Social accountability as a strategy to promote sexual and reproductive health entitlements for stigmatized issues and populations.

Social accountability is often put forward as a strategy to promote health rights, but we lack a programmatic evidence base on if, when, and how social accountability strategies can be used to promote access to quality Sexual and Reproductive Health (SRH) care for stigmatized populations and/or stigmatized issues. In this Commentary, we discuss the potential advantages and disadvantages of social accountability strategies in promoting the availability of a full range of SRH services for excluded and historically oppressed populations. We accomplish this by describing four programs that sought to promote access to quality SRH care for stigmatized populations and/or stigmatized services. Program implementers faced similar challenges, including stigma and harmful gender norms among providers and communities, and lack of clear guidance, authority, and knowledge of Sexual and Reproductive Health and Rights (SRHR) entitlements at local level. To overcome these challenges, the programs employed several strategies, including linking their strategies to legal accountability, budgetary expenditures, or other institutionalized processes; taking steps to ensure inclusion, including through consultation with excluded or stigmatized groups throughout the program design and implementation process; specific outreach and support to integrating marginalized groups into program activities; and the creation of separate spaces to ensure confidentiality and safety. The program experiences described here suggest some general principles for ensuring that social accountability efforts are inclusive both in terms of populations and issues addressed. Further empirical research can test and further flesh out these principles, and deepen our understanding of context.

Human rights-based accountability for sexual and reproductive health and rights in humanitarian settings: Findings from a pilot study in northern Uganda.

Ensuring accountability for the realization of sexual and reproductive health and rights is a human rights obligation and central tenet of strategies to improve health systems and outcomes in humanitarian settings. This pilot study explored the feasibility and acceptability of deploying human rights strategies, specifically through a participatory community-led complaints mechanism, to hold humanitarian health systems to account for the sexual and reproductive health and rights of refugee and host community women and girls in northern Uganda. Over a fifteen-month period we conducted a multi-methods exploratory study with refugee and host community rights-holders and duty-bearers using longitudinal in-depth interviews, focus groups, and secondary data document review. Deductive and inductive coding techniques were used to analyze data iteratively for content and themes. 107 sexual and reproductive health and rights related complaints and feedback were collected through the community complaints mechanism. Complaints concerned experiences of disrespect and abuse by health care workers; lack of adolescent access to sexual and reproductive health services and information; sexual and gender-based violence; and lack of access to acceptable and quality health goods and services. Participants reported an increased understanding and claiming of human rights through the intervention, acceptability of rights-based accountability strategies among humanitarian health system actors, and improved access to remedies when sexual and reproductive health rights are not respected. Findings demonstrate integrating rights-based social accountability mechanisms at the level of humanitarian response as a promising approach for strengthening and holding humanitarian health systems accountable for the sexual and reproductive health and rights of women and girls affected by humanitarian situations.