the municipality and district / sub-district levels.

To map the informal governance sphere, we will use data collected through interviews with representatives of grassroot or community-based organisations, community or religious leaders, and informal middlemen. The latter are known to negotiate access to public services on behalf of vulnerable groups. We will also include local politicians, municipal administrators responsible for youth and / or adolescent health, youth leaders and staff of civil society organisations working with adolescents and young adults.

Finally, we will deepen the analysis by focusing on one grassroot organisation in each study site. We will map the governance relationships of the organisation, its (historical) relationships with stakeholders, and its context, including the informal settlement, the municipality, and the central and decentralized policy-making levels. To this end, we will carry out additional in-depth interviews and review the organisation’s documents and records.

Interview guides will be prepared for the interviews and the focus group discussions. In line with realist principles, the topics will be based on the initial programme theory, whereby for the adolescent girls, the focus will be on their experiences, their living conditions and their views on their health and rights. For the other respondents, the questions will probe for their views on and experience with accountability, their agency and their context, including the governance arrangements.

The accountability ecosystem

We will map the actual accountability practices, again using the grassroots organisation as entry point. The focus will be on self-organisation and emergent collective action to demand services through agonistic and/or consensus-building strategies [31, 32]. These strategies are based on different causal pathways and underlying mechanisms, such as trust and reciprocity, but also voice or neighbourhood solidarity. I will apply an adapted accountability mapping tool I developed in Ghana [71]. Local researchers will use in-depth interviews and focus group discussions to collect data on local accountability practices. The respondents will include the adolescents engaged in grassroots organisations, the leaders and volunteers of the organisations and other networks in the neighbourhood, community and religious leaders, and middlemen or women who negotiate access to services for vulnerable groups. [9, 66]. I will select adolescents who are willing to be interviewed from the focus group discussions.

Data analysis

In realist research, the context-mechanism-outcome configuration is used as the main heuristic for data analysis [33]. Given the multiple sources of potential methodological confusion [37], refining methods for realist analysis remains a priority.

In practice, we will analyse governance arrangements and accountability practices in 2 steps. First, we will qualify the formal and informal governance relationships with actionable governance terms such as ‘reports to’, ‘is formally accountable to’, ‘is informally accountable to’, ‘informs’, ‘monitors’, ‘supervises’, ‘funds’, etc. This method was piloted in the previous study on accountability in the urban health system in Ghana [65] and will be adapted considering qualifiers of the WHO Euro governance mapping tool [72]. Second, we will analyse and appraise the accountability practices and strategies (the accountability ecosystem), which includes analysing the formal mandates of actors and the intersectoral action related to adolescent health, answering the question: who is supposed to be accountable to whom? To analyse and appraise accountability practices, we will assess the actual practices in four dimensions: the social, political, organisational and service provision dimension. The results will be presented in spidergrams that present accountability according to these dimensions [65, 73]. A separate analytical tool will be designed to differentiate accountability practices in agonistic and consensus building strategies, and to assess the potential for transformative agency.

A context mapping tool will be designed to extract and analyse relevant context data from the in-depth interviews and focus group discussions. This tool will include temporal dimensions such as the evolution of the local governance context (eg. change in political power at city level; growth of grassroots organization) and place-based dimensions (including meaning / perceptions of different actors regarding the neighbourhood). The output of these steps will be thick descriptions of the case in each study site.

Based on the governance and accountability mapping and analysis, we will develop the most plausible explanations of the observed outcomes of accountability towards vulnerable girls and female adolescents in each site. In practice, this analysis starts with applying an adapted version of the heuristic tool commonly used in RE, which we call the ICAMO configuration (for Intervention-Context-Actors-Mechanism-Outcome), to the thick case descriptions. We use the ICAMO configuration instead of the CMO, as it stimulates the researcher to focus the analysis of the causal pathways on the actors. In this case, adolescents living in informal settlements should not be a priori considered to be a homogeneous group. Adding ‘Intervention’ to the heuristic helps in describing the actual interventions, policies, programmes, activities, etc. that shape the outcomes (or not) [74].

It is at this stage in realist research that the mechanisms are identified: mechanisms are the drivers of actors’ actions, generated under specific context conditions. In this study, they may include trust, social exchange, empowerment, voice, etc. For each site, I will identify and describe the salient context features that may influence how individual and collective action for accountability generates social change in the system or not.

The analysis results in ICAMO configurations, formulated in a narrative that includes the practices reflecting actors’ agency, and ‘if …, then …, because …’ clauses. We will use process-tracing techniques, developed in political science, as a means to verify the robustness of the causal inferences made in the ICAMOs. These include four main tests: smoking gun, hoop, double decisive and straw in the wind [75].


The last step of any realist study is the abstraction of the findings as represented in ICAMO configurations to the level of a refined programme theory. The in-case synthesis consists of comparing the ICAMO configuration(s) with the initial PT, whereby the latter is adapted: some clauses may be confirmed and others refuted, while for other parts, there may be no evidence for confirmation nor refutation. After step 4, we will have 4 programme theories, each resulting from empirical testing in one city.

The cross-case analysis allows for a more powerful refining of the initial programme theory. According to Beach and colleagues [67], mechanism-based methodologies such as realist research can benefit from causal case study comparison, which allows testing theories on a social phenomenon through the combination of within-case and cross-case analysis. There is, however, little guidance on how to combine within-case analysis and cross-case comparison. Our study, and all studies looking at complex, multi-level structure-agency interactions meant to generate social change, reflect the methodological issue of equifinality, where the same outcome can be reached by multiple pathways given different sets of context conditions. One of the ways to analyse across cases is Mill’s methods of agreement, through which an initial programme theory is revised by eliminating conditions and we will use it to disconfirm clauses in the initial PT as being a necessary cause [67]. We will do this by comparing the city-specific PTs against the initial PT and charting the different layers of context conditions as presented by the cases.


Since the publication of the seminal work of Pawson and Tilley in 1997, realist research has taken hold in applied research domains, such as education and health. However, several methodological questions remain. First, in my experience, researchers applying RE in public health tend to favour individual-level, cognitive-psychological mechanisms to the detriment of meso-level (team, organisation, network) and macro-level (social system) mechanisms [20, 75]. Second, methods to explore how social structure and agency mutually bring about change are under-developed. Third, there is little guidance on assessing the interaction between context and mechanism, on how to extract the salient features of multi-layered contexts, and on how to specify the temporal context in which causal mechanisms are expected to be triggered. With this study, I argue that innovative methodological developments from political science, most notably in terms of causal case study design and methods to strengthen causal inference, can be usefully combined to address some methodological challenges of doing realist research.

One of the key powers of realist evaluation, its focus on theory-building, has been left somewhat underused in global health research [76]. Most studies do not reach the stage of refining a programme theory that can be used by researchers as a starting point for a new theory-building cycle in other settings [49]. This may be due to the fact that realist evaluation, synthesis and review have been mainly applied within the context of health programme and project evaluations, and in PhD research in the field of health in LMIC. Short-term project funding often sets limitations to the duration and depth of studies. This study builds upon my previous research, indeed taking the end point of that study as the starting point for this study and will thus offer a second round of adaptation on the basis of the case studies in India, Benin and Uganda.

Finally, in terms of content, this study will contribute to refining the theories that underlie accountability for adolescents and their sexual and reproductive health and rights because of its focus on multi-level analysis: starting from accountability practices and their outcomes, I will analyse the meso- and macro-level to assess how context and individual and collective agency interact in shaping the causal pathways underlying accountability, an all too often neglected area with accountability research.

Ethical considerations

In this study, I recognise the vulnerability of the groups under study, in particular adolescents and young women of urban poor neighbourhoods who are engaged in the activities of the grassroots organizations [77].

I will place particular emphasis on:

  • Cultural sensitivity: The data collection methods will be aligned to the socio-cultural norms and preferences of people in their daily life and within organizational settings (for example, ensuring interviews with members of the grassroots organisations do not disrupt their activities unduly). The country research teams will be composed of well-experienced researchers with a long-standing expertise in research in the local political, cultural and social context.

  • Do no harm: Respondents will be well informed of their rights to withdraw from the study at any point in time and all efforts will be made to ensure that no discomfort or stress is experienced by respondents as a result of the research. This includes allowing respondents to choose their preferred location and time for interviews with care taken to ensure privacy to the greatest degree possible. Informed consent/assent, privacy and confidentiality, as well as respect for participants’ time will be prioritized. If needed, respondents who require psychological or other care will be referred to appropriate providers in consultation with the country research team members.

  • Confidentiality and non-attribution: I will adopt a privacy-by-design approach when designing data collection tools. Personal data will be processed according to the EU GDPR regulations. All data is to be encrypted and password protected with the use of secured software and servers for data storage. All measures are put in place to maximize confidentiality such as pseudonymization. Once transcripts are produced, audio files are to be destroyed.

  • Only the principal investigator and the country researchers will have access to raw data. All documents and audio recordings will be treated with the strictest confidence. The organizations and locations including the poor neighbourhoods and health and administrative districts where they work will be anonymized to ensure confidentiality of the respondents. All communication between the author and the country research teams will be done through an encrypted mail system. Reports will be compiled with the intention to protect the identity of respondents to the maximum while representing their views and opinions as accurately and fairly as possible.


The objective of this study is to contribute to a better understanding of the causal configurations underlying accountability in sexual and reproductive health for adolescent girls and young women in urban informal settlements in LMIC. The study adopts an interdisciplinary approach towards analysing how emergent local collective action impacts on accountability in a political context with entrenched inequities. It will also show how realist research could offer a way of dialogue and collaboration across and between different scientific disciplinary communities and how its analytical strategy can be enriched with methods from political science.

Availability of data and materials

Data sharing is not applicable to this protocol as no datasets were generated or analysed.



Adolescent sexual and reproductive health and rights


Context- -Mechanism-Outcome


Community of Practitioners on Accountability and social Action in Health


Fonds voor Wetenschappelijk Onderzoek (fund for scientific research)




Low-and middle-income countries


Millennial Development Goal


Non-governmental organisation


Programme theory


Realist evaluation


Sexual and reproductive health


United Nations


World Health Organization


  1. United Nations, World Urbanization Prospects: The 2018 Revision. 2018, Geneva, Switzerland: Population Division of the Department of Economic and Social Affairs of the United Nations.

  2. Swahn MH, LeConté JD, Palmier JB, Kasiyere R. Girls and Young Women Living in the Slums of Kampala: Prevalence and Correlates of Physical and Sexual Violence Victimization. SAGE Open. 2015:1–8.

  3. Renzaho AMN, Kamara JK, Georgeou N, Kamanga G. Sexual, reproductive health needs, and rights of young people in slum areas of Kampala, Uganda: a cross sectional study. Plos One. 2017;12(1).e0169721.

  4. Pommells M.S.-W, Watt C, C Mulawa Z. Gender violence as a water, sanitation, and hygiene risk: uncovering violence against women and girls as it pertains to Poor WaSH access in violence against women. Violence against women. 2018;24(15):1851–62.

    PubMed  Google Scholar 

  5. Caruso BA, Clasen TF, Hadley C, Yount KM, Haardörfer R, Rout M, Dashmopatra M, Cooper HL. Understanding and defining sanitation insecurity: women's gendered experiences of urination, defecation and menstruation in rural Odisha, India. BMJ Global Health. 2017;9(2(4)):11.

  6. Sommer M, Ferron S, Cavill S, House S. Violence, gender and WASH: spurring action on a complex, under-documented and sensitive topic. Environ Urban. 2015;27(1):105–16.

    Google Scholar 

  7. Winter S, Dzombo MN, Barchi F. Exploring the complex relationship between women’s sanitation practices and household diarrhea in the slums of Nairobi: a cross-sectional study. BMC Infect Dis. 2019;19(242):13.

  8. Yadhav A, Weitzman A, Smith-Greenaway E. Household sanitation facilities and women’s risk of non- partner sexual violence in India. BMC Public Health. 2016;16(1139):10.

    Google Scholar 

  9. Stacey P. State of Slum. Precarity and Informal Governance at the Margins in Accra. London: Zed Books; 2019.

    Google Scholar 

  10. UNICEF. Ending child marriage and teenage pregnancy in Uganda, A Formative research to guide the implementation of the natioonal strategy on ending child marriage and teenage pregnancy in Uganda. Final report. Kampala: United Nations Children's Fund Uganda Office; 2015. p. 140.

  11. Batyra E, Pesando LM. Trends in child marriage and new evidence on the selective impact of changes in age-at-marriage laws on early marriage. SSM - Population Health. 2021;14(100811):12.

    Google Scholar 

  12. Krishna A, Sriram MS. Prakash, P, Slum types and adaptation strategies: identifying policy-relevant differences in Bangalore. Environ Urban. 2014;26(2):568–85.

    Google Scholar 

  13. Nolan A. Holding non-state actors to account for constitutional economic and social rights violations: Experiences and lessons from South Africa and Ireland. Int J Cons Law. 2014;12(1):61–93.

    Google Scholar 

  14. Richmond A, Myers I, Namuli H. Urban Informality and Vulnerability: A Case Study in Kampala, Uganda. Urban Science. 2018;2(22):13.

  15. Corburn J, Karanja I. Informal settlements and a relational view of health in Nairobi, Kenya: sanitation, gender and dignity. Health Promot Int. 2016;31(2):258–69.

    PubMed  Google Scholar 

  16. Meagher K, De Herdt T, Titeca K. Unravelling public authority. Paths of hybrid governance in Africa, in Rsearch Series, I. /IDPM, Editor. 2014: Antwerp.

  17. de Sardan O, Pierre J, De Herdt T. eds. Real Governance and Practical Norms in Sub Sahara Africa. Routledge: London: The game of the rules2017. 

  18. Van Belle S, Boydell V, George AS, Brinkerhoff DW, Khosla R. Broadening understanding of accountability ecosystems in sexual and reproductive health and rights: a systematic review. Plos One.  2018;13(5):e0196788.

  19. De Kok BC. Between orchestrated and organic: accountability for loss and the moral landscape of childbearing in Malawi. Soc Sci Med. 2019;220:441–9.

    PubMed  Google Scholar 

  20. Van Belle S. What can we learn on public accountability from non-health disciplines – a meta-narrative review. BMJ Open. 2014;6(7):12.

    Google Scholar 

  21. Joshi A, Houtzager PP. Widgets or Watchdogs? Conceptual Explorations in Social AccountabilityPublic Management Review. 2012;145–62.

  22. Sen G, Iyer A, Chattopadhyay S, Khosla R. When accountability meets power: realizing sexual and reproductive health and rights. Int J Equity Health. 2020;19(111):11.

    Google Scholar 

  23. Balestra G.L, Pinto E.P. Social accountability in health in East and Southern Africa. Practitioners’ perspectives of trends, strengths, challenges and opportunities in the field, COPASAH), Editor. New Delhi: Centre for Health and Social Justice; 2018.

    Google Scholar 

  24. Dunn JT, Lesyna K, Zaret A. The role of human rights litigation in improving access to reproductive health care and achieving reductions in maternal mortalityBMC Pregnancy Childbirth2017;17(367):71–83.

  25. Mecwan S, Sheth M, Khanna R. Enhancing social accountability through adolescent and youth leadership: a case study on sexual and reproductive health from Gujarat. India Gender and Development. 2021;29(1):159–61.

    Google Scholar 

  26. Priyadarshi M.K. S. Accountability in Healthcare in India. Indian J Comm Med. 2020;45:125–9.

    Google Scholar 

  27. Salifou K, Obossou AAA, Sidi RL, Hounkpatin B, Komogui D, Adisso S. Perrin, R.X., Audit of management of immediate postpartum hemorrhages in Parakou (Benin). Clinics in Mother and Child Health. 2015;12(173).

  28. Faye AC, Houssou R. Légalisation de l'avortement au Bénin: le débat continue, 6 questions pour comprendre. BBC News Afrique. 2021

  29. Saizonou J, Ouendo EM, Dujardin B. Maternal Deaths Audit in Four Benin Referral Hospitals: Quality of Emergency Care, Causes and Contributing FactorsAfr J Reprod Health. 2006;10(3):28–40.

  30. Genovese U, Del Sordo S, Pravettoni G, Akulin IM, Zoja E, Casali M. A new paradigm on health care accountability to improve the quality of the system: four parameters to achieve individual and collective accountability. J Global Health. 2017;7(1):010301.

  31. Agonistics Mouffe C. Thinking the World Politically. New York: Free Press; 2013.

    Google Scholar 

  32. Habermas J. The Theory of Communicative Action Volume 2: Lifeworld and System. a critique of functionalist reason. Boston: Beacon Press; 1987.

    Google Scholar 

  33. Pawson R, Tilley N. Realistic Evaluation. London: Sage; 1997.

    Google Scholar 

  34. Westhorp G. Using complexity-consistent theory for evaluating complex systems. Evaluation. 2012;18(4):405–20.

    Google Scholar 

  35. Merton RK. On sociological theories of the middle range, in Classical Sociological Theory, C. Calhoun, Gerteis J, Moody J, Pfaff S, Virk I, Editor. Oxford: Blackwell; 1949. p. 448–58.

  36. Kaidesoja T. A dynamic and multifunctional account of middle range theories. Br J Sociol. 2019;70(4):1469–89.

    PubMed  Google Scholar 

  37. Marchal B, Van Belle S, Van Olmen J, Hoerée T, Kegels G. Is realist evaluation keeping its promise? A literature review of methodological practice in health systems research. Evaluation. 2012;18(2):192–212.

    Google Scholar 

  38. Termeer CJAM, Dewulf A, van Lieshout M. Disentangling scale approaches in Governance Approaches: Comparing Monocentric, Multilevel and Adaptive Governance. Ecol Soc. 2010;15(4):29.

    Google Scholar 

  39. Tilly C. Why and how history matters, in Oxford Handbook of Contextual Political Analysis. Goodin RE, Tilly C. Editor. Oxford: Oxford University Press; 2006.

  40. Braun V, Clarke V. The Ebbs and Flows of Qualitative Research. Time, change and the slow wheel of interpretation, in Temporality in Qualitative Inquiry. Theories, Methods and Practices. Clift BC, Gore J, Gustaffson S, Bekker S, Battle IC, Hatchard J, Editor. London: Routledge; 2021.

  41. Sharma M, Pinto AD, Kumagai AK. Teaching the Social Determinants of Health: A Path to Equity or a Road to Nowhere?. Academic Medicine. 2018;93(1).

  42. King G, Keohane RO, Verba S. Designing social inquiry. Scientific inference in qualitative research. Princeton: Princeton University Press; 1994.

  43. Westhorp G. Complexity-consistent theory in a realist investigation. Evaluation. 2013;19(4):364–82.

    Google Scholar 

  44. Archer M.S. Realist Social Theory. Cambridge: Cambridge University Press; 1995.

    Google Scholar 

  45. Archer MS. The Morphogenetic Approach; Critical Realism’s Explanatory Framework Approach, in Agency and Causal Explanation in Economics. Virtues and Economics. Rona P, Zsolnai L, Editor. Cham: Springer; 2020.

  46. Moncrieffe J. Relational accountability. Complexities of Structural Injustice. London: Zed Books; 2011. p. 195.

    Google Scholar 

  47. May CR, Johnson M, Finch T. Implementation, context and complexity. Implementation Science. 2016;11(141).

  48. Harris J. Why context matters;: a comprative perspective on education reform and policy implementation. Educ Res Policy Pract. 2018;17:195–207.

    Google Scholar 

  49. Pozzoni G, Kaidesoja T. Context in Mechanism-Based Explanation. Philosophy of the Social Sciences. 2021;51(6):523–54.

    Google Scholar 

  50. Richards P, Mokuwa GA, Vandi A, Mayhew SH, Ebola Gbalo Research Team. Re-analysing Ebola spread in Sierra Leone: The importance of local social dynamics. PlosOne. 2020;15(11);18.

  51. Krumeich A, Meershoek A. Health in global context: beyond the social determinants of health? Global Health Action. 2013;7(1):8.

    Google Scholar 

  52. Adu PA, Spiegel JM, Yassi A. Towards TB elimination: how are macro-level factors perceived and addressed in policy initiatives in a high burden country? Globalization and Health. 2021;17(11):11.

    PubMed  PubMed Central  Google Scholar 

  53. Banasiak K, Hux J, Lavergne C, Luk J, Sohal P, Paty B. Facilitating barriers: Contextual factors and self- management of type 2 diabetes in urban settings. Health Place. 2020;61(102267).

  54. Cannon LAL, Kelechi EO, Ter Goon D. Socio-economic drivers of drug-resistant tuberculosis in Africa: a scoping review. BMC Public Health. 2021;21(488):8.

  55. Kittelsen SK, Fukuda-Parr S, Storeng KT. Editorial: the political determinants of health inequities and universal health coverage. Globalization and Health. 2019;15(73).

  56. Mackenbach JP. Political determinants of health. Eur J of Public Health. 2014;24(1):2.

    Google Scholar 

  57. Berry I, Berrang-Ford L. Leishmaniasis, conflict, and political terror: A spatio-temporal analysisSoc Sci Med. 2016;140–9.

  58. Bin Wong R. Detecting the Significance of Place, in Oxford Handbook of Contextual Political Analysis. Goodin RE, Tilly C, Editor. Oxford: Oxford University Press; 2013.

  59. Arabindoo P. Beyond the return of the slum: an introduction. City. 2011;15(6):631–5.

    Google Scholar 

  60. Roy A. Urban Informality.Towards an epistemology of planning. J Am Plann Assoc. 2007;71(2):147–58.

    Google Scholar 

  61. MacFarlane C. Rethinking Informality: Politics, Crisis and the City. Planning Theory & Practice. 2012;13(1):89–108.

    Google Scholar 

  62. Van Belle S, Affun-Adegbulu C, Soors W, Prashanth N. Srinivas, Hegel G, Van Damme W, Saluja D, Abeijirinde E, Wouters E, Masquillier C, Tabana H, Chenge F, Polman K, Marchal B. Covid-19 and informal settlements: an urgent call to rethink urban governance. Int J Equity Health. 2020;19(81):2.

  63. Sheng Y.K, Brown A. Prosperity for all: Enhancing the informal economy through participatory slum upgrading. Cardiff: UNHabitat / Cardiff University; 2018. p. 41.

    Google Scholar 

  64. Van Belle S, Wong G, Westhorp G, Pearson M, Rmmel N, Manzano A, Marchal B. Can, “realist” randomised controlled trials be genuinely realist? Trials. 2016;17(313):6.

    Google Scholar 

  65. Van Belle S, Mayhew SH. Public accountability needs to be enforced – a case study of the governance arrangements and accountability practices in a rural health district in Ghana. BMC Health Serv Res. 2016;16(258):14.

  66. Van Belle S. Accountability in Sexual and Reproductive Health. How relations between INGOs and state actors shape public accountability. a study of two local health systems in Ghana, London School of Hygiene and Tropical Medicine. London: University of London; 2014.

    Google Scholar 

  67. Beach D.R, Pedersen R.P. Causal case study methods. Foundations for Comparing, Matching and Tracing. Ann Arbor: University of Michigan Press; 2016.

    Google Scholar 

  68. Faletti TG, Lynch JF. Context and Causal Mechanisms in Political Analysis. Comparative Political Studies. 2009;42:1143–66.

    Google Scholar 

  69. Baumgartner F.R., Jones B.D., Wilkerson J. Comparative political studies of policy dynamics. Comp Pol Stud. 2011;44(8):947–72.

    Google Scholar 

  70. Mahoney J, Thelen KA. Explaining Institutional Change: Ambiguity, Agency and Power. Cambridge: Cambridge University Press; 2009.

    Google Scholar 

  71. Van Belle S, Mayhew SH. Public accountability needs to be enforced – a case study of the governance arrangements and accountability practices in a rural health district in GhanaBMC Health Serv Res. 2016;16(568):14.

  72. Tilioune A, Kosinska M, Schröder-Bäck P. Tool for mapping governance for health and well-being: the organigraph method. Copenhagen, Denmark: WHO Regional Office for Europe; 2018. p. 18.

    Google Scholar 

  73. Van Belle S. What can we learn on public accountability from non-health disciplines? A meta-narrative review. BMJ Open. 2016;6(7):12.

    Google Scholar 

  74. Marchal B, Kegels G, Van Belle S. Theory and realist methods, in Doing Realist Research. G.J. Emmel N, Manzano A, Editor. London: Sage Publications; 2018. p. 79–90.

  75. Beach D.R.P., Process Tracing Methods. Foundations and Guidelines. Ann Arbor. Michigan: University of Michigan Press; 2019.

    Google Scholar 

  76. Marchal B, Kegels G, Van Belle S. Theory and Realist Methods. In: Emmel N, Dalkin S, Manzano A, Greenhalgh J, Monaghan M, editors. Doing Realist Research. London: Sage; 2018. p. 79–90.

    Google Scholar 

  77. Liamputtong P. Researching the Vulnerable. A Guide to Sensitive Research Methods. London: Sage; 2006.

    Google Scholar 

Download references

About this supplement

This article has been published as part of International Journal for Equity in Health Volume 21 Supplement 1 2022: Social accountability and sexual and reproductive health—Implications for Research and Practice. The full contents of the supplement are available at


This research is supported by the Research Foundation—Flanders (FWO) senior postdoctoral fellowship 1221821 N and the Belgian Directorate-General for Development Cooperation and Humanitarian Aid (DGD). The publication costs of his paper were supported by the FWO grant.

Author information

Authors and Affiliations



SVB conceptualised and designed the study, wrote the study protocol and the manuscript and submitted the final manuscript. The author(s) read and approved the final manuscript.

Corresponding author

Correspondence to Sara Van Belle.

Ethics declarations

Ethics approval and consent to participate

The study was approved by the Institutional Review Board of the Institute of Tropical Medicine (protocol for India: 1486/21 and for Uganda and Benin: 1496/21), the ethics review board of the Uganda National Council for Science and Technology (SS1032ES), the SEHER ethics review committee (India), and the Benin Parakou University Comité Local d’Ethique pour la Recherche Biomédicale (0468/CLERB-UP/SP/R/SA).

Consent for publication


Competing interests

The author declares she has no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Van Belle, S. At the interface between the formal and informal, the actual and the real: a realist study protocol for governance and accountability practices in urban settings focusing on adolescent sexual and reproductive health and rights. Int J Equity Health 21, 40 (2022).

Download citation

  • Accepted:

  • Published:

  • DOI:


  • Accountability
  • Local governance
  • Sexual and reproductive health and rights
  • Urban health
  • Local health system
  • Realist evaluation