Can payment by results ensure equitable access to contraceptive services? a qualitative case study.

BACKGROUND: The Leave No One Behind (LNOB) agenda compels sexual and reproductive health and rights (SRHR) implementers to focus on the multiple and intersecting forms of discrimination and inequalities. One strategy to address these is Payment by Results (PbR). Using the Women's Integrated Sexual Health (WISH) programme as a case study, this paper examines if and how PbR can ensure equitable reach and impact. METHODS: Given the complexity of PbR mechanisms, a theory-based approach was used in the design and analysis of this evaluation, drawing on four case studies. These were conducted by reviewing global and national programme data and by interviewing 50 WISH partner staff at national level and WISH programme staff at global and regional levels. RESULTS: The case studies found that inclusion of equity-based indicators in the PbR mechanism had demonstrable effects on people's incentives, on how systems work, and on modes of working. The WISH programme was successful in achieving its desired programme indicators. The use of Key Performance Indicators (KPIs) clearly incentivised several strategies for service providers to innovate and reach adolescents and people living in poverty. However, there were trade-offs between performance indicators that increased coverage and others that increased equitable access, as well as several systemic challenges that limited the possible incentive effects. CONCLUSIONS: The use of PbR KPIs incentivised several strategies to reach adolescents and people living in poverty. However, the use of global indicators was too simplistic, resulting in several methodological issues.

The role of social accountability in changing service users' values, attitudes, and interactions with the health services: a pre-post study.

This study evaluated the effects of community engagement through social accountability on service users' values, attitudes and interactions. We conducted a pre-post study of the community and provider driven social accountability intervention (CaPSAI) over a 12-month period among 1,500 service users in 8 health facilites in Ghana and in Tanzania (n = 3,000).In both countries, there were significant improvements in women's participation in household decision-making and in how service users' perceive their treatment by health workers. In both settings, however, there was a decline in women's knowledge of rights, perception of service quality, awareness of accountability mechanisms and collective efficacy in the community. Though CaPSAI intervention set out to change the values, attitudes, and interactions between community members and those providing contraceptive services, there were changes in different directions that require closer examination.

Social Accountability Reporting for Research (SAR4Research): checklist to strengthen reporting on studies on social accountability in the literature.

BACKGROUND: An increasing number of evaluations of social accountability (SA) interventions have been published in the past decade, however, reporting gaps make it difficult to summarize findings. We developed the Social Accountability Reporting for Research (SAR4Research) checklist to support researchers to improve the documentation of SA processes, context, study designs, and outcomes in the peer reviewed literature and to enhance application of findings. METHODS: We used a multi-step process, starting with an umbrella review of reviews on SA to identify reporting gaps. Next, we reviewed existing guidelines for reporting on behavioral interventions to determine whether one could be used in its current or adapted form. We received feedback from practitioners and researchers and tested the checklist through three worked examples using outcome papers from three SA projects. RESULTS: Our umbrella review of SA studies identified reporting gaps in all areas, including gaps in reporting on the context, intervention components, and study methods. Because no existing guidelines called for details on context and the complex processes in SA interventions, we used CONSORT-SPI as the basis for the SAR4Research checklist, and adapted it using other existing checklists to fill gaps. Feedback from practitioners, researchers and the worked examples suggested the need to eliminate redundancies, add explanations for items, and clarify reporting for quantitative and qualitative study components. CONCLUSIONS: Results of SA evaluations in the peer-reviewed literature will be more useful, facilitating learning and application of findings, when study designs, interventions and their context are described fully in one or a set of papers. This checklist will help authors report better in peer-reviewed journal articles. With sufficient information, readers will better understand whether the results can inform accountability strategies in their own contexts. As a field, we will be better able to identify emerging findings and gaps in our understanding of SA.

Research and implementation interactions in a social accountability study: utilizing guidance for conducting process evaluations of complex interventions.

BACKGROUND: In recent years, researchers and evaluators have made efforts to identify and use appropriate and innovative research designs that account for the complexity in studying social accountability. The relationship between the researchers and those implementing the activities and how this impacts the study have received little attention. In this paper, we reflect on how we managed the relationship between researchers and implementers using the United Kingdom Medical Research Council (MRC) guidance on process evaluation of a complex intervention. MAIN BODY: The MRC guidance focuses on three areas of interaction between researchers and stakeholders involved in developing and delivering the intervention: (i) working with program developers and implementers; (ii) communication of emerging findings between researchers/evaluators and implementers; and (iii) overlapping roles of the intervention and research/evaluation. We summarize how the recommendations for each of the three areas were operationalized in the Community and Provider driven Social Accountability Intervention (CaPSAI) Project and provide reflections based on experience. We co-developed various tools, including standard operating procedures, contact lists, and manuals. Activities such as training sessions, regular calls, and meetings were also conducted to enable a good working relationship between the different partners. CONCLUSIONS: Studying social accountability requires the collaboration of multiple partners that need to be planned to ensure a good working relationship while safeguarding both the research and intervention implementation. The MRC guidance is a useful tool for making interaction issues explicit and establishing procedures. Planning procedures for dealing with research and implementers' interactions could be more comprehensive and better adapted to social accountability interventions if both researchers and implementers are involved. There is a need for social accountability research to include clear statements explaining the nature and types of relationships between researchers and implementers involved in the intervention.

Getting Intentional about Intention to Use: A Scoping Review of Person-Centered Measures of Demand.

In recent years, there has been much reflection on the measures used to assess and monitor contraceptive programming outcomes. The meaning and measurement of intention-to-use (ITU) contraception, however, has had less attention and research despite its widespread inclusion in many major surveys. This paper takes a deeper look at the meaning and measurement of ITU around contraception. We conducted a scoping review guided by the following questions: What is the existing evidence regarding the measurement of ITU contraception? What definitions and measures are used? What do we know about the validity of these measures? We searched databases and found 112 papers to include in our review and combined this with a review of the survey instruments and behavioral theory. Our review found growing evidence around the construct of ITU in family planning programming and research. However there are inconsistencies in how ITU is defined and measured, and this tends not to be informed by advances in behavioral theory and research. Further work is needed to develop and test measures that capture the complexity of intention, examine how intention differently relates to longer-range goals compared to more immediate implementation, and demonstrate a positive relationship between ITU and contraceptive use.

Adaptation and validation of social accountability measures in the context of contraceptive services in Ghana and Tanzania.

BACKGROUND: Changes in the values, attitudes, and interactions of both service users and health care providers are central to social accountability processes in reproductive health. However, there is little consensus on how best to measure these latent changes. This paper reports on the adaptation and validation of measures that capture these changes in Tanzania and Ghana. METHODS: The CaPSAI theory of change determined the dimensions of the measure, and we adapted existing items for the survey items. Trained data collectors used a survey to collect data from 752 women in Tanzania and 750 women in Ghana attending contraceptive services. We used reliability analysis, exploratory, and confirmatory factor analysis to assess the validity and reliability of these measures in each country. RESULTS: The measure has high construct validity and reliability in both countries. We identified several subscales in both countries, 10 subscales in Tanzania, and 11 subscales in Ghana. Many of the domains and items were shared across both settings. CONCLUSION: The study suggests that the multi-dimensional scales have high construct validity and reliability in both countries. Though there were differences in the two country contexts and in items and scales, there was convergence in the analysis that suggests that this measure may be relevant in different settings and should be validated in new settings. TRIAL REGISTRATION: ACTRN12619000378123 .

Implementing social accountability for contraceptive services: lessons from Uganda.

BACKGROUND: Growing evidence shows that social accountability contributes to improving health care services, with much promise for addressing women's barriers in contraceptive care. Yet little is known about how social accountability works in the often-complex context of sexual and reproductive health, particularly as sex and reproduction can be sensitive topics in the open and public formats typical of social accountability. This paper explores how social accountability operates in the highly gendered and complex context of contraceptive care. METHODS: This exploratory research uses a case study approach to provide a more grounded understanding of how social accountability processes operate in the context of contraceptive information and services. We observed two social accountability projects that predominantly focused on contraceptive care in Uganda over a year. Five instruments were used to capture information from different source materials and multiple respondents. In total, one hundred and twenty-eight interviews were conducted and over 1000 pages of project documents were collected. Data were analyzed and compiled into four case studies that provide a thick description of how these two projects operated. RESULTS: The case studies show the critical role of information, dialogue and negotiation in social accountability in the context of contraceptive care. Improved community and health system relationships, community empowerment, provider and health system responsiveness and enhanced availability and access to services were reported in both projects. There were also changes in how different actors related to themselves and to each other, and contraceptive care, a previously taboo topic, became a legitimate area for public dialogue. CONCLUSION: The study found that while social accountability in the context of contraceptive services is indeed sensitive, it can be a powerful tool to dissolving resistance to family planning and facilitating a more productive discourse on the topic.

Studying social accountability in the context of health system strengthening: innovations and considerations for future work.

There is a growing body of research on the role of social accountability in bringing about more accessible and better-quality healthcare. Here, we refer to social accountability as "citizens' efforts at ongoing meaningful collective engagement with public institutions for accountability in the provision of public goods" (Joshi, World Dev 99:160-172, 2017). These processes have multiple interrelated components and sub-processes and engage a range of actors in community-driven, often unpredictable and context-dependent actions, which pose many methodological challenges for researchers. In June 2017, scientists and implementers working in this area came together to share experiences, discuss approaches, identify research gaps and consider directions for future studies. This paper shares learnings from this discussion.In particular, participants considered (1) how best to define and measure the complex processual nature of social accountability; (2) the study of social accountability as an inherently political process; and (3) the challenges of generalising unpredictable, community-driven and context-dependent processes. Key among a range of consensus areas was the need for researchers to capture a broader range of outcomes and better understand the nuances of implementation processes in order to effectively test theories and assumptions. Furthermore, power relationships are inherent in social accountability and the research process itself. In presenting details on these deliberations, we hope to prompt a wider discussion on the study of social accountability in health programming.

Hidden in plain sight: A systematic review of coercion and Long-Acting Reversible Contraceptive methods (LARC).

In recent years there has been extensive promotion of long-acting reversible contraceptives (LARC) globally to increase access to what is widely considered a highly effective contraceptive method. Yet, despite these efforts, evidence points towards the worrying propensity for LARCS to be associated with coercion. Hence, we undertook a meta-narrative review across nine databases to draw together the heterogeneous and complex evidence on the coercive practices associated with LARC programs. A total of 92 papers were grouped into three metanarratives: (1) law, (2) public health and medicine, and (3) the social sciences. Across disciplines, the evidence supports the conclusion that coercive practices surrounding LARC programs always target marginalized, disadvantaged and excluded population(s). Looking at coercion across disciplines reveals its many forms, and we present a continuum of coercive practices associated with LARC programming. We found that each discipline provides only a partial picture of coercion, and this fragmentation is a knowledge practice that prevents us from collecting accurate information on this subject and may contribute to the perpetuation of these suspect practices. We present this review to address longstanding silences around coercion and LARCs, and to encourage the development of clinical and programmatic guidance to actively safeguard against coercion and uphold reproductive rights and justice.

Low fertility and fertility policies in the Asia-Pacific region.

Declining fertility is an increasing global trend. In many low fertility contexts, people are having fewer children then they want, and these unfulfilled fertility desires have been associated with wider socio-economic changes in education and labour force participation and conflicting and often contradictory expectations of women at home and at work. The right to determine if, when and how one has children is enshrined in international law yet many policies responses to low fertility fail to meet these standards. This paper summarizes why people in the Asia-Pacific region are having fewer children than they desire, and the range of policy responses, particularly those that make life easier for working parents. This raises two important points. First, we need to contend to the gender dynamics that underpin this in the region, despite gradual changes in women's roles, they are still seen as "caregivers" and undertake a disproportionate amount of unpaid care work, often having to lean-out of their employment, and/or face gender discrimination in the workplace. Second, the "emergency" of low fertility arises from complex social and economic conditions that cannot be solved by population policies solely focused on making babies.

Adapting to a global pandemic: a qualitative assessment of programmatic responses to COVID-19 in the multi-country Women's Integrated Sexual Health (WISH) programme.

The COVID-19 pandemic caused significant disruption to sexual and reproductive health and rights (SRHR) globally but there is little published evidence on the COVID-19 response of SRHR programmes, or lessons learned through their adaptations. To document the COVID-19 response of a global SRHR programme (the Women's Integrated Sexual Health programme), in-depth interviews were conducted between April and July 2021 with 22 key informants from implementing partners in Sierra Leone, Ethiopia and central or regional offices, the UK Foreign, Commonwealth and Development Office and the third-party monitoring partner. Framework analysis methods were used. Several rapid COVID-19 adaptations were identified: the development of crisis management and communication teams; increased partnership and engagement with government; reduced contact and risk in service delivery; reformulated community mobilisation; flexible performance management and remote methods of quality assurance; and sharing of learnings alongside the development of new guidance and tools. Throughout the pandemic, the programme was able to continue high-quality service delivery, though equity goals proved more difficult to reach. Challenges included the continually changing environment, competing pressures on governments, burdensome reporting, and staff burnout. The pandemic response was facilitated by prior experience of health emergencies, strong government relationships, a supportive workforce and some pre-existing approaches, tools, and systems. This study has identified important lessons that can inform programming in future crises, including the need for immediate recognition of SRHR as essential, sustained support for staff, use of multiple mechanisms to reach marginalised groups, adequate funding for equity goals, and a better balance between the burden of reporting and accountability needs.

Hostilities faced by people on the frontlines of sexual and reproductive health and rights: a scoping review.

Frontline workers for sexual and reproductive health and rights (SRHR) provide life-changing and life-saving services to millions of people every year. From accompanying the pregnant, delivering babies and caring for the newborn to supporting those subjected to sexual violence; from treating debilitating infections to expanding contraceptive choices; from enabling access to safe abortion services to countering homophobia: all over the world frontline SRHR carers and advocates make it possible for so many more to experience dignity in sex, sexuality and reproduction. Yet they are also subjected to hostility for what they do, for whom they provide care, for where they work and for the issues they address. From ostracistion and harassment in the workplace to verbal threats and physical violence, hostilities can extend even into their private lives. In other words, as SRHR workers seek to fulfil the human rights of others, their own human rights are put at risk. Yet, as grave as that is, it is a reality largely undocumented and thus also underestimated. This scoping review sets out to marshal what is known about how hostilities against frontline SRHR workers manifest, against whom, at whose hands and in which contexts. It is based on review of six sources: peer-reviewed and grey literature, news reports, sector surveys, and consultations with sector experts and, for contrast, literature issued by opposition groups. Each source contributes a partial picture only, yet taken together, they show that hostilities against frontline SRHR workers are committed the world over-in a range of countries, contexts and settings. Nevertheless, the narratives given in those sources more often treat hostilities as 'one-off', exceptional events and/or as an 'inevitable' part of daily work to be tolerated. That works in turn both to divorce such incidents from their wider historical, political and social contexts and to normalise the phenomena as if it is an expected part of a role and not a problem to be urgently addressed. Our findings confirm that the SRHR sector at large needs to step-up its response to such reprisals in ways more commensurate with their scale and gravity.

Adjusting the analytical aperture: propositions for an integrated approach to the social study of reproductive technologies.

The ever-expanding availability of reproductive technologies, the continued roll-out of 'family planning' and maternity services across low- and middle-income settings and the rapid development of the fertility industry mean that it is more likely than ever that individuals, especially women and gender non-conforming people, will engage with more than one RT at some point in their life. These multiple engagements with RTs will affect users' expectations and uptake, as well as the technologies' availability, commercial success, ethical status and social meanings. We argue that an integrated approach to the study of RTs and their users not only makes for better research, but also more politically conscious research, which questions some of the ideological precepts that have led to reproduction being parcelled out into biomedical specialisations and a disproportionate focus on particular forms of reproduction in particular disciplines within public health and social science research. We offer this article as part of a wider movement in the study of reproduction and reproductive technologies, which takes inspiration from the reproductive justice framework to address forms of exclusion, discrimination and stratification that are perpetuated in the development and application of reproductive technologies and the ways in which they are studied and theorised.

A summative content analysis of how programmes to improve the right to sexual and reproductive health address power.

INTRODUCTION: Power shapes all aspects of global health. The concept of power is not only useful in understanding the current situation, but it is also regularly mobilised in programmatic efforts that seek to change power relations. This paper uses summative content analysis to describe how sexual and reproductive health (SRH) programmes in low-income and middle-income countries explicitly and implicitly aim to alter relations of power. METHODS: Content analysis is a qualitative approach to analysing textual data; in our analysis, peer-reviewed articles that describe programmes aiming to alter power relations to improve SRH constituted the data. We searched three databases, ultimately including 108 articles. We extracted the articles into a spreadsheet that included basic details about the paper and the programme, including what level of the social ecological model programme activities addressed. RESULTS: The programmes reviewed reflect a diversity of priorities and approaches to addressing power, though most papers were largely based in a biomedical framework. Most programmes intervened at multiple levels simultaneously; some of these were 'structural' programmes that explicitly aimed to shift power relations, others addressed multiple levels using a more typical programme theory that sought to change individual behaviours and proximate drivers. This prevailing focus on proximate behaviours is somewhat mismatched with the broader literature on the power-related drivers of SRH health inequities, which explores the role of embedded norms and structures. CONCLUSION: This paper adds value by summarising what the academic public health community has chosen to test and research in terms of power relations and SRH, and by raising questions about how this corresponds to the significant task of effecting change in power relations to improve the right to SRH.

A Rapid Review of Sexual Pleasure in First Sexual Experience(s).

While researchers have thoroughly studied the who, what, and when of first sexual experiences, we know much less about how people construct, experience, and proceed (or not) with sexual pleasure in these experiences and beyond. To address this knowledge gap, the Global Advisory Board for Sexual Health and Wellbeing (GAB) coordinated a rapid review of published peer-reviewed research to determine what is currently known about sexual pleasure in first sexual experiences. We found 23 papers exploring this subject and its intersections with sexual health and sexual rights. The results reveal significant gaps in erotic education, gender equity, vulnerability and connection, and communication efficacy; and highlight important domains to consider in future research. Our findings draw out the key features of pleasurable first sexual experience(s), namely that individuals with the agency to formulate their definition and context of what pleasure means to them are more likely to experience pleasure at first sex. This finding points to promising ways to improve first sexual experiences through erotic skills building and through addressing knowledge gaps about having sex for the first time among disadvantaged groups.

The use of segmented regression for evaluation of an interrupted time series study involving complex intervention: the CaPSAI project experience.

An interrupted time series with a parallel control group (ITS-CG) design is a powerful quasi-experimental design commonly used to evaluate the effectiveness of an intervention, on accelerating uptake of useful public health products, and can be used in the presence of regularly collected data. This paper illustrates how a segmented Poisson model that utilizes general estimating equations (GEE) can be used for the ITS-CG study design to evaluate the effectiveness of a complex social accountability intervention on the level and rate of uptake of modern contraception. The intervention was gradually rolled-out over time to targeted intervention communities in Ghana and Tanzania, with control communities receiving standard of care, as per national guidelines. Two ITS GEE segmented regression models are proposed for evaluating of the uptake. The first, a two-segmented model, fits the data collected during pre-intervention and post-intervention excluding that collected during intervention roll-out. The second, a three-segmented model, fits all data including that collected during the roll-out. A much simpler difference-in-difference (DID) GEE Poisson regression model is also illustrated. Mathematical formulation of both ITS-segmented Poisson models and that of the DID Poisson model, interpretation and significance of resulting regression parameters, and accounting for different sources of variation and lags in intervention effect are respectively discussed. Strengths and limitations of these models are highlighted. Segmented ITS modelling remains valuable for studying the effect of intervention interruptions whether gradual changes, over time, in the level or trend in uptake of public health practices are attributed by the introduced intervention. Trial Registration: The Australian New Zealand Clinical Trials registry. Trial registration number: ACTRN12619000378123. Trial Registration date: 11-March-2019.

Accounting for complexity - Intervention design in the context of studying social accountability for reproductive health.

Background: Social accountability interventions aim to propel change by raising community voices and holding duty bearers accountable for delivering on rights and entitlements. Evidence on the role of such interventions for improving community health outcomes is steadily emerging, including for sexual and reproductive health and rights (SRHR). However, these interventions are complex social processes with numerous actors, multiple components, and a highly influential local context. Unsurprisingly, determining the mechanisms of change and what outcomes may be transferable to other similar settings can be a challenge. We report our methodological considerations to account for complexity in a social accountability intervention exploring contraceptive uptake and use in Ghana and Tanzania. Main Body: The Community and Provider driven Social Accountability Intervention (CaPSAI) study explores the relationship between a health facility-focused social accountability intervention and contraceptive service provision in two countries. This 24-month mixed-method quasi-experimental study, using an interrupted time series with a parallel control group, is being undertaken in 16 sites across Ghana and Tanzania in collaboration with local research and implementation partners. The primary outcomes include changes in contraceptive uptake and use. We also measure outcomes related to current social accountability theories of change and undertake a process evaluation. We present three design features: co-design, 'conceptual' fidelity, and how we aim to track the intervention as 'intended vs. implemented' to explore how the intervention could be responsive to the embedded routines, local contextual realities, and the processual nature of the social accountability intervention. Conclusions: Through a discussion of these design features and their rationale, we conclude by suggesting approaches to intervention design that may go some way in responding to recent challenges in accounting for social accountability interventions, bearing relevance for evaluating health system interventions.

Methods to measure effects of social accountability interventions in reproductive, maternal, newborn, child, and adolescent health programs: systematic review and critique.

BACKGROUND: There is no agreed way to measure the effects of social accountability interventions. Studies to examine whether and how social accountability and collective action processes contribute to better health and healthcare services are underway in different areas of health, and health effects are captured using a range of different research designs. OBJECTIVES: The objective of our review is to help inform evaluation efforts by identifying, summarizing, and critically appraising study designs used to assess and measure social accountability interventions' effects on health, including data collection methods and outcome measures. Specifically, we consider the designs used to assess social accountability interventions for reproductive, maternal, newborn, child, and adolescent health (RMNCAH). DATA SOURCES: Data were obtained from the Cochrane Library, EMBASE, MEDLINE, SCOPUS, and Social Policy & Practice databases. ELIGIBILITY CRITERIA: We included papers published on or after 1 January 2009 that described an evaluation of the effects of a social accountability intervention on RMNCAH. RESULTS: Twenty-two papers met our inclusion criteria. Methods for assessing or reporting health effects of social accountability interventions varied widely and included longitudinal, ethnographic, and experimental designs. Surprisingly, given the topic area, there were no studies that took an explicit systems-orientated approach. Data collection methods ranged from quantitative scorecard data through to in-depth interviews and observations. Analysis of how interventions achieved their effects relied on qualitative data, whereas quantitative data often raised rather than answered questions, and/or seemed likely to be poor quality. Few studies reported on negative effects or harms; studies did not always draw on any particular theoretical framework. None of the studies where there appeared to be financial dependencies between the evaluators and the intervention implementation teams reflected on whether or how these dependencies might have affected the evaluation. The interventions evaluated in the included studies fell into the following categories: aid chain partnership, social audit, community-based monitoring, community-linked maternal death review, community mobilization for improved health, community reporting hotline, evidence for action, report cards, scorecards, and strengthening health communities. CONCLUSIONS: A wide range of methods are currently being used to attempt to evaluate effects of social accountability interventions. The wider context of interventions including the historical or social context is important, as shown in the few studies to consider these dimensions. While many studies collect useful qualitative data that help illuminate how and whether interventions work, the data and analysis are often limited in scope with little attention to the wider context. Future studies taking into account broader sociopolitical dimensions are likely to help illuminate processes of accountability and inform questions of transferability of interventions. The review protocol was registered with PROSPERO (registration # CRD42018108252).

Accountability strategies for sexual and reproductive health and reproductive rights in humanitarian settings: a scoping review.

BACKGROUND: Many of the 35 million women and girls aged 15-49 requiring humanitarian assistance have inadequate access to the sexual and reproductive health (SRH) services to which they are entitled. Ensuring accountability is critical to realizing their SRH and reproductive rights (RR). OBJECTIVES: This scoping review examines the extent and nature of existing evidence on accountability strategies for SRH in humanitarian settings in different geographical scopes/contexts, and contextualizes these findings in the larger thematic literature. This review seeks to answer the following questions: What accountability strategies are employed to address the availability, accessibility, acceptability, and quality of SRH in humanitarian settings? What do we know about the successes and challenges of the given strategies? What are the implications for practice? METHODS: We consulted public health, social science, and legal databases including SCOPUS, PubMed, ProQuest, and LexisNexis for peer-reviewed articles, as well as Google Advanced search for grey literature; the search was conducted in March 2019. We searched for relevant articles and documents relating to accountability, humanitarian, and SRH and/or RR. To identify key challenges not reflected in the literature and additional grey literature, 18 key informants from international NGOs, local government bodies, academia, and donor agencies were interviewed from March-June 2019. RESULTS: A total of 209 papers and documents were identified via our literature searches and interviews for review. We identified three categories of approaches to accountability in our background reading, and we then applied these to the papers reviewed a priori. We created a fourth category based on our findings. The categories include: (1) humanitarian principles, codes of conduct, and legal instruments; (2) technical, performance, and impact standards; (3) efforts to solicit and address the rights and needs of the affected populations, or "listening and responding," and, (4) accountability demands made by affected populations themselves. Almost all papers identified referred to challenges to realizing accountability in humanitarian contexts. There are promising accountability approaches - some specific to SRH and some not - such as open-ended feedback from affected populations, quality improvement, and practical application of standards. Reflecting a largely top down orientation, papers concentrate on accountability mechanisms within humanitarian work, with much less focus on supporting affected populations to deepen their understanding of structural causes of their position, understand their entitlements, or access justice. CONCLUSION: In the last 20 years, there has been increasing standard and guideline development and program experiences related to accountability in humanitarian settings. Yet, the emphasis is on tools or mechanisms for accountability with less attention to changing norms regarding SRH and RR within affected communities, and to a lesser extent, among implementers of humanitarian programs or to institutionalizing community participation.