In many low- and middle-income countries (LMICs), particularly across sub-Saharan Africa, community health governance structures have become a central feature of primary health care governance. Although they vary in form, authority, and effectiveness, they are all inspired by the World Health Organisation and the Alma-Ata Declaration, which emphasised community involvement in health governance. They usually have the mandate of strengthening accountability, improving service delivery, and bridging the gap between communities and health providers. But a critical question remains; do these groups deliver on accountability?

This question is not just theoretical. It sits at the heart of ongoing debates about health system strengthening, especially in contexts where weak oversight, absenteeism, and informal practices continue to undermine the quality of care.

Understanding the Accountability Promise

Community health governance structures are typically composed of local representatives tasked with overseeing health facility operations, mobilising community participation, and ensuring that health workers remain responsive to local needs. In principle, they embody what is often described as social accountability; a process through which citizens collectively hold service providers and policymakers to account.

Embedding community oversight within PHCs meant that they would:

• Monitor staff attendance and performance

• Report misconduct or corruption
• Facilitate dialogue between providers and users
• Ensure that services reflect local priorities

The Reality on the Ground: Between Potential and Constraint

Evidence from multiple studies suggests that while these structures can contribute to accountability, their effectiveness is highly uneven and context-dependent.

A recurring pattern is that CHCs function less as formal enforcement bodies and more as relational intermediaries. They do not have the power to sanction, so they often rely on negotiation, persuasion, and social pressure.

This has both strengths and limitations.

On one hand, relational accountability can:

• Foster trust between providers and communities
• Encourage voluntary compliance by health workers
• Enable context-sensitive problem-solving

On the other hand, it may:

• Limit the willingness of committees to challenge entrenched power dynamics
• Reduce their capacity to address systemic issues like chronic absenteeism
• Lead to selective enforcement, especially where committee members have personal ties to health workers

Power, Capacity, and Legitimacy

Three interrelated factors consistently shape the effectiveness of community health governance structures in promoting accountability:

1. Power Relations
   Community members may feel constrained in confronting health workers, who are often perceived as more educated or socially elevated. In some cases, health workers themselves dominate committee structures, blurring lines of accountability.
2. Capacity and Knowledge
   Many committee members lack the technical knowledge required to effectively monitor service quality or interpret health data. Without adequate training, their oversight role becomes symbolic rather than substantive.
3. Institutional Linkages
   Perhaps most critically, CHCs are often poorly integrated into formal health system governance. When reports or complaints do not trigger action from higher authorities, community monitoring loses credibility.

When Do CHCs Work?

Despite these constraints, there are contexts where community health governance structures have demonstrated tangible impact. Their effectiveness tends to improve when:

• They are supported by clear legal mandates and defined roles
• There are functional feedback mechanisms linking them to higher-level authorities
• Members receive continuous training and capacity building
• There is external facilitation (e.g., NGOs) to strengthen their voice and autonomy
• Community awareness and engagement are high

In such settings, they can play a crucial role in identifying service delivery gaps, improving responsiveness, and even reducing informal payments.

Conclusion

Community health governance structures hold significant promise, but their impact on accountability is neither automatic nor guaranteed. They operate within complex social and institutional environments where power, relationships, and resource constraints shape their effectiveness. Ultimately, improving accountability in health systems is less about creating structures and more about ensuring that those structures are empowered, connected, and capable of action.

Chika had heard about it all her life: childhood immunisation is free. So, when she delivered her first baby, she did what the system expects of every responsible mother; she went to a public facility for routine vaccination. After hours of waiting, she was finally called in and asked to pay ₦200 for a syringe used in administering the vaccine.

The amount may seem small. But multiply ₦200 by dozens of children, twice a week, across thousands of facilities. What appears trivial at the individual level becomes systemic at scale. More importantly, it violates a simple promise: essential immunisation services are free.

This is not an isolated incident. It is a symptom of something deeper: corruption embedded in everyday health system practices.

Corruption Is Not Just About “Bad People”

In health systems research, corruption is broadly understood as the abuse of entrusted power for private gain. Transparency International and the World Health Organization (WHO) have documented how corruption manifests in health systems globally, particularly in low- and middle-income countries.

Common forms include:

• Informal payments or bribes for “free” services
• Procurement fraud and overpricing of supplies
• Diversion or theft of medicines and vaccines
• Absenteeism and ghost workers
• Nepotism in hiring and promotion
• Manipulation of service data to secure funding
• Facility-level extortion (“pay before your file moves”)

While policymakers often frame corruption as individual moral failure, evidence suggests it is frequently a predictable outcome of weak governance structures, distorted incentives, opaque financial flows, and limited accountability mechanisms.

When reform focuses only on punishment and publicity, corruption adapts. It rarely disappears.

Why Policymakers Get It Wrong

Many anti-corruption initiatives emphasize transparency campaigns, disciplinary measures, and public declarations. These are necessary but insufficient.

Three core misunderstandings often undermine reform:

1. Treating Corruption as Exceptional Rather Than Systemic

Corruption in health systems is rarely random. It often thrives where:

• Salaries are delayed or inadequate
• Supervision is weak
• Financial processes are opaque
• Supply chains are unreliable
• Reporting channels are unsafe

In such contexts, informal payments and absenteeism become normalized survival strategies rather than isolated misconduct.

2. Ignoring Structural Incentives

Low motivation, poor working conditions, and unclear career pathways create fertile ground for rent-seeking behaviour. When systems reward loyalty over competence or tolerate absenteeism, governance failure, not individual immorality, becomes the core driver.

3. Overlooking Procurement and Financing

Procurement is technically complex and politically sensitive. Yet this is where the largest financial leakages occur. Weak contract oversight, lack of price benchmarking, and closed bidding processes allow overpricing and supply diversion. Studies consistently show that opaque procurement is a major corruption risk in health sectors globally.

The Human Cost: Who Pays?

Corruption is not abstract. It reshapes health-seeking behaviour and health outcomes.

Women, children, and rural populations are disproportionately affected. When informal fees are attached to free maternal drugs, some women turn to traditional birth attendants. When staff are absent, patients delay care. When drugs are diverted, stock-outs push families toward expensive private alternatives or untreated illness.

Research across sub-Saharan Africa shows that informal payments reduce service utilization and erode trust in public systems. Over time, corruption weakens both access and quality – the two pillars of universal health coverage.

What Actually Works: Moving Beyond Punishment

Replacing one staff member or issuing public warnings may create short-term compliance. Sustainable reform requires system redesign.

Evidence-informed strategies include:

1. Strengthening Financial and Procurement Transparency

• Open contracting and competitive bidding
• Independent price benchmarking
• Digital procurement tracking systems
• Public disclosure of awarded contracts

Digital audit trails reduce discretionary control and create verifiable records of transactions.

2. Making Service Rules Visible

• Publicly displayed service charters
• Transparent fee schedules
• Clear referral and admission protocols
• Real-time stock visibility systems

When patients know what is free and what is not, informal charges become harder to justify.

3. Embedding Routine Accountability

• Independent facility audits
• Mystery patient surveys
• Spot checks
• Procurement red-flag analytics

These mechanisms detect patterns rather than waiting for whistleblower complaints.

4. Protecting Whistleblowers and Complainants

Accountability fails when reporting is unsafe. Confidential grievance systems, fair disciplinary procedures, and visible consequences for misconduct are critical.

5. Addressing Incentives and Workforce Conditions

Improved salary reliability, performance-linked incentives, supportive supervision, and clear promotion pathways reduce reliance on informal income streams. Anti-corruption reform is most effective when it aligns incentives, improves oversight, and reduces discretionary power simultaneously.

Conclusion

When governance improves, patients experience tangible change: shorter queues, predictable drug availability, respectful care, and genuine free services where promised. Chika’s ₦200 is not just a small informal fee. It represents the gap between policy promise and system reality. Closing that gap demands more than punishment. It demands redesigning the system so that it works for all.

The day-to-day problems people experience in many low- and middle-income countries (LMICs) (i.e. medicine stock-outs, long waiting times, understaffed facilities, weak referral systems, and high out-of-pocket payments) often reflect deeper system challenges. These can include weak infrastructure and maintenance, inconsistent financing, gaps in leadership and accountability, shortages or uneven distribution of skilled health workers, and supply chain problems. A useful way to understand these moving parts is the World Health Organization’s health system “building blocks”: service delivery, health workforce, health information, medicines and technologies, financing, and leadership/governance.

The consequences of these gaps were notable during the COVID-19 pandemic. The pandemic not only increased demand for care but also disrupted routine services in many LMICs.

Thus, governments, NGOs, and international partners often work together to improve performance. One major strategy they use is health system reform. This is the deliberate change in how health services are financed, organised, delivered, and governed, to improve access, quality, and fairness. Health reforms are often linked to the broader goal of universal health coverage, which is to ensure people can get the services they need without financial hardship.

So, if reforms are meant to strengthen systems, why do they so often fail to deliver the results people expect?

1) Reforms look good on paper, but implementation is weak

A reform is not a policy document. It is what changes in clinics, hospitals, and communities. Many reforms stall because the “how” is not clear: who will do what, with which resources, and how progress will be tracked. When accountability is weak, even a well-designed reform can lose direction and become symbolic. This is why it is emphasised that there must be accountable relationships among citizens, providers, and the state regarding how reforms will take place and who will do what.

2) Political commitment fades, but reforms need steady support

Health system reforms usually take years, not months. When leadership changes, budgets tighten, or attention shifts to a new priority, reforms can lose momentum. Over time, implementation becomes inconsistent, supervision reduces, and performance monitoring weakens. One notable challenge in this area is the fact that many countries’ governments sometimes “police” policies rather than build implementation capability.

3) Short-term funding cannot buy long-term system change

Strengthening a health system is expensive and ongoing: salaries, training, supply chains, data systems, facility operations, and quality improvement all require predictable financing. When funding is unstable, as is often the case with many LMICs, or tied to short project cycles, reforms may start strongly but fade before they mature.

This challenge can be bigger in settings where external funding plays a large role. Aid can be volatile relative to country budgets, and donor cycles do not always match the long timelines needed for system reforms.

4) Health workers are central, but reforms sometimes treat them as an afterthought

Reforms succeed or fail at the point of care. This is where health workers provide services, explain decisions, document care, and build trust with patients. When reforms do not address the realities health workers face (workload, pay, supervision, supplies, safety, and career progression), implementation suffers. Health workers may comply on paper without meaningful change in practice.

The idea here is well supported in health reform literature: reforms are highly context-dependent and require attention to workforce realities, not just technical designs.

5) Community involvement is often promised, but not built into the reform

Community engagement is frequently mentioned in reform plans, but it is not always funded, structured, or sustained. Yet communities can help define priorities, report barriers to access, and improve trust, especially when reforms affect costs, service hours, or the way care is delivered.

When communities feel excluded, trust can drop, and people may delay care, self-treat, or stop using services, even when services technically exist. This is part of why quality and trust are treated as central, not optional, to progress in health systems.

What makes reform more likely to succeed?

Identifying gaps is a strong start, but successful reform usually includes:

• A realistic implementation plan: clear roles, timelines, and feedback loops, not just a policy launch.
• Stable financing: funding that supports core system functions over the years, not only short projects.
• Workforce-centred design: fair and timely remuneration, supportive supervision, training, and the tools needed to do the job.
• Accountability: incentives and oversight that make it easier to do the right thing and harder for resources to leak or plans to stall.
• Context-fit solutions: borrowing ideas from other countries can help, but reforms must match local culture, institutions, and community realities.

Conclusion

Health system reforms in LMICs often fail not because reform is pointless, but because systems are complex and change takes sustained effort. Policies must be matched with implementation capacity, stable financing, meaningful involvement of health workers and communities, and accountability that stays strong long after take-off.

Efforts to tackle corruption in the health sector often fail not because social accountability is ineffective, but because it is applied too narrowly.

In our recent blog, authored by Aloysius Odii and Nnenna Mba‑Oduwusi, and published by the Global Network for Anti-corruption, transparency and accountability in health (GNACTA), we argue that social accountability should be understood and designed as a multi-component strategy, rather than a single intervention. Using the Nigerian health sector as a case study, the article showcases how power, incentives and systems can help sustain anti-corruption efforts.

Meaningful impact emerges when social accountability mechanisms are intentionally linked to institutional responsiveness, oversight structures, enforcement pathways, and feedback loops. When these components work together, citizen voice is more likely to translate into improved service delivery and better health outcomes.

We are encouraged that this perspective resonated with reviewers and that the blog was recognised by the Accountability & Anticorruption SDG Thematic Working Group, Health Systems Global (TWG-AAA), through a competitive review process for its relevance to advancing the field. More importantly, we hope the ideas contribute to deeper reflection on how social accountability is designed, funded, and implemented in Nigeria and similar contexts. 

Read about the blog here

One major reason health interventions fail to achieve their intended impact is poor or delayed engagement of key stakeholders. Stakeholder engagement is the engine of any successful health intervention. Without it, even the most well-funded or technically sound projects risk performing below expectations once implemented.

Stakeholders, whether policymakers, community leaders, healthcare workers, beneficiaries, or implementing partners, hold critical influence over how interventions are received, implemented, and sustained. Their voices shape the design, relevance, and long-term viability of any health programme. Yet, in many cases, stakeholder engagement is not taken seriously.

What Stakeholder Engagement Really Means

Stakeholder engagement goes beyond holding consultative meetings or sharing progress reports. It is about the active and meaningful involvement of people and institutions who influence or are affected by an intervention. True engagement means that stakeholders are not passive recipients of information, but co-creators in the process. That means they help shape objectives, implementation strategies, and evaluation frameworks.

This collaborative process is vital because it brings together diverse experiences and local knowledge. When communities and professionals jointly define problems and propose solutions, interventions become more contextually grounded, feasible, and sustainable.

Why Early Engagement Matters Most

Our experience from multiple projects consistently demonstrates that the timing of stakeholder engagement is as important as the engagement itself. Early engagement, beginning from the conception and design stage, sets the foundation for success.

When stakeholders are engaged early, several benefits follow:

• Interventions are better aligned with local realities. Stakeholders help identify community needs, socio-cultural barriers, and political sensitivities that outsiders may overlook.
• Trust and accountability are built from the start. Early dialogue fosters transparency, reduces suspicion, and ensures that roles and responsibilities are clearly defined.
• Ownership and sustainability are enhanced. When people feel that they have contributed to shaping an intervention, they are more likely to champion it and sustain it beyond project timelines.

Early engagement also helps identify potential risks before they become major obstacles. Whether it’s community resistance, policy misalignment, or operational gaps, these issues can be mitigated when stakeholders are part of the planning.

The Consequences of Late or Superficial Engagement

On the other hand, delayed or poor stakeholder engagement often leads to disconnection between the intervention and the realities it seeks to address. Projects designed without early local input tend to misalign with community priorities, resulting in weak ownership, low adoption, and poor outcomes.

Delayed engagement can also create operational bottlenecks. For example, frontline health workers may resist new reporting systems if they were never consulted about their practicality. Policymakers may deprioritise interventions they were not involved in shaping. Ultimately, poor engagement translates to poor coordination, wasted resources, and unacceptable results.

Laying the Foundation for Success

Early stakeholder engagement is not merely about starting conversations; it is about establishing a partnership built on mutual trust, respect, and accountability. It allows implementers to see the intervention through the eyes of those who will live with its outcomes. It ensures that health interventions are not just designed for people but with them.

At InSiGHt, we have learned that meaningful engagement must begin at the earliest possible moment, and that is when the problem is being defined, not after the solution is decided. This approach transforms stakeholders from external observers into active partners and helps to bridge the common divide between project design and implementation reality.

Conclusion

Health interventions succeed not only because of strong technical design but because of strong relationships. Early stakeholder engagement builds those relationships. It provides the foundation on which trust, coordination, and sustainability rest. Without it, even the most ambitious health projects may struggle to take root.

The next part in this series will explore how to engage stakeholders effectively. We will outline practical steps and tested strategies for inclusive, transparent, and sustained collaboration across all stages of a health intervention.

Every year, millions of newborns around the world take their first breath, and for many in sub-Saharan Africa, it is also their last. To put this into context, in 2022, about 2.3 million children died within the first 28 days of life. Nigeria has a high neonatal mortality rate, put at 30 to 40 deaths per 1,000 live births. Many of these deaths occur in the first 24 hours after birth and are preventable with timely and skilled care.

In our recent study published in Simulation in Healthcare, we offer new evidence that digital learning platforms can help save newborn lives by strengthening the capacity of frontline health workers in Nigeria. The study, supported by the Bill & Melinda Gates Foundation and implemented by the American Academy of Paediatrics (AAP), examined how nurses, midwives, and doctors in northern Nigeria were affected by a digitally delivered Essential Newborn Care (ENC) training program.

Saving lives: digitally

When the COVID-19 pandemic disrupted in-person training across much of Africa, medical educators had to innovate. The Nigerian team adopted a remote facilitation model that combined online sessions via Zoom with in-facility, hands-on practice supported by neonatal simulators, particularly NeoNatalie Live (NNL), a high-fidelity manikin that provides digital feedback on newborn resuscitation skills.

Health workers from four secondary health facilities in Borno, Yobe, and Gombe States participated in the training, guided by facilitators from the Pediatric Association of Nigeria (PAN), AAP, and InSiGHt Health Consulting (IHC). Using the digital ENC Course and the NeoNatalie app, participants learned evidence-based practices such as drying and stimulating the baby immediately after birth, avoiding unnecessary suctioning, ensuring proper ventilation at 40 breaths per minute, delaying cord clamping, and promoting skin-to-skin contact and early breastfeeding.

What we found

At the end of the exercise, we conducted Interviews and focus group discussions (FGDs) with the participants. Our findings revealed that the participants not only learned new techniques but also transformed their approach to newborn care. Many reported abandoning outdated and potentially harmful practices, such as turning babies upside down after delivery, and instead applying methods that prioritise the newborn’s breathing and bonding with the mother.

These behavioural shifts were more than theoretical. Several health workers observed tangible improvements in their wards (i.e., fewer asphyxiated babies, fewer referrals, and fewer deaths). One facility that used to record around 11 neonatal deaths per month reported a reduction to just 3 following the training.

Barriers on the path to progress

Yet, the journey was far from smooth. The study participants identified several barriers that limited the full potential of digital training.

First, access to simulators was a recurring issue. With only a few NeoNatalie manikins available per facility, health workers often had to queue for practice, which constrained learning opportunities.

Second, poor internet connectivity, a common challenge across many parts of Nigeria, disrupted real-time instruction and feedback. Third, workload pressures and staff shortages made it difficult to apply newly learned skills in busy maternity wards. Some health workers admitted that when labour rooms became crowded, they reverted to older shortcuts to save time. Finally, resistance to new practices among untrained colleagues slowed adoption.

Way forward

These challenges have shown that training alone is not enough. Digital learning can empower health workers with new skills, but systemic barriers, ranging from inadequate staffing to weak infrastructure, must also be addressed for sustainable impact.

Thus, successful scale-up requires “a dual focus on education and health system strengthening.” That means providing more training equipment, improving connectivity, redistributing workloads, and ensuring that refresher training is built into health systems. Continuous mentoring, peer-to-peer learning, and institutional support can help trained staff sustain and spread their skills.

Conclusion

Our study suggests that we can save more lives by improving healthcare workers’ skills and capacity in newborn care. This study from Nigeria offers hope: that by combining technology, training, and teamwork, health systems can bridge the gap between knowledge and survival.

Furthermore, we acknowledge the challenges of implementing a digital education in resource-constrained settings. Yet, there is evidence that digital and simulation-based training can be locally adapted, affordable, and impactful, even in fragile contexts. As Nigeria and other countries work toward the Sustainable Development Goal of ending preventable newborn deaths, scaling up such innovations is critical.