“Free healthcare, free die”:the efficacy of social accountability interventions in the health sector in Sierra Leone

Since the beginning of the 21st century, aid donors, NGOs and development research institutions have turned their focus to the question of how the quality of basic public service delivery in developing countries can be improved. While it has become clear that the most important factor in the improvement of services is tackling problems related to the workforce that provides public services, it has not been easy to find effective ways to improve the standards of, for example, health and education services by changing the behaviour of public service providers. One approach which has received a lot of attention, and is now being used worldwide, is the use of ‘social accountability’. A myriad of social accountability approaches exist: many focus on citizen-service provider dialogue, others encompass participatory planning processes at district or even national level, or track how budgets are being spent. This study examines a sub-section of social accountability practice, and focuses specifically on interventions that aim to improve primary health service delivery. Social accountability methodology has evolved greatly over the past decade, and our understanding of why certain interventions work better than others has been enhanced by a greater focus on contextual influences and a deeper understanding of the power dynamics and politics that have an impact on service delivery decisions. However, while the technical and academic understanding of practical social accountability failures has improved, many of those who are engaged in the practice of social accountability have yet to catch up. This research aims to provide a greater understanding of the realities and the challenges faced by NGOs, CSOs and individuals who are involved in implementing social accountability interventions. By examining a series of social accountability interventions in Sierra Leone, a country with weak governance and high levels of corruption, this study provides a unique insight into the dichotomy between the advanced policy guidance that is available within the world of social accountability research, and the messy reality of social accountability implementation in a fragile state environment. This study ultimately provides a simple framework which outlines six key components that need to be taken into account for the design or evaluation of a social accountability intervention. While this is no failsafe solution to the challenges of designing a social accountability intervention, this framework, and the narrative account of four social accountability interventions in the health sector contained within this thesis, aims to narrow the gap between practitioners and theorists of social accountability.