Citizen-Led Accountability: Applying systems thinking to understand and strengthen health system responsiveness to marginalized communities

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In many low and middle income countries, the full enjoyment of the right to health is inhibited by deficiencies in the health system, including inadequate infrastructure, human resources, and medicines and equipment. Citizen-led accountability initiatives have the potential to foster bottom up responses. They can contribute to strengthening health systems by mobilizing marginalized communities with limited access to quality health care and supporting their engagement with state authorities to demand accountability. Over the last decade, numerous examples have shown that these initiatives have been effective in making the health sector, and other public sectors, more responsive and accountable. However, understanding of the complex pathways through which citizen-led accountability initiatives lead to positive change remains limited. Their function depends on building networks of relationships that connect citizens in collective action, and engage them in dynamic interactions with state authorities. Adaptation to political and social context is also critical. Innovative methodological approaches are needed to understand how these network-generating processes function and how they can be enhanced to improve health system responsiveness to marginalized communities. The proposed research will address this challenge by applying a systems thinking approach. The science of systems thinking offers valuable tools for understanding and strengthening complex change processes. This project will employ the systems thinking tool called Social Network Analysis to study how networks of marginalized citizens work together and interact with authorities to demand health system accountability. The research will be carried out in two phases with indigenous communities participating in a well-established citizen-led accountability initiative in rural Guatemala. Citizen networks in these communities are actively working to monitor health system deficiencies, participate in local health decision-making spaces, communicate their needs to state authorities, and form alliances to advocate for structural improvements. In the first phase, social network analysis will be applied in these communities to provide insight into: 1. patterns of communication and support within the citizen networks that carry out these activities, and 2. patterns of interaction between citizens and state authorities at different levels and the responses they receive. Following in the systems thinking approach, this knowledge will be applied to strengthen the citizen networks in the second phase. In this phase, participants from the first phase will interpret: 1. how the patterns identified influence their capacity to meet their goals, and 2. how their network is influenced by local political and social context. Participants will draw on these insights to identify strategic actions to strengthen their networks' effectiveness in mobilizing their communities and communicating with authorities.The knowledge produced by this project will be directly relevant for strengthening citizen-led action for health system accountability to marginalized communities in Guatemala. Understanding of the influence of network qualities on citizen-led initiatives' capacity to meet their goals will be more broadly relevant to development agencies and practitioners working to support the mobilization of bottom up pressure for accountability. The development of an applied Social Network Analysis tool through this project will also offer a valuable resource for researchers to gain insights into the function of citizen networks in other settings, and identify broader patterns in their interactions that contribute to strengthen health system responsiveness.