Broadening understanding of accountability ecosystems in sexual and reproductive health and rights: A systematic review

The impact of community and provider-driven social accountability interventions on contraceptive use: findings from a cohort study of new users in Ghana and Tanzania

BACKGROUND

Although contraceptive use has increased over 15 years, discontinuation rates remain high. Contraceptive use is becoming more important when addressing unmet need for family planning. Social accountability, defined here as collective processes for holding duty bearers to account for their actions, is a rights-based participatory process that supports service provision and person-centred care, as well as, informed decision-making among community members regarding their health. A study implemented in Ghana and Tanzania was designed to understand and evaluate how social accountability and participatory processes influences quality of care and client satisfaction and whether this results in increased contraceptive uptake and use. We report here on the relationship between social accountability and the use of modern contraceptives, i.e., contraceptive method discontinuation, contraceptive method switching, and contraceptive discontinuation.

METHODS

As part of Community and Provider driven Social Accountability Intervention (CaPSAI) Project, a cohort of women aged 15 to 49 years who were new users of contraception and accessing family planning and contraceptives services at the study facilities across both intervention and control groups were followed-up over a 12-month period to measure changes contraceptive use.

RESULTS

In this cohort study over a one-year duration, we did not find a statistically significant difference in Ghana and Tanzania in overall method discontinuation, switching, and contraceptive discontinuation after exposure to a social accountability intervention. In Ghana but not in Tanzania, when stratified by the type of facility (district level vs. health centre), there were significantly less method and contraceptive discontinuation in the district level facility and significantly more method and contraceptive discontinuation in the health centres in the intervention group. In Ghana, the most important reasons reported for stopping a method were fear of side-effects, health concerns and wanting to become pregnant in the control group and fear of side-effects wanting a more effective method and infrequent sex in the intervention group. In Tanzania, the most important reasons reported for stopping a method were fear of side-effects, wanting a more effective method, and method not available in the control group compared to wanting a more effective method, fear of side-effects and health concerns in the intervention group.

CONCLUSIONS

We did not demonstrate a statistically significant impact of a six-month CaPSAI intervention on contraceptives use among new users in Tanzania and Ghana. However, since social accountability have important impacts beyond contraceptive use it is important consider results of the intermediate outcomes, cases of change, and process evaluation to fully understand the impact of this intervention.

TRIAL REGISTRATION

The CaPSAI Project has been registered at Australian New Zealand Clinical Trials Registry (ACTRN12619000378123, 11/03/2019).

A Realist-Informed Review of Digital Empowerment Strategies for Adolescents to Improve Their Sexual and Reproductive Health and Well-being

The use of digital technologies for health has been rapidly gaining ground in the last decade, including as a strategy to empower adolescents living in urban resource-constrained settings. Nevertheless, unclarity and incoherence remain regarding which programme strategies generate which outcomes, as well as regarding the importance of context. We set out to answer the question "How do digital empowerment strategies work to improve adolescent health and well-being?". We conducted a realist-informed review, the first on this subject matter to our knowledge. The realist methodology is geared towards the understanding of socially complex interventions, such as digital empowerment. We synthesized the data into a programme theory uncovering social mechanisms and context conditions underlying specific programme strategies. We found that digital technologies enlarge the space for adolescents to access information to health services on their own terms and provide anonymity, which leads to a sense of safety if access is not curbed by gatekeepers. If adolescents have access to information adapted to their needs, they will be able to make informed decisions, and this will contribute to improved health outcomes because their better understanding enlarges their sense of individual agency. We identified two main gaps in the literature on digital interventions for adolescents. Both are related to an under-theoretisation of the concepts the programmes rely on in implementation: (1) the urban environment the programme has to operate in and its meaning for the adolescents; (2) the socio-developmental stage of the adolescents the programmes work in.

The role of blogs in restoring the self-integrity of women victims of intimate partner sexual violence

Purpose

This paper aims to identify the role of blogs in helping women victims of intimate partner sexual violence to restore their self-integrity.

Design/methodology/approach

The authors’ research uses an interpretive stance, supported by motivational and “self” theories to analyze 33 blogs reporting the experiences of women in Brazil who suffered sexual violence perpetrated by an intimate partner.

Findings

This study identifies the reasons why women who suffer violence from intimate partners write blog posts. It also develops an analytical framework that bridges the gap between the design and use of IT-artifacts and the context of sexual violence from an intimate partner. Women who suffer violence from intimate partners look for blogs in order to find a safe space for expression, a knowledge hub and a social support network. Blogs play a pivotal role in supporting the journey of reconstructing their self-integrity.

Research limitations/implications

The results help to understand the role of blogs in helping victims in vulnerable situations trying to restore their self-integrity. It also contributes to improve the design and functionality of such platforms as an important resource for social support networks.

Practical implications

This study shows the positive impact of blogs as a tool to support victims in the process of restoring their self-integrity.

Social implications

This study aims to promote the use of digital artifacts such as blogs as a complementary instrument to fight violence against women.

Originality/value

The analytical framework used in this paper helps to understand the role of IT-artifacts in the context of sexual violence from an intimate partner.

Social Accountability Reporting for Research (SAR4Research): checklist to strengthen reporting on studies on social accountability in the literature

BACKGROUND

An increasing number of evaluations of social accountability (SA) interventions have been published in the past decade, however, reporting gaps make it difficult to summarize findings. We developed the Social Accountability Reporting for Research (SAR4Research) checklist to support researchers to improve the documentation of SA processes, context, study designs, and outcomes in the peer reviewed literature and to enhance application of findings.

METHODS

We used a multi-step process, starting with an umbrella review of reviews on SA to identify reporting gaps. Next, we reviewed existing guidelines for reporting on behavioral interventions to determine whether one could be used in its current or adapted form. We received feedback from practitioners and researchers and tested the checklist through three worked examples using outcome papers from three SA projects.

RESULTS

Our umbrella review of SA studies identified reporting gaps in all areas, including gaps in reporting on the context, intervention components, and study methods. Because no existing guidelines called for details on context and the complex processes in SA interventions, we used CONSORT-SPI as the basis for the SAR4Research checklist, and adapted it using other existing checklists to fill gaps. Feedback from practitioners, researchers and the worked examples suggested the need to eliminate redundancies, add explanations for items, and clarify reporting for quantitative and qualitative study components.

CONCLUSIONS

Results of SA evaluations in the peer-reviewed literature will be more useful, facilitating learning and application of findings, when study designs, interventions and their context are described fully in one or a set of papers. This checklist will help authors report better in peer-reviewed journal articles. With sufficient information, readers will better understand whether the results can inform accountability strategies in their own contexts. As a field, we will be better able to identify emerging findings and gaps in our understanding of SA.

Accounting for complexity - Intervention design in the context of studying social accountability for reproductive health

Background: Social accountability interventions aim to propel change by raising community voices and holding duty bearers accountable for delivering on rights and entitlements. Evidence on the role of such interventions for improving community health outcomes is steadily emerging, including for sexual and reproductive health and rights (SRHR). However, these interventions are complex social processes with numerous actors, multiple components, and a highly influential local context. Unsurprisingly, determining the mechanisms of change and what outcomes may be transferable to other similar settings can be a challenge. We report our methodological considerations to account for complexity in a social accountability intervention exploring contraceptive uptake and use in Ghana and Tanzania. Main Body: The Community and Provider driven Social Accountability Intervention (CaPSAI) study explores the relationship between a health facility-focused social accountability intervention and contraceptive service provision in two countries. This 24-month mixed-method quasi-experimental study, using an interrupted time series with a parallel control group, is being undertaken in 16 sites across Ghana and Tanzania in collaboration with local research and implementation partners. The primary outcomes include changes in contraceptive uptake and use. We also measure outcomes related to current social accountability theories of change and undertake a process evaluation. We present three design components: aspects of co-design, 'conceptual' fidelity, and how we aim to track the intervention as 'intended vs. implemented' to explore how the intervention could be responsive to the embedded routines, local contextual realities, and the processual nature of the social accountability intervention. Conclusions: Through a discussion of these design components and their rationale, we conclude by suggesting approaches to intervention design that may go some way in responding to recent challenges in accounting for social accountability interventions, bearing relevance for evaluating health system interventions.

Accounting for complexity – Intervention design in the context of studying social accountability for reproductive health

Background: Social accountability interventions aim to propel change by raising community voices and holding duty bearers accountable for delivering on rights and entitlements. Evidence on the role of such interventions for improving community health outcomes is steadily emerging, including for sexual and reproductive health and rights (SRHR). However, these interventions are complex social processes with numerous actors, multiple components, and a highly influential local context. Unsurprisingly, determining the mechanisms of change and what outcomes may be transferable to other similar settings can be a challenge. We report our methodological considerations to account for complexity in a social accountability intervention exploring contraceptive uptake and use in Ghana and Tanzania.

Main Body: The Community and Provider driven Social Accountability Intervention (CaPSAI) study explores the relationship between a health facility-focused social accountability intervention and contraceptive service provision in two countries. This 24-month mixed-method quasi-experimental study, using an interrupted time series with a parallel control group, is being undertaken in 16 sites across Ghana and Tanzania in collaboration with local research and implementation partners. The primary outcomes include changes in contraceptive uptake and use. We also measure outcomes related to current social accountability theories of change and undertake a process evaluation.

We present three design components: aspects of co-design, ‘conceptual’ fidelity, and how we aim to track the intervention as ‘intended vs. implemented’ to explore how the intervention could be responsive to the embedded routines, local contextual realities, and the processual nature of the social accountability intervention.

Conclusions: Through a discussion of these design components and their rationale, we conclude by suggesting approaches to intervention design that may go some way in responding to recent challenges in accounting for social accountability interventions, bearing relevance for evaluating health system interventions.

Building social accountability to improve reproductive, maternal, newborn and child health in Nigeria

Background

Like many places in Nigeria, Niger, a predominantly rural and poor state in the north of the country, has high fertility, low contraceptive prevalence, and high maternal mortality. This paper presents a descriptive, contextualized case study of a social accountability campaign run by the nongovernmental organization White Ribbon Alliance Nigeria to strategically mobilize collective action to demand quality maternal health care and improve government responsiveness to those demands. We treat maternal health as a component of reproductive health, while recognizing it as a less contested area.

Methods

Data come from more than 40 interviews with relevant actors in Niger State in 2017 and 2018 during the initial phase of the campaign, and follow-up interviews with White Ribbon Alliance Nigeria staff in 2019 and 2021. Other data include White Ribbon Alliance Nigeria’s monthly reports. We analyzed these data both deductively and inductively using qualitative techniques.

Results

During its first phase, the campaign used advocacy techniques to convince the previously reticent state government to engage with citizens, and worked to amplify citizen voice by hosting community dialogues and town halls, training a cadre of citizen journalists, and shoring up ward health development committees. Many of these efforts were unsustainable, however, so during the campaign’s second phase, White Ribbon Alliance Nigeria worked to solidify state commitment to durable accountability structures intended to survive beyond the campaign’s involvement. Key challenges have included a nontransparent state budget release process and the continued need for significant support from White Ribbon Alliance Nigeria.

Conclusion

These findings reveal the significant time and resource inputs associated with implementing a strategic social accountability campaign, important compromises around the terminology used to describe “accountability,” and the constraints on government responsiveness posed by unrealistic budgeting procedures. The campaign’s contributions towards increased social accountability for maternal health should, however, also benefit accountability for reproductive health, as informed and empowered woman are better prepared to demand health services in any sector.

Social accountability and health systems' change, beyond the shock of Covid-19: drawing on histories of technical and activist approaches to rethink a shared code of practice

BACKGROUND

Recognition of the value of "social accountability" to improve health systems performance and to address health inequities, has increased over the last decades, with different schools of thought engaging in robust dialogue. This article explores the tensions between health policy and systems research and practice on the one hand, and health equity-focussed activism on the other, as distinct yet interacting processes that have both been impacted by the shock effects of the Covid-19 pandemic. This extended commentary brings multidisciplinary voices seeking to look back at health systems history and fundamental social-institutional systems' behaviors in order to contextualize these current debates over how best to push social accountability efforts forward.

ANALYSIS

There is a documented history of tension between long and short processes of international health cooperation and intervention. Social accountability approaches, as a more recent strategy to improve health systems performance, intersect with this overarching history of negotiation between differently situated actors both global and local on whether to pursue sustained, slow, often community-driven change or to focus on rapid, measurable, often top-down interventions. Covid-19, as a global public health emergency, resulted in calls for urgent action which have unsurprisingly displaced some of the energy and aspiration for systemic transformation processes. A combination of accountability approaches and mechanisms have their own legitimacy in fostering health systems change, demanding collaboration between those that move both fast and slow, top-down and bottom-up.

CONCLUSION

We argue that social accountability, much like all efforts to strengthen health systems, is "everybody's business" and that we must understand better the historical processes that have shaped the field of practice over time to move forward. These differences of perspective, knowledge-base and positioning vis-a-vis interventions or longer-term political commitment should not drive a conflict of legitimacy but instead be named, subsequently enabling the development of a shared code of conduct that applies to the breadth of actors involved in social accountability work. If we are concerned about the state of/status of social accountability within the context of "building back better" we must approach collaboration with a willingness to create dialogue across distinct disciplinary, technical and politically-informed ways of working.

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

BACKGROUND

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.

METHODS

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.

DISCUSSION

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.

Accountability in AI: From principles to industry-specific accreditation

Recent AI-related scandals have shed a spotlight on accountability in AI, with increasing public interest and concern. This paper draws on literature from public policy and governance to make two contributions. First, we propose an AI accountability ecosystem as a useful lens on the system, with different stakeholders requiring and contributing to specific accountability mechanisms. We argue that the present ecosystem is unbalanced, with a need for improved transparency via AI explainability and adequate documentation and process formalisation to support internal audit, leading up eventually to external accreditation processes. Second, we use a case study in the gambling sector to illustrate in a subset of the overall ecosystem the need for industry-specific accountability principles and processes. We define and evaluate critically the implementation of key accountability principles in the gambling industry, namely addressing algorithmic bias and model explainability, before concluding and discussing directions for future work based on our findings.

Social accountability as a strategy to promote sexual and reproductive health entitlements for stigmatized issues and populations

Social accountability is often put forward as a strategy to promote health rights, but we lack a programmatic evidence base on if, when, and how social accountability strategies can be used to promote access to quality Sexual and Reproductive Health (SRH) care for stigmatized populations and/or stigmatized issues. In this Commentary, we discuss the potential advantages and disadvantages of social accountability strategies in promoting the availability of a full range of SRH services for excluded and historically oppressed populations. We accomplish this by describing four programs that sought to promote access to quality SRH care for stigmatized populations and/or stigmatized services. Program implementers faced similar challenges, including stigma and harmful gender norms among providers and communities, and lack of clear guidance, authority, and knowledge of Sexual and Reproductive Health and Rights (SRHR) entitlements at local level. To overcome these challenges, the programs employed several strategies, including linking their strategies to legal accountability, budgetary expenditures, or other institutionalized processes; taking steps to ensure inclusion, including through consultation with excluded or stigmatized groups throughout the program design and implementation process; specific outreach and support to integrating marginalized groups into program activities; and the creation of separate spaces to ensure confidentiality and safety. The program experiences described here suggest some general principles for ensuring that social accountability efforts are inclusive both in terms of populations and issues addressed. Further empirical research can test and further flesh out these principles, and deepen our understanding of context.

Necessary but not sufficient: a scoping review of legal accountability for sexual and reproductive health in low-income and middle-income countries

Background

This paper is a scoping review of the impact of legal accountability efforts for sexual and reproductive health and rights (SRHR), exploring the links between legal accountability strategies and changes in the desired SRHR outcomes.

Methods

We defined legal accountability as use of the judicial system following state failure to respect, protect or fulfil SRHR as enshrined in national law, as well as individuals’ or the state’s use of criminal law mechanisms to prevent unwanted behaviour and to provide remedy. We undertook a keyword search in PubMed, Scopus and LexisNexis and then consulted a group of experts to provide guidance regarding further peer-reviewed and grey literature, yielding a total of 191 articles.

Results

The majority of the empirical, peer-reviewed articles identified were regarding abortion law and abortion care availability, followed by violence against women. Most of these articles explore the gaps between law and practice. We identified seven key factors that shape the efficacy of legal accountability efforts, including the ways a law or court decision is formulated, access to courts, the (dis)advantages of criminal law in the given context, cultural norms, politics, state capacity and resources and the potential for further litigation. Many articles explained that use of the judiciary may be necessary to effect change and that the act of claiming rights can empower, but that legal avenues for change can be imperfect tools for justice.

Conclusions

Legal accountability can be effective as part of a broader, long-term strategy, with due attention to context.

Juridification of maternal deaths in Ethiopia: a study of the Maternal and Perinatal Death Surveillance and Response (MPDSR) system

Juridification of maternal health care is on the rise globally, but little is known about its manifestations in resource constrained settings in sub-Saharan Africa. The Maternal and Perinatal Death Surveillance and Response (MPDSR) system is implemented in Ethiopia to record and review all maternal and perinatal deaths, but underreporting of deaths remains a major implementation challenge. Fear of blame and malpractice litigation among health workers are important factors in underreporting, suggestive of an increased juridification of birth care. By taking MPDSR implementation as an entry point, this article aims to explore the manifestations of juridification of birth care in Ethiopia. Based on multi-sited fieldwork involving interviews, document analysis and observations at different levels of the Ethiopian health system, we explore responses to maternal deaths at various levels of the health system. We found an increasing public notion of maternal deaths being caused by malpractice, and a tendency to perceive the juridical system as the only channel to claim accountability for maternal deaths. Conflicts over legal responsibility for deaths influenced birth care provision. Both health workers and health bureaucrats strived to balance conflicting concerns related to the MPDSR system: reporting all deaths vs revealing failures in service provision. This dilemma encouraged the development of strategies to avoid personalized accountability for deaths. In this context, increased juridification impacted both care and reporting practices. Our study demonstrates the need to create a system that secures legal protection of health professionals reporting maternal deaths as prescribed and provides the public with mechanisms to claim accountability and high-quality birth care services.

Sexual and reproductive health services in universal health coverage: a review of recent evidence from low- and middle-income countries

If universal health coverage (UHC) cannot be achieved without the sexual and reproductive health (SRH) needs of the population being met, what then is the current situation vis-à-vis universal coverage of SRH services, and the extent to which SRH services have been prioritised in national UHC plans and processes? This was the central question that guided this critical review of more than 200 publications between 2010 and 2019. The findings are the following. The Essential Package of Healthcare Services (EPHS) across many countries excludes several critical SRH services (e.g. safe abortion services, reproductive cancers) that are already poorly available. Inadequate international and domestic public funding of SRH services contributes to a sustained burden of out-of-pocket expenditure (OOPE) and inequities in access to SRH services. Policy and legal barriers, restrictive gender norms and gender-based inequalities challenge the delivery and access to quality SRH services. The evidence is mixed as to whether an expanded role and scope of the private sector improves availability and access to services of underserved populations. As momentum gathers towards SRH and UHC, the following actions are necessary and urgent. Advocacy for greater priority for SRH in government EPHS and health budgets aligned with SRH and UHC goals is needed. Implementation of stable and sustained financing mechanisms that would reduce the proportion of SRH-financing from OOPE is a priority. Evidence, moving from descriptive towards explanatory studies which provide insights into the "hows" and "whys" of processes and pathways are essential for guiding policy and programme actions.

Community Mobilization to Promote and Protect the Sexual and Reproductive Rights of Women Living with HIV in Latin America

Between 2009 and 2014, the International Community of Women Living with HIV in Latin America and the Mexican feminist civil society organization Balance coordinated a five-country community-led intervention that brought together women living with HIV (WLHIV), trans women, sex workers, and feminist lawyers to document and respond to sexual and reproductive health and rights (SRHR) violations of WLHIV and advocate for legal, policy, and programmatic changes to fulfill SRHR. The experiences of involved community leaders (n=26) indicate that knowledge of national, regional, and international human rights commitments and up-to-date medical information positively influenced personal health behaviors, empowered WLHIV as subject matter experts, and emboldened them to hold duty-bearers to account. The research evidence generated through collective action was critical for legitimating SRHR violations of WLHIV with decision-makers and for positioning the issue in the advocacy agendas of national and regional HIV and women's movements. Collective action contributed to social cohesion among diverse groups of women living with and affected by HIV and increased available technical, financial, and organizational resources and political opportunities by linking organizations and networks. Collectively, community leaders mobilized to influence policy, legal frameworks, and service delivery to promote and protect the SRHR of WLHIV.

Towards a multilevel governance framework on the implementation of patient rights in health facilities: a protocol for a systematic scoping review

INTRODUCTION

Patient rights are "those rights that are attributed to a person seeking healthcare". Patient rights have implications for quality of healthcare and acts as a key accountability tool. It can galvanise structural improvements in the health system and reinforces ethical healthcare. States are duty bound to respect, protect and promote patient rights. The rhetoric on patient rights is burgeoning across the globe. With changing modes of governance arrangements, a number of state and non-state actors and institutions at various levels play a role in the design and implementation of (patient rights) policies. However, there is limited understanding on the multilevel institutional mechanisms for patient rights implementation in health facilities. We attempt to fill this gap by analysing the available scholarship on patient rights through a critical interpretive synthesis approach in a systematic scoping review.

METHODS

The review question is 'how do the multilevel actors, institutional structures, processes interact and influence the patient rights implementation in healthcare facilities? How do they work at what level and in which contexts?" Three databases PubMed, LexisNexis and Web of Science will be systematically searched until 30 th April 2020, for empirical and non-empirical literature in English from both lower middle-income countries and high-income countries. Targeted search will be performed in grey literature and through citation and reference tracking of key records. Using the critical interpretive synthesis approach, a multilevel governance framework on the implementation of patient rights in health facilities which is grounded in the data will be developed.

ETHICS AND DISSEMINATION

The review uses published literature hence ethics approval is not required. The findings of the review will be published in a peer-reviewed journal.

REGISTRATION NUMBER

PROSPERO 2020 CRD42020176939.

Social accountability for reproductive, maternal, newborn, child and adolescent health: A review of reviews

Globally, increasing efforts have been made to hold duty-bearers to account for their commitments to improve reproductive, maternal, newborn, child and adolescent health (RMNCAH) over the past two decades, including via social accountability approaches: citizen-led, collective processes for holding duty-bearers to account. There have been many individual studies and several reviews of social accountability approaches but the implications of their findings to inform future accountability efforts are not clear. We addressed this gap by conducting a review of reviews in order to summarise the current evidence on social accountability for RMNCAH, identify factors contributing to intermediary outcomes and health impacts, and identify future research and implementation priorities. The review was registered with the International Prospective Register of Systematic Reviews (PROSPERO CRD42019134340). We searched eight databases and systematic review repositories and sought expert recommendations for published and unpublished reviews, with no date or language restrictions. Six reviews were analysed using narrative synthesis: four on accountability or social accountability approaches for RMNCAH, and two specifically examining perinatal mortality audits, from which we extracted information relating to community involvement in audits. Our findings confirmed that there is extensive and growing evidence for social accountability approaches, particularly community monitoring interventions. Few documented social accountability approaches to RMNCAH achieve transformational change by going beyond information-gathering and awareness-raising, and attention to marginalised and vulnerable groups, including adolescents, has not been well documented. Drawing generalisable conclusions about results was difficult, due to inconsistent nomenclature and gaps in reporting, particularly regarding objectives, contexts, and health impacts. Promising approaches for successful social accountability initiatives include careful tailoring to the social and political context, strategic planning, and multi-sectoral/multi-stakeholder approaches. Future primary research could advance the evidence by describing interventions and their results in detail and in their contexts, focusing on factors and processes affecting acceptability, adoption, and effectiveness.

The development of a new accountability measurement framework and tool for global health initiatives

The Global Strategy for Women’s Children’s and Adolescents’ Health emphasizes accountability as essential to ensure that decision-makers have the information required to meet the health needs of their populations and stresses the importance of tracking resources, results, and rights to see ‘what works, what needs improvement and what requires increased attention’. However, results from accountability initiatives are mixed and there is a lack of broadly applicable, validated tools for planning, monitoring and evaluating accountability interventions. This article documents an effort to transform accountability markers—including political will, leadership and the monitor–review–act cycle—into a measurement tool that can be used prospectively or retrospectively to plan, monitor and evaluate accountability initiatives. It describes the development process behind the tool including the literature review, framework development and subsequent building of the measurement tool itself. It also examines feedback on the tool from a panel of global experts and the results of a pilot test conducted in Bauchi and Gombe states in Nigeria. The results demonstrate that the tool is an effective aid for accountability initiatives to reflect on their own progress and provides a useful structure for future planning, monitoring and evaluation. The tool can be applied and adapted to other accountability mechanisms working in global health.

Twelve tips for incorporating the study of human rights into medical education

In order for patients to be adequately cared for by clinicians, an awareness and acknowledgement of the factors that affect their well-being, including adherence to internationally recognized human rights, should be part of the professional education of all health care professionals. Worldwide conflicts, which have led to record forced global displacement, and ongoing international human rights violations have had profound effects on the health and well-being of millions of patients. Trainees early in their careers should be educated about these and related population-level issues that affect the health of their patients, so they can better care and advocate for their patients and communities throughout their careers.

When accountability meets power: realizing sexual and reproductive health and rights

This paper addresses a critical concern in realizing sexual and reproductive health and rights through policies and programs - the relationship between power and accountability. We examine accountability strategies for sexual and reproductive health and rights through the lens of power so that we might better understand and assess their actual working. Power often derives from deep structural inequalities, but also seeps into norms and beliefs, into what we 'know' as truth, and what we believe about the world and about ourselves within it. Power legitimizes hierarchy and authority, and manufactures consent. Its capillary action causes it to spread into every corner and social extremity, but also sets up the possibility of challenge and contestation.Using illustrative examples, we show that in some contexts accountability strategies may confront and transform adverse power relationships. In other contexts, power relations may be more resistant to change, giving rise to contestation, accommodation, negotiation or even subversion of the goals of accountability strategies. This raises an important question about measurement. How is one to assess the achievements of accountability strategies, given the shifting sands on which they are implemented?We argue that power-focused realist evaluations are needed that address four sets of questions about: i) the dimensions and sources of power that an accountability strategy confronts; ii) how power is built into the artefacts of the strategy - its objectives, rules, procedures, financing methods inter alia; iii) what incentives, disincentives and norms for behavior are set up by the interplay of the above; and iv) their consequences for the outcomes of the accountability strategy. We illustrate this approach through examples of performance, social and legal accountability strategies.

Accountability strategies for sexual and reproductive health and reproductive rights in humanitarian settings: a scoping review

Background

Many of the 35 million women and girls aged 15–49 requiring humanitarian assistance have inadequate access to the sexual and reproductive health (SRH) services to which they are entitled. Ensuring accountability is critical to realizing their SRH and reproductive rights (RR).

Objectives

This scoping review examines the extent and nature of existing evidence on accountability strategies for SRH in humanitarian settings in different geographical scopes/contexts, and contextualizes these findings in the larger thematic literature. This review seeks to answer the following questions: What accountability strategies are employed to address the availability, accessibility, acceptability, and quality of SRH in humanitarian settings? What do we know about the successes and challenges of the given strategies? What are the implications for practice?

Methods

We consulted public health, social science, and legal databases including SCOPUS, PubMed, ProQuest, and LexisNexis for peer-reviewed articles, as well as Google Advanced search for grey literature; the search was conducted in March 2019. We searched for relevant articles and documents relating to accountability, humanitarian, and SRH and/or RR. To identify key challenges not reflected in the literature and additional grey literature, 18 key informants from international NGOs, local government bodies, academia, and donor agencies were interviewed from March–June 2019.

Results

A total of 209 papers and documents were identified via our literature searches and interviews for review. We identified three categories of approaches to accountability in our background reading, and we then applied these to the papers reviewed a priori. We created a fourth category based on our findings. The categories include: (1) humanitarian principles, codes of conduct, and legal instruments; (2) technical, performance, and impact standards; (3) efforts to solicit and address the rights and needs of the affected populations, or “listening and responding,” and, (4) accountability demands made by affected populations themselves. Almost all papers identified referred to challenges to realizing accountability in humanitarian contexts. There are promising accountability approaches – some specific to SRH and some not - such as open-ended feedback from affected populations, quality improvement, and practical application of standards. Reflecting a largely top down orientation, papers concentrate on accountability mechanisms within humanitarian work, with much less focus on supporting affected populations to deepen their understanding of structural causes of their position, understand their entitlements, or access justice.

Conclusion

In the last 20 years, there has been increasing standard and guideline development and program experiences related to accountability in humanitarian settings. Yet, the emphasis is on tools or mechanisms for accountability with less attention to changing norms regarding SRH and RR within affected communities, and to a lesser extent, among implementers of humanitarian programs or to institutionalizing community participation.

Building a transformative agenda for accountability in SRHR: lessons learned from SRHR and accountability literatures

Global strategies and commitments for sexual and reproductive health and rights (SRHR) underscore the need to strengthen rights-based accountability processes. Yet there are gaps between these ambitious SRHR rights frameworks and the constrained socio-political lived realities within which these frameworks are implemented. This paper addresses these gaps by reviewing the evidence on the dynamics and concerns related to operationalising accountability in the context of SRHR. It is based on a secondary analysis of a systematic review that examined the published evidence on SRHR and accountability and also draws on the broader literature on accountability for health. Key themes include the political and ideological context, enhancing community voice and health system responsiveness, and recognising the complexity of health systems. While there is a range of accountability relationships that can be leveraged in the health system, the characteristics specific to SRHR need to be considered as they colour the capabilities and conditions in which accountability efforts occur.

Awareness and perceptions of women regarding human rights related to maternal health in rural Bangladesh

Background

The global development community has increasingly come to frame preventable maternal mortality and morbidity principally as a violation of women’s basic human rights, necessitating a human rights-based approach to be appropriately addressed. In this article, we explore how human rights are understood and perceived in relation to maternal health at the local level in rural Bangladesh. This is essential given the momentum at the global level to promote rights and apply rights-based approaches to maternal health.

Methods

A community-based, cross-sectional household survey was conducted in three upazilas (sub-districts) of Brahmanbaria district, Bangladesh in 2018. A total of 1367 women with a birth outcome in the past 12 months were interviewed. Descriptive statistics were used to report the awareness and perceptions of human rights related to maternal health. Multiple logistic regression was used to identify the associations between awareness and perceptions of human rights and background characteristics and, finally, with the use of skilled maternal health services.

Results

Over two-thirds of women reported that they were aware that women have human rights related to maternal health. However, less than 10% were able to mention at least three specific human rights related to maternal health. Half of the women mentioned husbands as duty-bearers, while only 20% mentioned the government as a duty-bearer. One-third of women reported that they are able to realize their rights related to maternal health satisfactorily. Awareness and perceptions of human rights related to maternal health were significantly associated with higher educational attainment and wealth status. They were also associated with increased use of antenatal care.

Conclusions

These findings suggest that interventions promoting the awareness of human rights related to maternal health would be appropriate within the communities of rural Bangladesh as part of a broader human rights-based approach to improving maternal health.

Correction: Broadening understanding of accountability ecosystems in sexual and reproductive health and rights: A systematic review

[This corrects the article DOI: 10.1371/journal.pone.0196788.].