Case studies of each project are presented in narratives of how social accountability operated in the context of contraceptive care.
Case study A: the community scorecard approach
Prior to the implementation of the project in both districts, there was limited awareness about family planning. There was open hostility to family planning with rumors abound about its detrimental side-effects such as cancer, fatigue, and weight gain. Given the project’s focus on wider health system strengthening, RHU only began to focus their activities on family planning in the second year of the project. RHU introduced the topic of family planning to the project’s existing health authority partners, champions and community organizations (CO) who had already been trained in community mobilization, monitoring and advocacy. RHU introduced the new focus on family planning by training their community based organization (CBO) partners on contraception and supporting them to identify gaps in contraceptive care locally and to integrate these issues into their existing work plans.
After the training, the CBO partners undertook extensive community mobilization on family planning alongside sensitizations about health rights. The health rights training was important because community members learnt about their entitlements and what standards of care they should expect. A local teacher said, “You cannot solve the problem you don’t know” (A2). Community members shared their new knowledge of entitlements with other community members. The project staff also worked with local religious leaders from different denominations to actively make positive statements about family planning to their congregations.
Community members recalled the family planning activities and stressed that family planning was something they had to ‘learn’, as a local champion explained:
Family planning did not emerge from a community dialogue because we learnt about family planning …. even on Sundays [when I would] go to church and tell the Reverend that today I would like to teach family planning or maternal health. Now the Reverend also accepts it and gives me a few hours and I teach men, women and all the children when they have all come to church (A1).
In tandem with these community focused activities, the project staff sensitized health providers and local health officials about health rights, accountability and family planning. Local health officials found this training helpful in their work. A local official explained, “Actually it was useful because what they were telling us was more or less teaching us how to uplift our area, especially the communities, because there are very many questions or problems or challenges in our communities” (A2).
After separate sensitization with both the community and the health systems actors, both groups came together in interface meeting to jointly identify issues, develop priorities and strategic actions to address them. Together they identified shared concerns about misconceptions surrounding family planning, commodity stock outs and untrained service providers and how to address them. The desired changes were then regularly monitored by the community.
The interactions generated mutual understanding, and empathy between community members and health system actors. Community members felt empowered that they could raise their voice, as a local church leader commented, “It was important because what community people said, they got time to say things they don’t have [the ability to say] anywhere else” (A1). A health care provider explained how these exchanges made her appreciate the communities’ voice:
If there is no voice from the community, it may take forever to have a better policy or, if a policy is in place and the community doesn’t understand what that policy says or what they will benefit when that policy is implemented, then it may also be another hindrance in policy implementation. So that is where we say we are heading to, we may not be there, but we are somewhere, we have achieved a few milestones along the way (A1).
Health system actors began to view community inputs as valuable and forwarded the joint concerns to sub-country and district authorities for further action. There was an emergent sense of collaboration between the community and the health system. A community member who was involved in one such initiative explained, “I have been able to learn many things like working together as a group for the better of our community” (A1).
Some facility-related issues, such as poor road access, limited water and electricity supplies, poor provider behavior and lack of security, were attended to locally without relying on assistance from local officials or NGOs. A community member explained this established practice:
We as community members…decided to come together, make an effort to solve some of these problems on our own without having to wait for outside help, which should come in later, at least we need to do half of these things ourselves (A1).
The project did not report on changes in contraceptive care because this was not part of its performance monitoring requirements. However, there were several changes attributed to the project that indirectly benefitted contraceptive care, such as the recruitment of new health care providers and changes in provider behavior (e.g. wearing of uniforms and posting of duty rosters). The project participants themselves reported increased awareness of health issues, including family planning; having more confidence in the health system, and felt that their local health care providers and local leaders listened and acted on the issues they raised. Though the project tended to focus on broader health systems strengthening rather than family planning, it was apparent that, over time, access to family planning became a legitimate concern for discussion in community forums.
Case study B: community dialogue approach
There were frequent reports of social resistance and opposition to contraception in both districts where the project was implemented. A project champion explained, “Women used to fear to come out in the open to demand a family planning method of their choice. They feared that if people knew they were using family planning, they would think they are a prostitute, that, along with their husband, is there another one (126:54)?” There were misconceptions about how contraception worked and what kind of effects it had like causing foetal abnormalities, cancer and fibroids. Another champion explained how contraceptive use was influenced by gender norms: “When they [women] get married, their bodies, including the sex part, traditionally belongs to the man. The man decides when to have sex, when to have children and how many children” (B1).
In contrast with case study A, family planning was integral from the outset of the project. There was ongoing sensitization of both communities and local health systems actors on family planning to dispel myths and tackle social resistance. The sensitization was conducted through women’s pressure groups, male role model groups, radio programs, couple counseling seminars and workshops among sub-county leaders. These activities were key, as a champion said, to “Clearing the image that people were painting of family planning” (B1).
RHU trained community champions (local women with social standing who had experience and skills in negotiating with leaders) and supported the formation of women-only “pressure groups (PG)” in the project villages. The champions and PG members met every 2 months to learn about family planning, prioritize which access barriers to address and report on the number of people they sensitized about family planning. Often RHU sent in their own service providers to conduct the training as a high degree of technical knowledge was required. The barriers they discussed ranged from transport costs, male resistance, myths and misconceptions, religious opposition, disrespectful providers and lack of information in local languages.
The newly formed groups organized the meetings, developed their activities and led sensitization about family planning in person or at social gatherings. To attract members, RHU launched income-generating activities in catering, animal rearing and savings. The activities proved so successful that these groups registered with the local authorities as independent organization so they could access additional funds.
As male opposition was considered a barrier to accessing family planning services, the project supported couple counseling and the formation of male role models (MRM). Male role models were local men with social standing trained to promote family planning with other men, both individually and in groups.
Participants in these community meetings thought they were catalytic and helped them develop personally and gain self-worth. One MRM said, “Every time you are with a person, you bring a good idea, and someone claps for it, it means it is of value” (B1). A youth leader felt that they could make a difference, “What did I learn? I learned that even though you are small, you can make an impact” (B1). A project champion observed these changes:
The people who attended were so free, why am saying that, when these things started there were people who had low self-esteem most especially pressure groups they used to fear, when they would see champions they would fear. But slowly we started visiting them in their activities, we would be called, and we go to explain to them where they do not understand. So you look and see a champion sitting here, a pressure group sitting there, but it was never there (B1).
Members appreciated learning from each other and working together, as one community member said:
Everyone was getting a chance. You know in that group we have health workers, we have village women, teachers … so to say there is also a class of people that do government work and also a class of women who do their own work in the villages but we were in the meeting and everyone was being given a chance to talk (B2).
Once the barriers to contraceptive care were identified in the community meetings, the project champions and RHU met with local authorities to advocate for change. For example, a barrier identified was that women could not seek contraceptive services because of the prohibitively high transport costs or fees charged during private outreach programs. The champions and RHU, therefore, advocated with the district health authorities to integrate family planning into ongoing immunization outreach. These advocacy efforts were relatively successful, with sub-country and district funds committed to family planning in the first year of the project. In the subsequent years, the advocacy focused on ensuring the committed funds were released and used as intended.
In the meetings with local authorities, people with different backgrounds shared their experiences and ideas, and learned from and about each other. Local officials came to value inputs from the surrounding community, “We lack such information and yet people run to us to provide a solution to them, so we need such information more than ever” (B2). Officials also appreciated learning about family planning and shared this with their constituencies, “My role was to participate, to see what family planning is, to understand what they have taught so that I can go back and spread the gospel to my people who have not got this chance” (B1).
Over time, however, participants reported divisions among the community actors. The champions were treated differently; they received additional training, and directly engaged with officials that the other community groups did not. This difference was palpable, as a pressure group member stated: “We have the champions, those that are higher than us, because for us, we are lower as PG members” (B1). These social differences among community members played out in what was included in the dialogues with health system actors; quality of care issues identified by the Pressure Group received less attention than policy related barriers, particularly those with budgetary implications. Over the course of the study, the MRMs began mobilizing for other projects they were involved in, and the PGs set up autonomous groups with funding from other sources.
The project successfully secured several budget lines for family planning, many self-sustaining women’s groups were formed, and the district-wide platform to coordinate family planning was established. There was a more positive attitude towards family planning, and it had become a legitimate public concern. One champion said,
There has been some change, because back then we had our people who never wanted to hear anything about family planning because they were taking it in a very different way, they would say stop-stop don’t even tell us, so that is what has been on ground. But now they even visit us and also us we visit them after, so we see a great change because people are now involved in family planning, something that had never happened in the past (B2).