Cathy Green
Publication Date
December 1, 2008

Social Development Technical Adviser to PATHS (ended in June 2008) c/o Health Partners International

How can greater voice and accountability (V&A) for citizens bring about improved health services in Nigeria? This 36-page technical brief from Partnerships for Transforming Health Systems Programme (PATHS) reviews 7 V&A initiatives supported by PATHS in Kano, Jigawa, and Kaduna in the North West, Ekiti in the South West, and Enugu in the South East. PATHS was funded by the Department for International Development (DFID); it ended in June 2008.


As detailed in this report, prior to 2002, awareness of rights was almost universally low among Nigeria's general public. Mechanisms that would allow clients to challenge poor-quality health services were largely absent, and health providers and policymakers lacked incentives to respond appropriately to client needs. The result was very low utilisation of public health facilities and a breakdown in the relationship between health facilities and communities. PATHS initiatives were designed to create opportunities to begin to strengthen citizen voices on health and to address accountability failures. Looking at the period 2003 to 2008, this review examines the following initiatives:

  • Patient Focused Quality Assurance (PFQA)
  • Peer Participatory Rapid Health Appraisal for Action (PPRHAA)
  • Integrated Supportive Supervision (ISS)
  • Facility Health Committees (FHCs)
  • Standards of Care and Patient Charters
  • Safe Motherhood Demand-side Initiative (SMI-D)
  • Community Action Cycle (CAC)


A review of these initiatives carried out in late 2007/early 2008 found that involving clients and community representatives in the assessment and monitoring of service delivery (through PFQA, PPRHAA, and ISS) not only helped to open up space for citizen voices to be heard in the health sector, but also strengthened provider responsiveness to client needs. Across the PATHS states, there were many examples of how changes had been made in provider behaviour or in the way health services were delivered in response to expressed client and community concerns about poor-quality services. The review also found that involving members of the community in the governance of health facilities through FHCs led to communities challenging a variety of accountability failures, either at the health facility level or "higher up the system".


Initiatives that provided a formal mechanism through which citizen voices could reach policy makers (e.g. PPRHAA, ISS, and CAC) seemed to offer the most potential from a V&A perspective. In contrast, where citizens tried to influence policymakers through informal routes (e.g. SMI-D, FHCs) there was no guarantee that they would get an audience with, or a response from, a policymaker. These attempts to strengthen V&A were prone to failure in the absence of parallel efforts to strengthen public accountability at local government level. Furthermore, although implementation of systems strengthening and service delivery improvement initiatives resulted in improved accountability of health providers to local communities, for various reasons efforts to strengthen accountability between policymakers and communities proved more challenging.


Some conclusions and lessons learned from implementation of the 7 initiatives include:

  1. Involving clients and community representatives in the assessment and monitoring of service delivery opened up space for citizen voices to be heard in the health sector and helped strengthen provider responsiveness to client needs. Approaches such as PPRHAA, integrated supportive supervision, and PFQA are promising from a V&A perspective, and could easily be adapted for replication in other Nigerian states.
  2. Clients and communities need to be supported so that they can participate in processes such as PPRHAA and ISS in ways that extend beyond token involvement. This requires greater investment in the provision of training and mentoring support than was the case in some of the PATHS states. Finding ways to improve the quality of women's participation in these processes is important. Ignoring gender differences in experience and confidence to participate in public fora will mean that men's voices continue to take precedence in these processes.
  3. Involving members of the community in the governance of health facilities through FHCs proved an effective way to progress a V&A agenda. However, to ensure that these committees functioned effectively, considerable capacity-building support, in the form of formal training and ongoing mentoring support, was required. The quality of community participation in FHCs was low in the PATHS states that relied on a one-off training, whereas in Kaduna, where the support was more broad-ranging and extensive, early results pointed to some interesting V&A outcomes.
  4. Initiatives that provided formal mechanisms through which citizen voices could reach health providers and policy makers appeared to offer the most potential from a voice and accountability perspective. Examples were PPRHAA, ISS, and CAC. In the PATHS states these initiatives not only placed an obligation on different parts of government to listen to the voice of the people, but also introduced incentives to respond.
  5. In contrast, initiatives that relied on citizens trying to influence policymakers via informal routes (e.g. SMI-D and FHCs) could not guarantee that citizens would get an audience with a policymaker, while getting a response appeared to depend on a policymaker's personal initiative or whim. Such initiatives are likely to fail in the absence of parallel efforts to strengthen public accountability at local government level. This highlights the importance of timing work on V&A so that it links in with other initiatives that aim to strengthen performance management and public accountability at local government level. One implication from the above is that where facility health committees are being supported, V&A outcomes may be better if committee members are encouraged to channel their demands to local government through performance monitoring and supervisory processes such as PPRHAA and ISS. This calls for better integration - on the ground - between different systems-strengthening processes.
  6. Government-led V&A initiatives, such as defining standards of care and introducing patient charters, can help create an enabling environment for voice and accountability. However, it is crucial that these initiatives do not remain a "paper exercise". Their provisions need to be widely publicised so that service users and communities are better informed and better able to use the standards as a reference point for claiming their entitlements.
  7. Citizens' willingness to challenge policymakers about poor-quality health services in some instances opened up a space for providers to manoeuvre for improved resources or working conditions. For example, an FHC in Kaduna documented the arrival of free maternal and child health (MCH) drugs, calculated the gaps in provision, and then wrote to the State Free MCH Committee to complain about the under-supply of essential drugs. More work is needed to document the extent to which, and how, growing citizen confidence to claim improvements in services catalyses and influences providers' efforts to demand change from policymakers.
  8. Civil society organisations, such as non-governmental organisations (NGOs) and community-based organisations (CBOs), have a potentially important role to play in creating space for voice and catalysing changes in accountability between providers, policymakers, and communities.

Governance and Social Development Resource Centre (GSDRC) website, March 1 2010; and email from Cathy Green to The Communication Initiative on March 16 2010.