Community Involvement in Health Decision Making: ARHR’s use of Social Accountability to Demand Responsiveness and Accountability from Health Policy and Decision Makers in Ghana

By Vicky T. Okine Executive Director, Alliance for Reproductive Health Rights

Introduction

The Alma Ata Declaration on Primary Health Care (PHC) in 1978 reiterated a very central component of health; the importance of community involvement and participation in health decision-making processes in order to achieve a “people-centred” health system that is robust, effective and sustainable and at the same time provides the opportunity to identify and address the needs of communities. Indeed, in more than 40 years since this declaration, this point has never become clearer than now as countries across the world work assiduously to attain Universal Health Coverage under the Sustainable Development Goal 3 by 2030.

Ghana’s Health Sector

Since committing to the PHC declaration and other international health treaties, Ghana has attained some progress in improving the health status of Ghanaians. However, decades of investments in health have not yielded significant improvements in access to maternal, newborn, child and adolescent health as well as other health outcomes. Significantly, part of the challenge can be attributed to cultural factors and the low participation of communities in health decision making. In Ghana, the health sector (Ministry of Health/Ghana Health Service) has been largely involved in the implementations and monitoring of Ghana’s policies with minimal involvement of civil society and the citizenry for whom health care services are provided and for this reason, healthcare managers are mostly not held accountable for results in health service delivery. Due to this, accountability, transparency and responsiveness in the health sector remains weak.

Increasing Community Participation in Health Processes

In efforts to change the narrative and provide platforms for communities to engage with their duty bearers, the Alliance for Reproductive Health Rights (ARHR) has been engaging with CSOs and communities to build their capacities and empower them to use social accountability mechanisms (SAM) such as the community scorecards approach to generate evidence on gaps in health service delivery. ARHR’s scorecards are usually designed to assess the readiness of health facilities to provide health services, government’s implementation of its health commitments and client satisfaction with health services provided.

Establishing Joint Assessment Teams — the Strategy

In past experiences, ARHR has worked with combined assessment teams of duty bearers and right holders at the district level to assess the readiness of health facilities to provide MNCH and other health services. The assessment teams usually comprises members of district health management team (the health administrative body at the district level), personnel from the district assembly which is the local authority, staff from a community-based organization and community members who are usually members of community health committees. The rationale behind creating multi-stakeholder assessment teams is to provide opportunities for duty bearers (from both administrative and political bodies) and rights holders to work collectively to identify and address gaps across the local health sector.

Interface and Multi-stakeholder Dialogues

The results of the assessments are shared through interface meetings and multi-stakeholder dialogues organised at the community, district and national levels. These multi-stakeholder dialogues bring together heads of all assessed health facilities, local government representatives at the district level, health authorities at national and sub-national level community leaders, media and community based organisations. The results from the scorecards are used during the meetings to identify gaps and propose solutions for each facility. These meetings promote understanding between clients, providers, and communities, for example around the skills and resource constraints under which facility staff worked. During these meetings communities work with decision makers and providers to draw action plans with clear allocation of responsibilities and timelines for each solution proposed. The process fosters transparency and accountability for improved quality of health care.

Major Achievements and Highlights of the Approach

ARHR’s use of this approach has resulted in shared ownership and community empowerment. Through the participatory methodology, ARHR found that local communities and their representatives have an opportunity to know and act upon the state of health services in their areas. Many communities took the initiative to resolve health issues themselves, either by fundraising or practical action and many also used the data to advocate to district health management or district assembly personnel for funds to fill gaps in infrastructure.

Conclusion

ARHR’s experience in the use of social accountability mechanism such as the community scorecards has revealed that the involvement of communities in activities such as evidence generation on gaps within their health systems helps to strengthen the relationships between right holders and duty bearers. Additionally, the social accountability mechanism provides opportunities for communities to have a shared sense of ownership as they become involved in health decision making processes and feel empowered to demand from duty bearers pragmatic and feasible strategies to improve their health.