Despite significant investment by governments and donors in many poor countries, development indicators remain abysmal. There is increasing evidence that strengthening the accountability of these services to local communities and end users can play a critical role in improving both access and quality. Innovations that provide people with more information about essential services and the ways in which they can participate in shaping how these services are delivered have been shown to improve development results. In rural India, “social audits” – the process by which details of the resources used by public agencies for development initiatives are shared with their beneficiaries – have been successful in exposing and recovering misappropriated funds and have consequently been incorporated into the national job creation scheme.

A recent randomized controlled trial found that a “community score card” intervention applied in health clinics in Uganda reduced child mortality by 30 per cent in one year. Such social accountability efforts tend to focus exclusively on the nexus between community and service provider or between community and local government, without the possibility of seeking remedies from the broader network of state authority when local pressure fails. On the other hand, while the protection of rights and the pursuit of redress is the core business of legal empowerment programs, those programs usually focus more on solving disputes and less on failures in public services such as health and education.

Our hypothesis is that a model that draws on the strengths of these two approaches – social accountability and legal empowerment – could better integrate accountability for service delivery into national governance structures and lead to significant, life-saving improvements in the delivery of essential services. Namati is engaged in a two-country experiment, which aims to explore the synergies between social and legal approaches to accountability for health services. Through our work in Sierra Leone and Mozambique, we hope to generate lessons that will inform and strengthen both government and civil society efforts on a broader scale. Specifically we aim to:

• Increase patient and provider knowledge of key health policies and legislation by making information accessible to the most marginalized, including those with limited literacy
• Cultivate greater civic engagement by developing capacity directly among the poor to pursue their entitlements and engage in governance of the health sector
• Engage, support and galvanize village health committees to defend and advance the right to health by playing a more active role in advocacy and in monitoring system performance
• Support health professionals as key agents of change in advancing equity, transparency and social justice
• Strengthen the capacity of civil society to apply pressure by pursing legal and administrative remedies for breaches of health policy or health-related rights
• Collaborate with government to improve mechanisms for providing redress for grievances
• Influence policy and practice through dissemination of research findings at local, national and international levels

In both Sierra Leone and Mozambique, Namati and its partners are bringing together health workers, village health committees and community members to analyze aggregate data and encourage collective action, including compacts aimed at improving health service delivery outside of formal reporting channels. Namati has developed standardized case forms that are being used by paralegals and health advocates to document both individual and collective grievances. These are initiated by clients and collected during discussions with village health committee members, clinic staff, and community members. These forms are then entered into a central database, enabling comparative analysis within and across countries and communities.