The role of social audit as a social accountability mechanism for strengthening governance and service delivery in the primary health care setting of Nepal: a qualitative study

Social audit is a mechanism used to hold frontline health service providers accountable. Using the case of the social audit process in Dang District, Nepal, this study explored the role of social audit in facilitating direct accountability between service providers and community. This relationship was summarised by three elements: information/data collection, dialogue/forum, and sanctions. A total of 39 interviews were held with health facility operation and management committee members, service providers, district level health managers and non-government organisation members. Reviews of records of social audit action plans were undertaken at 10 health facilities. Participants reported that the social audit process was able to facilitate information provision/data collection, and provided opportunities for dialogue between community and service providers, but the provision of sanctions was found to be weak. While social audit had a positive role in increasing transparency, accessibility and quality of services, its effectiveness in addressing perennial governance problems was mixed. Manipulation of the participation process, falsification of information, and lack of authority affected the role of social audit in facilitating accountability. These factors are essential to consider while designing and implementing social audit processes. While giving more power and control to the community to monitor and implement social audit action plans seems appealing, the concept of partnership between community and service providers with joint problem-solving and an emphasis on relational elements of accountability are most likely to build trust and responsiveness. If social audit is used alongside existing traditional accountability mechanisms, it could help to address governance and accountability issues.