Community matters – community responds. Yet many health planners still consider people as passive recipients of programs. Social audits respond to the voice of different stakeholders, including intended beneficiaries, in order to improve health planning and service delivery. The introductory and concluding papers of a special supplement to BioMed Central, discusses the evolution of Centro de Investigación de Enfermedades Tropicales (CIET)’s social audit methods, the lessons learned, and the way forward to the next generation of social audits

A Sen

D Manandhar

J Morrison

M Chan

M Nichter

M Viswanathan

MK Nations

N Andersson

P Freire

R Chambers

Susanna Hausmann-Muela

BMC Health Services Research

English

PubMed

Hausmann-Muela Susanna

Directory of Open Access Journals

The community counts: a participatory approach to social audits

Hausmann-Muela, Susanna

International Development Research Centre: IDRC Digital Library

INTRODUCTION Open AccessThe community counts: a participatory approachto social auditsSusanna Hausmann-Muela“The people have to be seen … as actively involved—giventhe opportunity—in shaping their own destiny, and not justas passive recipients of the fruits of cunning developmentprograms”Amartya Sen, Development as Freedom [1]Community matters – community responds. Yet manyhealth planners still consider people as passive recipientsof programmes.WHO Director-General Dr. Margaret Chan drewattention to this in the global approach to the H1N1pandemic: “Although the virus has not yet delivered anydevastating surprises, we have seen some surprises onother fronts. We anticipated problems in producingenough vaccine fast enough, and this did indeed happen.But we did not anticipate that people would decide notto be vaccinated” [2].Social audits respond to the voice of different stake-holders, including intended beneficiaries, in order toimprove health planning and service delivery. Over thelast two decades, government and private donors haveincreased their demands for evidence of the impacts oftheir supported programmes, to enhance accountabilityand transparency of investments. However, most decisionsin health care are still taken without benefit of solid evi-dence from the concerned communities and intendedbeneficiaries. While it is true that people are increasinglyconsulted, their voice is still a faint murmur at policy andplanning levels. The CIET approach to social auditresponds to this long standing shortfall.This Supplement marks CIET’s 25 years of experience indeveloping and conducting social audits. Over this period,the methodology has evolved, from the early sentinel com-munity surveillance and community-based service-deliverysurveys, through reiterative survey and feedback cyclesthat propose service changes and monitor their effects, torandomised controlled trials - that measure the impact ofinterventions. The systematic and rigorous social auditmethods provide solid evidence from communities thatencourage health planners to plan with and for thecommunities.While the methodological approach has evolved andmatured over the past quarter century, with social auditscovering a wide range of topics in many countries, theunderlying philosophy of CIET’s social audits has endured.CIET’s social audit approach was inspired by the Italianlabour movement and its “alternativa operaia” [3] thatinvolved workers and their knowledge in the conduct ofoccupational epidemiology. Applied in Nicaragua andHonduras in the context of monitoring the “child survivalrevolution” in the mid-1980s [4], this approach foundcommon ground with the Latin American tradition ofparticipatory action research, theoretically grounded inFreire’s philosophy of education. Social audits follow adialogic approach to health-for-all, based on a two-way,symmetrical communication between professionals andthe social groups that health interventions are aimed at.Using Freire’s [5] words, “[i]t is not our role to speak tothe people about our own view of the world, nor toattempt to impose that view on them, but rather to dialo-gue with the people about their view and ours” (p.96).A key feature of CIET’s social audits, as distinct fromFreire’s approach, is the use of epidemiology in gatheringand systematizing evidence from communities. The inten-tion is to combine scientific rigour with communityengagement and social commitment. A methodology todeal with people’s live-worlds (see Nations [6]) should berigorous but not rigid (the rigor mortis of a blinkeredscience). As Neil Andersson [7] states in the introductorypaper of this Supplement: “behind our social auditapproach is the idea of epidemiology as an evolving andself-organising system, a language rather than a rigid tool,with increasingly informed community engagement andincreasing relevance of the emerging solutions”.CIET social audits systematically share reliable, scientifi-cally valid and actionable local evidence with communitiesand service providers, through mechanisms includingfocus groups and dialogues with community and serviceCorrespondence: shausmann@ciet.orgCentro de Investigación de Enfermedades Tropicales (CIET), UniversidadAutónoma de Guerrero, Calle Pino, El Roble, Acapulco, MéxicoHausmann-Muela BMC Health Services Research 2011, 11(Suppl 2):I1http://www.biomedcentral.com/1472-6963/11/S2/I1© 2011 Hausmann-Muela; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.representatives. This formalised mechanism for commu-nity participation in interpreting local evidence and devel-oping solutions [8] nourishes the critical voice issuingfrom this dialogue. This process of socializing of evidencefor participatory action (SEPA) is iterative: repeated cyclesof research and action building confidence among com-munities to identify and solve their own problems.The introductory and concluding papers of this supple-ment discuss the evolution of CIET’s social audit methods,the lessons learned, and the way forward to the next gen-eration of social audits. Other papers illustrate the spreadof social audits in the sphere of health: across five conti-nents and covering topics from corruption in medical edu-cation in Mexico, through local health interventions inindigenous communities in Canada, to national servicesreform programmes in South Asia. Nearly all the socialaudits described in this supplement had at least two cyclesof data collection, analysis and feedback, illustrating theopportunities and challenges of an evidence-based dialo-gue with different stakeholders. The early micro-regionalplanning initiative in Mexico describes how social auditspurred a long-term dialogue among communities andwith local governments. Some of the repeat cycles showedimprovements following actions guided by the initial cycle,as in the Mexico medical school audit, in anti-corruptionefforts in Nicaragua, and in reproductive health services inthe Maldives.In other cases, such as in Bangladesh, Pakistan and SouthAfrica, repeat social audits provided evidence reform pro-grammes and interventions were having little or no impacton the experience and views of communities and serviceusers. Several of the papers describe social audits conductedin the previous century and reflect on their challenges andlessons, while others describe new social audit programmes,such as in Nigeria and the Northwest Territories of Canada.Three papers make specifically methodological contribu-tions: one draws on experience of collecting evidence aboutunofficial payments in six countries; another describes theuse of maps for communicating social audit findings; andanother describes a method of taking account of clusteringin the cross-sectional surveys which are part of most socialaudits.CIET’s use of epidemiology to build the voice of thecommunities into planning has been successful in manycases. In an era where the search for technological ratherthan human solutions predominates, and where impact ismeasured as ‘social returns on investments’, it is encoura-ging to see robust and field-tested methods for buildingsocial capital and community empowerment.There are other examples of epidemiological approachesto building the community voice into planning. In LatinAmerica the tradition of participatory action research(PAR) is rooted in the work of Paulo Freire [5] andOrlando Fals Borda [9] In the UK and the Commonwealthcountries rapid rural appraisal associated with RobertChambers shares much of the same philosophy [10]. InNorth America such approaches are generally referred toas community-based participatory research (CBPR) [11].In Nepal, Manandhar and colleagues have been conduct-ing studies that have incorporated social mobilisation intocluster randomised controlled trials involving maternaland child health [12,13].Parallel movements of participatory action research aregaining strength in public health and transdisciplinaryresearch; formative research [14] and asset-based commu-nity development [15] are well developed and have goodtrack-records in implementation and developmentprograms.Common to these approaches and the CIET socialaudit approach is the recognition that behaviour changeand community empowerment take time. Sustainablechange is a long-term social process; there is no short-cut and no miraculous technological quick-fix to showimmediate results. A systematic review of CBPR studiesin 2004 found many studies that had strong community-institution collaborations while relatively few combinedsuch collaboration with solid research methods [16]. Theresearch methods presented in this supplement are bothsolid and transparent.This Supplement on CIET social audit advocates for aparticipatory approach in health policy and planning,that gives people the opportunity to participate in shap-ing their own destiny – that gives them a voice.AcknowledgementsThis article has been published as part of BMC Health Services ResearchVolume 11 Supplement 2, 2011: Social audit: building the community voiceinto health service delivery and planning. The full contents of thesupplement are available online at http://www.biomedcentral.com/1472-6963/11?issue=S2.Published: 21 December 2011References1. Sen A: Development as Freedom. Oxford: Oxford University Press; 1999.2. Chan M: Progress in public health during the previous decade andmajor challenges ahead. Report by the Director-General to the ExecutiveBoard at its 126th session, Geneva, Switzerland, 18 January 2010 World HealthOrganization; 2010 [http://www.who.int/dg/speeches/2010/executive_board_126_20100118/en/index.html].3. Diario prevenzione magazine. 1993 [http://www.diario-prevenzione.net/diarioprevenzione/html/modules.php?name=News&file=article&sid=1295].4. Andersson N: Impact, Coverage and Costs: An Operational Frameworkfor Monitoring Child Survival, Emerging from Two UNICEF Projects inCentral America. UNICEF Area Office for Central America and Panama,Mimeo; 1985.5. Freire P: Pedagogy of the Oppressed. New York: The Seabury Press; 1974.6. Nations MK: Epidemiological research on infectious disease: quantitativerigor or rigor mortis? Insights from ethnomedicine. In Anthropology andEpidemiology. Dordrecht: D.Reidel Publishing Company;Janes CR, Stall R,Gifford SM 1986:.7. Andersson N: Building the community voice into planning: 25 years ofmethods development in social audit. BMC Health Services Research 2011,11(Suppl 2):S1.Hausmann-Muela BMC Health Services Research 2011, 11(Suppl 2):I1http://www.biomedcentral.com/1472-6963/11/S2/I1Page 2 of 38. Ledogar R, Andersson N: Social Audits: Fostering accountability to localconstituencies. Capacity.org 2002, 15: 2-4 [http://lencd.com/data/docs/74-Capacity%20for%20Voice.pdf ].9. Action and Knowledge: Breaking the Monopoly with ParticipatoryAction. New York, NY: Apex Press/Intermediate Technology Publications;Fals Borda O, Rahman A 1991.10. Chambers R: Rural Appraisal: Rapid, Relaxed and Participatory. DiscussionPaper 311 Brighton, England: Institute of Development Studies; 1992.11. Community-Campus Partnerships for Health. [http://depts.washington.edu/ccph/commbas.html].12. Manandhar D, Osrin D, Shrestha BP, Mesoko N, Morrison J,Tumbahangphe KM, Tamang S, Thapa S, Shrestha D, Thapa B, Shrestha JR,Wade A, Borghi J, Standing H, Manandhar M, Costello A, members of theMIRA Makwanpur trial team: Effect of a participatory intervention withwomen’s groups on birth outcomes in Nepal: cluster-randomisedcontrolled trial. The Lancet 2004, 364:970-79.13. Morrison J, Tumbahangphe KM, Budhathoki B, Neupane R, Sen A, Dahal K,Thapa R, Manandhar R, Manandhar D, Costello A, Osrin D: Communitymobilisation and health management committee strengthening toincrease birth attendance by trained health workers in rural Makwanpur,Nepal: study protocol for a cluster randomised controlled trial. Trials2011, 12(1):128.14. Nichter M, Acuin CS, Vargas A: Introducing zinc in a diarrhoeal controlprogramme: guide to conducting formative research. Geneva: World HealthOrganization; 2008, http://extranet.who.int/iris/bitstream/123456789/1005/1/9789241596473_eng.pdf.15. The Asset-Based Community Development Institute. [http://www.abcdinstitute.org/].16. Viswanathan M, Ammerman A, Eng E, Gartlehner G, Lohr KN, Griffith D,Rhodes S, Samuel-Hodge C, Maty S, Lux L, Webb L, Sutton SF, Swinson T,Jackman A, Whitener L: Community-Based Participatory Research: Assessingthe Evidence. Evidence Report/Technology Assessment No. 99. AHRQPublication 04-E022-2. Rockville, MD: Agency for Healthcare Research andQuality; 2004.doi:10.1186/1472-6963-11-S2-I1Cite this article as: Hausmann-Muela: The community counts: aparticipatory approach to social audits. BMC Health Services Research 201111(Suppl 2):I1.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitHausmann-Muela BMC Health Services Research 2011, 11(Suppl 2):I1http://www.biomedcentral.com/1472-6963/11/S2/I1Page 3 of 3

Community counts : a participatory approach to social audits

Crossref

A: Introducing zinc in a diarrhoeal control programme: guide to conducting formative research. Geneva: World Health Organization;

Building the community voice into planning: 25 years of methods development in social audit.

Community-Based Participatory Research: Assessing the Evidence. Evidence Report/Technology Assessment No. 99. AHRQ Publication 04-E022-2. Rockville, MD: Agency for Healthcare Research and Quality;

Community-Campus Partnerships for Health.

Coverage and Costs: An Operational Framework for Monitoring Child Survival, Emerging from Two

Development as Freedom.

Epidemiological research on infectious disease: quantitative rigor or rigor mortis? Insights from ethnomedicine.

Knowledge: Breaking the Monopoly with Participatory Action.

members of the MIRA Makwanpur trial team: Effect of a participatory intervention with women’s groups on birth outcomes in Nepal: cluster-randomised controlled trial. The Lancet

Osrin D: Community mobilisation and health management committee strengthening to increase birth attendance by trained health workers in rural Makwanpur, Nepal: study protocol for a cluster randomised controlled trial. Trials

Pedagogy of the Oppressed.

Progress in public health during the previous decade and major challenges ahead. Report by the Director-General to the Executive Board at its 126th session,

Rural Appraisal: Rapid, Relaxed and Participatory. Discussion Paper 311

The Asset-Based Community Development Institute.

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The community counts: a participatory approach to social audits

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