HFC baseline situation.

Community governance, the direct (co-)management of public services by community members, is a popular approach to improve the quality of, and access to, healthcare services–including in so-called ‘fragile’ states. The effectiveness of such approach is, however, debated, and scholars and practitioners have emphasised the need to properly reflect on the contextual features that may influence social accountability interventions. We study a randomised intervention during which community-elected health facility committee members were trained on their roles and rights in the co-management of primary healthcare facilities. 328 publicly-funded health facilities of Burundi and Sud Kivu in DR Congo were followed over a period of one year. In Kivu, but not in Burundi, the intervention strengthened the position of the committee vis-à-vis the health facility nurses and affected the management of the facility. HFC members mostly focused on improving the elements most accessible to them: hiring staff and engaging in basic construction and maintenance work. Using survey data and interviews, we argue that part of the discrepancy in results between the two contexts can be explained by differences in health facilities’ management (whether they primarily depend on a local church or more distant authorities) as well as different local histories of relationship to public service providers. The former affects the room available for change, while the latter affects the relevance of the citizens’ committee as an acceptable way to interact with healthcare providers. No effect was found on the perceived quality of and access to services, and the committees, even when strengthened, appear disconnected from the citizens. The findings are an invitation to re-think the conditions under which bottom-up accountability mechanisms such as citizens committees can be effective in ‘fragile’ settings.社区治理，即社区成员直接（共同）管理公共服务，是提升医疗服务质量与可及性的常用路径，在所谓的‘脆弱国家’（Fragile States）中亦被广泛应用。然而，此类路径的有效性尚存争议，学者与实务界人士均强调，需深入审视可能影响社会问责（Social Accountability）干预举措的各类情境特征。本研究针对一项随机干预试验展开分析：试验中，经社区选举产生的医疗机构委员会（Health Facility Committee，简称HFC）成员接受了关于其在基层医疗设施共同管理中职责与权利的培训。研究共随访了布隆迪与刚果民主共和国（DR Congo）南基伍省（Sud Kivu）的328家公立医疗设施，随访周期长达一年。在南基伍省，该干预措施强化了HFC相较于医疗机构护士的话语权，并对设施管理产生了影响；而在布隆迪则未观察到此类效果。HFC成员主要聚焦于改善自身可直接参与的事务：招聘工作人员、开展基础建设与维护工作。本研究通过调研数据与访谈资料分析后认为，两地研究结果存在差异的部分原因，可归结为医疗机构管理模式的不同（即机构主要依附于地方教会还是更上级的管理部门），以及当地与公共服务提供者的关系历史存在差异。前者影响变革的可行空间，后者则决定了公民委员会作为与医疗服务提供者互动的可接受方式的相关性。研究未发现干预对服务感知质量与可及性产生任何影响；即便HFC得到强化，其仍似乎与普通民众脱节。本研究结果呼吁重新审视：在‘脆弱’环境中，诸如公民委员会这类自下而上的问责机制，需具备何种条件才能发挥实效。