Citizen-Led Accountability: Applying systems thinking to understand and strengthen health system responsiveness to marginalized communities

In many low and middle income countries, the full enjoyment of the right to health is inhibited by deficiencies in the health system, including inadequate infrastructure, human resources, and medicines and equipment. Citizen-led accountability initiatives have the potential to foster bottom up responses. They can contribute to strengthening health systems by mobilizing marginalized communities with limited access to quality health care and supporting their engagement with state authorities to demand accountability. Over the last decade, numerous examples have shown that these initiatives have been effective in making the health sector, and other public sectors, more responsive and accountable. However, understanding of the complex pathways through which citizen-led accountability initiatives lead to positive change remains limited. Their function depends on building networks of relationships that connect citizens in collective action, and engage them in dynamic interactions with state authorities. Adaptation to political and social context is also critical. Innovative methodological approaches are needed to understand how these network-generating processes function and how they can be enhanced to improve health system responsiveness to marginalized communities. The proposed research will address this challenge by applying a systems thinking approach. The science of systems thinking offers valuable tools for understanding and strengthening complex change processes. This project will employ the systems thinking tool called Social Network Analysis to study how networks of marginalized citizens work together and interact with authorities to demand health system accountability.

The research will be carried out in two phases with indigenous communities participating in a well-established citizen-led accountability initiative in rural Guatemala. Citizen networks in these communities are actively working to monitor health system deficiencies, participate in local health decision-making spaces, communicate their needs to state authorities, and form alliances to advocate for structural improvements. In the first phase, social network analysis will be applied in these communities to provide insight into: 1. patterns of communication and support within the citizen networks that carry out these activities, and 2. patterns of interaction between citizens and state authorities at different levels and the responses they receive. Following in the systems thinking approach, this knowledge will be applied to strengthen the citizen networks in the second phase. In this phase, participants from the first phase will interpret: 1. how the patterns identified influence their capacity to meet their goals, and 2. how their network is influenced by local political and social context. Participants will draw on these insights to identify strategic actions to strengthen their networks' effectiveness in mobilizing their communities and communicating with authorities.

The knowledge produced by this project will be directly relevant for strengthening citizen-led action for health system accountability to marginalized communities in Guatemala. Understanding of the influence of network qualities on citizen-led initiatives' capacity to meet their goals will be more broadly relevant to development agencies and practitioners working to support the mobilization of bottom up pressure for accountability. The development of an applied Social Network Analysis tool through this project will also offer a valuable resource for researchers to gain insights into the function of citizen networks in other settings, and identify broader patterns in their interactions that contribute to strengthen health system responsiveness.

Citizen-led accountability initiatives have great potential to strengthen health systems by mobilizing collective action and supporting civic engagement with authorities to bolster responsiveness. While positive results have been demonstrated, the current evidence base is limited by the methodological challenge of capturing the complex nature of change pathways. This project seeks to develop a systems thinking approach that will help address this challenge by generating understanding of the function of networks in citizen-led accountability initiatives and how they contribute to health system strengthening. The research will be carried out in two phases, in indigenous communities participating in a well-established citizen-led accountability initiative in rural Guatemala. Social network analysis (SNA) will be employed in the first phase to define transmission of information and other resources and qualities of relationships that connect citizens in networks of collective action, and to examine patterns of interaction between these networks and state authorities. SNA permits visualization of the structure of a network and patterns of connections among actors, as well as identification of key actors that facilitate connectivity. The second phase will employ qualitative interpretation of SNA results to enable deeper insight into what the relational qualities mean in practice, as well understanding of conditions shaping the network's capacity to achieve health system responsiveness. The knowledge generated through this approach will be highly relevant for understanding the function of citizen-led initiatives as networks of collective action, and indicating directions for strengthening alliance-building and communication strategies. Research outputs will contribute to strengthening citizen action for health system accountability in Guatemala, advancement of conceptual understanding of accountability networks, and will provide methodological tools for further study.

The proposed work aims to apply a systems thinking approach to generate knowledge that is useful for strengthening the network-generating processes that underpin the mobilization of marginalized communities and their engagement with state authorities to demand accountability for their right to health. This knowledge is of great relevance for three main groups: indigenous communities engaged in the accountability initiative in the study setting, civil society organizations that support accountability efforts at the national level, and international communities of practitioners and researchers seeking to understand and strengthen collective citizen action for health system accountability in other LMIC settings. The potential benefits that the research outputs of this project would provide to these groups are described below.

Through this project, we will engage with indigenous communities in rural municipalities of Guatemala that are actively working to monitor health system deficiencies, participate in local health decision-making spaces, communicate their needs to state authorities, and form alliances to advocate for structural improvements. Application of social network analysis in these municipalities will provide insight into relational qualities of the citizen networks that carry out these activities, and existing gaps that may be improved to enhance the impact of collective action for accountability. Systems thinking tools are recognized for their capacity to engage practitioners in co-construction of knowledge with contextual relevance, enable the development of adaptive strategies tailored to the conditions and capacities of different systems, and facilitate transformational change. This project is designed to take advantage of these capacities by engaging participants in interpretation of the network qualities captured, local conditions shaping their interactions, and identification of strategic action to strengthen their network's effectiveness in mobilizing their communities, alliance building and communication with authorities.

The knowledge generated through this project will also benefit the broader network of civil society organizations engaged in action to hold state authorities accountable for health and human rights in Guatemala. Accountability processes operate through diverse pathways in the national context, and often civil society organizations are not fully aware of the processes activated by others with common goals. Engagement with civil society organizations at the national level through a workshop will provide the opportunity to disseminate lessons learned about the role of network-generating processes in citizen-led efforts to promote health system responsiveness in rural, indigenous communities. The workshop will facilitate collective reflection on the role of networks within and across health accountability efforts at the national level, and provide opportunity to identify possibilities for enhancing coordination and coalition building.

International communities of accountability researchers and practitioners will benefit from the outputs of this project through its provision of a tested systems thinking approach to understand and strengthen the networks of relationships and interactions that drive health accountability efforts. Insights into network-generating processes and their interaction with local conditions in Guatemala will further contribute to advancing conceptual understanding of the complex function of citizen-led accountability initiatives and the contextually embedded pathways through which they contribute to health system responsiveness. Close collaboration with our Project Partners - AMDD at Columbia University, the T/A Initiative and Umea University - will help ensure that the social network analysis tool and conceptual insights generated are both scientifically rigorous and of practical relevance to the international community of health accountability practitioners.