From favours to entitlements: community voice and action and health service quality in Zambia

Schaaf, Marta, Topp, Stephanie M., and Ngulube, Moses (2017) From favours to entitlements: community voice and action and health service quality in Zambia. Health Policy and Planning, 32 (6). pp. 847-859.

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Social accountability is increasingly invoked as a way of improving health services. This article presents a theory-driven qualitative study of the context, mechanisms and outcomes of a social accountability program, Citizen Voice and Action (CVA), implemented by World Vision (WV) in Zambia. Primary data were collected between November 2013 and January 2014. It included in-depth interviews and focus group discussions with program stakeholders. Secondary data were used iteratively—to inform the process for primary data collection, to guide primary data analysis and to contextualize findings from the primary data. CVA positively impacted the state, society, state–society relations and development coordination at the local level. Specifically, sustained improvements in some aspects of health system responsiveness, empowered citizens, the improved provision of public goods (health services) and increased consensus on development issues appeared to flow from CVA. The central challenge described by interviewees and FGD participants was the inability of CVA to address problems that required central level input. The mechanisms that generated these outcomes included productive state–society communication, enhanced trust, and state–society co-production of priorities and the provision of services. These mechanisms were activated in the context of existing structures for state–society interaction, willing political leaders, buy-in by traditional leaders, and WV’s strong reputation and access to resources. Prospective observational research in multiple contexts would shed more light on the context, mechanisms and outcomes of CVA programs. In addition to findings that are intuitive and well supported in the literature we identified new areas that are promising areas for future research. These include (1) the context of organizational reputation by the organization(s) spearheading social accountability efforts; (2) the potential relationship between social accountability efforts and making ambitious national programs operational at the frontlines of the health system and (3) the feasibility of scale up for certain types of local level responsiveness.

Item ID: 48160
Item Type: Article (Research - C1)
ISSN: 1460-2237
Keywords: health systems, low and middle income countries, social accountability, social change, Sub-Saharan Africa, trust
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© The Author 2017. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (, which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited.

Funders: Danish Ministry of Foreign Affairs (DMFA), World Vision International (WVI)
Date Deposited: 03 Apr 2017 02:20
FoR Codes: 44 HUMAN SOCIETY > 4410 Sociology > 441001 Applied sociology, program evaluation and social impact assessment @ 40%
42 HEALTH SCIENCES > 4206 Public health > 420699 Public health not elsewhere classified @ 40%
44 HUMAN SOCIETY > 4401 Anthropology > 440101 Anthropology of development @ 20%
SEO Codes: 92 HEALTH > 9202 Health and Support Services > 920299 Health and Support Services not elsewhere classified @ 100%
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