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Background Accountability for ensuring sexual and reproductive health and rights is increasingly receiving global attention. Less attention has been paid to accountability mechanisms for sexual and reproductive health and rights at national and sub-national level, the focus of this systematic review. Methods We searched for peer-reviewed literature using accountability, sexual and reproductive health, human rights and accountability instrument search terms across three electronic databases, covering public health, social sciences and legal studies. The search yielded 1906 articles, 40 of which met the inclusion and exclusion criteria (articles on low and middle-income countries in English, Spanish, French and Portuguese published from 1994 and October 2016) defined by a peer reviewed protocol. Results Studies were analyzed thematically and through frequencies where appropriate. They were drawn from 41 low- and middle-income countries, with just over half of the publications from the public health literature, 13 from legal studies and the remaining six from social science literature. Accountability was discussed in five health areas: maternal, neonatal and child health services, HIV services, gender-based violence, lesbian/gay/bisexual/transgender access and access to reproductive health care in general. We identified three main groupings of accountability strategies: performance, social and legal accountability. Conclusion The review identified an increasing trend in the publication of accountability initiatives in Sexual and Reproductive Health and Rights (SRHR). The review points towards a complex ‘accountability ecosystem’ with multiple actors with a range of roles, responsibilities and interactions across levels from the transnational to the local. These accountability strategies are not mutually exclusive, but they do change the terms of engagement between the actors involved. The publications provide little insight on the connections between these accountability strategies and on the contextual conditions for the successful implementation of the accountability interventions. Obtaining a more nuanced understanding of various underpinnings of a successful approach to accountability at national and sub national levels is essential.
The review methodology was initially structured with a realist and multi-disciplinary intent to ask “what works in terms of accountability mechanisms in the field of sexual and reproductive health rights (SRHR) at sub-national and national levels, how, why and in which context?”. The review is based on a protocol that was reviewed by an international expert technical committee. We were guided by a meta-interpretation approach [13], which maintains an interpretive epistemology in its analysis, congruent with primary qualitative research. The guiding principles of meta-interpretation are (1) avoiding predetermined exclusion criteria; (2) a focus on meaning in context; (3) using interpretation as unit for synthesis; (4) an iterative approach to theoretical sampling of the studies, and (5) a transparent audit trail to ensure the integrity of the synthesis. It is suitable for this review because it allows capturing the different dimensions relevant to accountability strategies at national and sub-national levels relevant to SRHR accountability. To capture the accountability strategies across multiple disciplines, we used three search engines: PubMed (health literature), Web of Knowledge (social sciences) and LexisNexis Academic (law). The search terms included combinations of free-text words in TI and /or all fields, depending on the search strategies allowed by the database in question (Table 1 and S1 Table). We refer to the latter for the Boolean operators used for each database search strategy. Options to select languages other than English were limited in the three databases. In LexisNexis Academic, two categories of law reviews were available to cover different languages: (1) UK and European journals and (2) Brazilian, Asian law and French language journals and reviews. The UK/European law journals also include journals on legal traditions from LMIC, e.g. Journal of African Law and the Journal of Asian Law. No specific language or country selection options could be made in PubMed and Web of Science. Each abstract was screened using the inclusion and exclusion criteria presented in Table 2, covering time period, geographic range, language and publication type. The abstracts that met the inclusion criteria (articles on low and middle income countries in English, Spanish, French and Portuguese published from 1994 onwards—the year of the first International Conference on Population and Development was organised publications on low and middle income countries) were then reviewed to assess if they (1) relate to any accountability strategy or mechanism, (2) relate to a SRHR area or (3) a national level judicial or reconciliation mechanism (such as court proceedings of international war tribunals). The latter included studies reviewing jurisprudence from supreme, constitutional or other national and provincial level courts. To verify fidelity to the inclusion criteria, a sample of 20 abstracts per database were checked for inclusion/exclusion by a second senior researcher. Two researchers discussed the papers for which they had a different opinion until a consensus was reached. After the full text review, articles were further excluded based on the exclusion criteria (e.g. articles related to global and regional accountability mechanisms). We present the papers that were included in S2 Table. The review question guided the data extraction. Categories included in the data extraction include: (1) author; (2) SRHR issue; (3) year of publication; (4) number of citations (Google Scholar); (5) year of intervention; (6) original language; (7) funding source; (8) study setting; (9) type of study; (10) accountability type according to the article or as deduced by the researcher; (11) accountability relationship (from whom to whom); (12) accountability strategy and implementation instrument; (13) level at which strategy is supposed to work; (14) purpose (why?); (15) lessons learned; (16) reported outcomes; (17) mechanisms; (18) equity effects; (19) description of the intervention or action; (20) scale of the intervention or action; (21) target population and finally (22) the actors involved in the accountability strategy. Since this review covers several disciplines (public health, social sciences, legal studies) with different disciplinary standards for writing and quality appraisal, it is difficult to apply a single framework to assess quality across the cases. Legal reviews, for instance, apply a critical (post-positivist) paradigm and typically do not provide a methodology section. Other studies included do not neatly distinguish between reporting and interpreting results. To gauge quality across the papers, we applied the principles of data quality appraisal for qualitative research [14] and used “Not applicable (NA)” when criteria were not applicable (see S3 Table). Narrative synthesis [15] was used to summarize results and numerical frequencies per category were calculated, whenever this was applicable. Thematic analysis was used to examine the different categories of accountability strategies that emerged.
