Falisse Jean-Benoit, Nkengurutse Hugues, Ntakarutimana Léonard
School of Social and Political Science and Edinburgh Future Institute, University of Edinburgh, Edinburgh, United Kingdom.
Centre d'analyse et de recherche interdisciplinaire pour le développement des grands lacs (CARID-RGL), Université du Lac Tanganyika, Burundi.
PLOS Glob Public Health. 2023 Aug 15;3(8):e0001697. doi: 10.1371/journal.pgph.0001697. eCollection 2023.
Community governance, the direct (co-)management of public services by community members, is a popular approach to improve the quality of, and access to, healthcare services-including in so-called 'fragile' states. The effectiveness of such approach is, however, debated, and scholars and practitioners have emphasised the need to properly reflect on the contextual features that may influence social accountability interventions. We study a randomised intervention during which community-elected health facility committee members were trained on their roles and rights in the co-management of primary healthcare facilities. 328 publicly-funded health facilities of Burundi and Sud Kivu in DR Congo were followed over a period of one year. In Kivu, but not in Burundi, the intervention strengthened the position of the committee vis-à-vis the health facility nurses and affected the management of the facility. HFC members mostly focused on improving the elements most accessible to them: hiring staff and engaging in basic construction and maintenance work. Using survey data and interviews, we argue that part of the discrepancy in results between the two contexts can be explained by differences in health facilities' management (whether they primarily depend on a local church or more distant authorities) as well as different local histories of relationship to public service providers. The former affects the room available for change, while the latter affects the relevance of the citizens' committee as an acceptable way to interact with healthcare providers. No effect was found on the perceived quality of and access to services, and the committees, even when strengthened, appear disconnected from the citizens. The findings are an invitation to re-think the conditions under which bottom-up accountability mechanisms such as citizens committees can be effective in 'fragile' settings.
社区治理，即由社区成员直接（共同）管理公共服务，是一种提高医疗服务质量和可及性的流行方法，包括在所谓的“脆弱”国家。然而，这种方法的有效性存在争议，学者和从业者强调需要适当反思可能影响社会问责干预措施的背景特征。我们研究了一项随机干预措施，在此期间，社区选举产生的卫生设施委员会成员接受了关于其在初级卫生保健设施共同管理中的角色和权利的培训。对布隆迪和刚果民主共和国南基伍的328家公共资助的卫生设施进行了为期一年的跟踪。在基伍，而不是在布隆迪，该干预措施加强了委员会相对于卫生设施护士的地位，并影响了设施的管理。卫生设施委员会成员主要专注于改善他们最容易接触到的方面：招聘工作人员以及参与基本建设和维护工作。通过使用调查数据和访谈，我们认为两种背景下结果差异的部分原因可以通过卫生设施管理的差异（它们主要依赖当地教会还是更遥远的当局）以及与公共服务提供者关系的不同当地历史来解释。前者影响变革的空间，而后者影响公民委员会作为与医疗服务提供者互动的可接受方式的相关性。未发现对服务的感知质量和可及性有影响，而且这些委员会即使得到加强，似乎也与公民脱节。这些研究结果促使人们重新思考诸如公民委员会等自下而上的问责机制在“脆弱”环境中能够有效的条件。
