Unpacking power dynamics in research and evaluation on social accountability for sexual and reproductive health and rights

Abstract

Over the past decade, social accountability for health has coalesced into a distinct field of research and practice. Whether explicitly stated or not, changed power relations are at the heart of what social accountability practitioners seek, particularly in the context of sexual and reproductive health. Yet, evaluations of social accountability programs frequently fail to assess important power dynamics. In this commentary, we argue that we must include an examination of power in research and evaluation of social accountability in sexual and reproductive health, and suggest ways to do this. The authors are part of a community of practice on measuring social accountability and health outcomes. We share key lessons from our efforts to conduct power sensitive research using different approaches and methods.First, participatory research and evaluation approaches create space for program participants to engage actively in evaluations by defining success. Participation is also one of the key elements of feminist evaluation, which centers power relations rooted in gender. Participatory approaches can strengthen ‘traditional’ health evaluation approaches by ensuring that the changes assessed are meaningful to communities.Fields from outside health offer approaches that help to describe and assess changes in power dynamics. For example, realist evaluation analyses the causal processes, or mechanisms, grounded in the interactions between social, political and other structures and human agency; programs try to influence these structures and/or human agency. Process tracing requires describing the mechanisms underlying change in power dymanics in a very detailed way, promoting insight into how changes in power relationships are related to the broader program.Finally, case aggregation and comparison entail the aggregation of data from multiple cases to refine theories about when and how programs work. Case aggregation can allow for nuanced attention to context while still producing lessons that are applicable to inform programming more broadly.We hope this brief discussion encourages other researchers and evaluators to share experiences of analysing power relations as part of evaluation of social accountability interventions for sexual and reproductive health so that together, we improve methodology in this crucial area.

‘History obligates us to do it’: political capabilities of Indigenous grassroots leaders of health accountability initiatives in rural Guatemala

“…Our framing focus on Williams’ three dimensions of political capabilities was selected post-hoc, and thus, the interviews did not fully engage with the participants’ views on political learning, reshaping their network and patterns of representation with authorities. However, the dimensions were well-matched with the main aspects of CEGSS’ approach for supporting the defenders to lead local accountability initiatives,38 and our analysis adds to a growing literature responding to calls for more politicised assessments of initiatives’ contribution to sustainable shifts in power dynamics 16 55 56. Additionally, expressions of countervailing power vary widely by context, and our interpretations were guided by the defenders’ perceptions of what constituted gains.…”

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

“…Even without a big tent approach to reproductive health, however, the campaign’s focus on increasing accountability around primary health care services stands to ultimately benefit reproductive health care in the state because primary health care is a patient’s entry point to the health system and the main coordinator of care. Features of high quality maternal health care, such as the availability of drugs, respectful treatment of patients, and well-staffed clinics all motivate the use of primary health care facilities [ 16 , 17 ], benefitting overall health, as well as reproductive and maternal health. Given that 74% of married women who use modern contraception in Niger State access it through the public sector [ 2 ], making public health facilities appealing is key to ensuring those who wish to use contraception will do so.…”

“…Third, social accountability efforts are fundamentally efforts to change power relations between citizens and the state [ 16 , 33 , 34 ]. This characterization is particularly true in the health field in settings where people receive health care in public clinics funded by the government, and power is especially relevant to accountability relations in the context of reproductive health [ 34 ].…”

Research and implementation interactions in a social accountability study: utilizing guidance for conducting process evaluations of complex interventions

“…In their commentary discussing approaches to measurement and evaluation of social accountability efforts to improve sexual and reproductive health and rights (SRHR), Schaaf, et al, argued that participatory approaches to evaluation and research are well-suited for understanding the shifts in power dynamics, which is central to social accountability processes [ 16 ]. Participatory approaches ensure that the outcomes assessed are meaningful to the communities involved [ 16 ]. Examples of evaluations that actively engaged program participants were able to identify the indicators and changes that were important to the participants themselves [ 33 , 34 ].…”