Community-led monitoring as a driver of health service improvement: role of citizen observatories in Burkina Faso, Guinea, and Niger

¹Recherche pour la Santé et le Développement, Ouagadougou, Burkina Faso, ²Département de Santé Publique, Université Joseph Ki-Zerbo, Ouagadougou, Burkina Faso, ³Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Im Neuenheimer Feld, Heidelberg, Germany, ⁴Département de Santé Publique, Institut de Médecine Tropicale, Kronenburgstraat, Belgique, ⁵Réseau Accès aux Médicaments Essentiels, Ouagadougou, Burkina Faso

^&Corresponding author
Issa Kaboré, Recherche pour la Santé et le Développement, Ouagadougou, Burkina Faso

Introduction    

Universal Health Coverage (UHC) is a key objective of health sector reforms in many countries, aiming to achieve the Sustainable Development Goals (SDGs), particularly target 3.8 [1]. To accelerate progress toward UHC, many sub-Saharan African countries have adopted a variety of reforms, including community health strategies, performance-based financing, community or national health insurance schemes, and exemptions from user fees for vulnerable groups such as women, children under five, and the indigent [2]. These countries have also reaffirmed their commitment to primary health care through their participation in the adoption of the Astana Declaration in 2018 and the Operational Framework for Primary Health Care in 2020 [2,3].

Despite these efforts, African health systems continue to face significant challenges related to equity of access, quality of care, transparency, and governance [4,5]. To address these challenges, it has become essential to increase community involvement in health service delivery to improve effectiveness, equity, quality, and accountability. Since the 2010s, many countries, through community-based and civil society organizations, have invested in the implementation of community-led monitoring (CLM) mechanisms to improve access to health services. These initiatives are supported by international institutions such as the Global Fund, UNAIDS, the President's Emergency Plan for AIDS Relief (PEPFAR), and the Partnership for Maternal, Newborn & Child Health [6-9]. The CLM approach is a strategic tool to promote accountability by involving local communities in citizen monitoring, evidence generation, advocacy, and the strengthening of community engagement [10,11]. As such, CLM represents a major driver of progress, particularly in low- and middle-income countries, toward achieving UHC and the SDGs [6].

A 2023 report by UNAIDS highlights the renewed interest in CLM, which had long been overlooked by global health actors, due to its contribution to fighting diseases such as HIV, tuberculosis, and malaria [9]. The role of CLM in improving health service delivery has been documented in several African countries, including South Africa [12], Zambia [13], and Zimbabwe [14]. Additionally, a few systematic reviews have shown the potential of various CLM models to improve health services in a range of low- and middle-income contexts through monitoring, data collection and analysis, awareness-raising, and advocacy [10,15,16]. Most of this literature on CLM in Africa is concentrated on Anglophone countries.

In Francophone Africa, CLM initiatives implemented to strengthen health services have become increasingly visible over the past decade. One example is the Citizen Observatory on Access to Health Services (OCASS), which has been implemented since 2014 by the NGO named Essential Medicines Access Network (Réseau Accès aux Médicaments Essentiels or RAME) in collaboration with partner organizations in Burkina Faso, Guinea, and Niger. The objective is to enhance social accountability in the health sector, particularly in relation to HIV, tuberculosis, malaria, and maternal and child health services [17].

However, little attention has been given to the documentation or comparative analysis of CLM experiences in Francophone Africa, including that of OCASS. This study therefore aimed to analyze and document the role of OCASS in the implementation of health programs and policies in Burkina Faso, Guinea, and Niger, with a focus on achievements, best practices, and lessons learned.

Methods     

Conceptual framework of the study: the study used the availability, accessibility, acceptability, and quality (AAAQ) framework, used in the field of the right to health [18], to analyze the impact of the OCASS programs on health services. Availability was assessed by examining the capacity of the service provision to meet the needs of the population. Accessibility was assessed in its physical, financial, and social dimensions, including non-discrimination and access to information. Acceptability referred to the extent to which health services respect ethical standards, cultural norms and confidentiality. Quality was analyzed in terms of provider competence, adherence to clinical standards, and user satisfaction.

Study setting: the study was conducted in three Francophone West African countries where the OCASS programs are implemented, namely Burkina Faso, Guinea, and Niger. The program is led in Burkina Faso by RAME, in Guinea by the Coalition of Women Leaders of Guinea (COFEL), and in Niger by the Niger Network of People Living with HIV/AIDS (RENIP+). All three countries have predominantly young populations.

Burkina Faso is a landlocked Sahelian country located in the heart of West Africa, covering a surface area of 274,200 km² with an estimated population of over 22 million in 2024. Its health system follows a pyramidal structure, comprising six tertiary-level hospitals, 70 health districts, and more than 2,200 health facilities. Over the past decade, significant health interventions including the strengthening of health infrastructure, training of qualified human resources, targeted disease and malnutrition control programs, and policies for exemption from direct payments have contributed to improvements in key health indicators.

Niger is a vast landlocked Sahelian country covering more than 1.2 million km², with an estimated population of over 23 million in 2022 and an annual growth rate of 3.9% [19]. Its health system also follows a pyramidal structure, consisting of 72 health districts, eight regional health structures, and tertiary-level facilities. To address health challenges, Niger has implemented various initiatives, including the reduction or elimination of direct payments for services related to conditions such as HIV, malaria, and tuberculosis.

Guinea is a coastal country spanning 245,857 km² with an estimated population of approximately 14 million in 2021. Its health system is also structured in a pyramidal model, comprising 38 health districts and eight regional health divisions. Health service delivery is anchored by three national hospitals, eight regional hospitals, 26 prefectural hospitals, and more than 2,700 lower-level health facilities [20].

Despite notable progress, the health systems in these countries continue to face multiple challenges related to service availability and quality, geographic and socioeconomic disparities in service coverage and accessibility, and financial risks faced by populations. These countries also have a similar epidemiological profile, with a continued burden of communicable diseases and the rising prevalence of non-communicable diseases [19]. Additionally, Guinea's dense forested areas expose it to recurrent outbreaks of viral hemorrhagic fevers [21]. Moreover, Burkina Faso and Niger have been facing a security and humanitarian crisis for a decade. In all three countries, the public health system is supplemented by the private sector.

Study design and data collection: this study was conducted as a documentation and capitalization exercise using a qualitative approach. Data were collected between November 2024 and January 2025 through semi-structured qualitative interviews and document review. Two researchers, IK and YK, reviewed OCASS program and health sector reports using an AAAQ-based extraction template. Using an AAAQ-based interview guide, research assistants (AZ and BD in Burkina Faso; EFS and IB in Guinea; SSN and MMA in Niger) conducted 52 semi-structured interviews with purposively sampled key informants from OCASS leading organizations, health providers, ministries of health, and partners (16 in Burkina Faso, 16 in Guinea, 20 in Niger). Interviews were audio-recorded with prior informed consent from participants, then transcribed verbatim. For participants declining recording, handwritten notes were taken. Data were analyzed using a thematic and deductive approach.

Ethical considerations: the study was approved by Burkina Faso's Health Research Ethics Committee (Deliberation No. 2024-10-328). All participants consented; anonymity was protected via coding, with strict data confidentiality.

Results     

Implementation and functioning of OCASS programs in the three countries: since 2014, OCASS programs have been implemented in Burkina Faso, Guinea, and Niger, under the leadership of RAME, COFEL, and RENIP+, respectively. These lead organizations work with local community-based organizations active in the health sector and committed to improving access to services for people affected by HIV, tuberculosis, and malaria. These local partners serve as the operational arms of OCASS, conducting citizen monitoring, collecting and transmitting data on service delivery, primarily for HIV/AIDS, malaria, and tuberculosis, and engaging in advocacy and capacity-building for providers and users regarding the right to health.

Each organization appoints one or two data collectors, supervised by organizational leaders. Data collection, initially paper-based, was digitized in 2021 using the KoboToolbox application on Android tablets. Data are centralized, analyzed by specialists, and used to produce quarterly and annual reports, which are validated in national stakeholder workshops involving beneficiaries, civil society, technical and financial partners, and decision-makers. These workshops also serve as advocacy platforms. To ensure data quality, supervision is conducted biannually from national leads to local partners, and quarterly from local organizations to field collectors.

In Burkina Faso, OCASS operates in all 70 health districts. Each quarter, 25% of public health facilities are surveyed, reaching full coverage annually. Two collectors per organization gather data from both health facilities (providers and users) and households. They also conduct awareness-raising campaigns. A toll-free hotline (80001120) allows users to report issues and suggestions. In Guinea, the program covers 27 health facilities. Sixty-five local organization members collect data at fixed sites under the supervision of nine regional supervisors. In Niger, OCASS operates across 40 sites in 21 of 72 health districts. As in Guinea, data are collected at fixed sites from users and facility staff, without community-level outreach.

Observatoires Citoyens sur l'Accès aux Services de Santé contribution to the improvement of health services (2014-2024)

Availability of health services: through data collection, community monitoring, and advocacy, the OCASS program has significantly contributed to improving the availability of health services in Burkina Faso, Guinea, and Niger, particularly in the areas of HIV, tuberculosis, malaria, and maternal and child health. OCASS programs have enabled the identification and reporting of service delivery issues such as medicine stock-outs, equipment shortages or breakdowns, and insufficient numbers or absenteeism among health personnel. These issues have been reported to health authorities to prompt corrective action. As one OCASS promoter from Guinea noted: "It is thanks to the OCASS system that all these weaknesses were exposed, drawing the attention of national authorities so they could take appropriate measures progressively" (Gui1).

The alerts, reports, and advocacy actions of OCASS have helped reduce medicine stock-outs, lower absenteeism among healthcare workers, prompt the redeployment of staff to underserved areas, and support the acquisition of new equipment in health facilities. A Burkina Faso OCASS promoter stated: "Based on community-reported data, changes have been made. Although not always structural, these alerts often help solve immediate issues such as stock-outs, staffing gaps, or other dysfunctions in service delivery" (Bur2). Likewise, a user in Niger reported: "We received new staff assignments, including three doctors, and acquired new equipment, including GenXpert machines to improve diagnostic access" (Nig2).

Accessibility of health services: OCASS has improved service accessibility by helping to reduce financial, geographic, and information barriers in all three countries. On the financial front, OCASS advocacy has supported the adoption of partial or full exemptions from user fees for women, children under five, indigent populations, and for priority diseases such as HIV, tuberculosis, and malaria. One OCASS promoter in Burkina Faso explained: "From initial advocacy for free ARVs, we have progressed to free healthcare for pregnant women and children. Policies are now in place, with directives ensuring that users are not charged inappropriately" (Bur2).

Geographically, OCASS has contributed to the strengthening of referral and counter-referral systems, thereby reducing delays in accessing appropriate care. It has also supported the provision of supplies for certain chronic patients and advocated for multi-month dispensing of medicines to reduce therapeutic interruptions for individuals living far from health facilities. On the informational level, OCASS actors have led awareness-raising campaigns, broadcast radio programs, and produced posters to improve knowledge of patients' and providers' rights and responsibilities in the context of patient-centered care. As one Niger-based facilitator noted: "Awareness-raising activities on users' rights and duties have raised community consciousness" (Nig8).

Acceptability of health services: OCASS has contributed to improved acceptability of health services by promoting ethics, confidentiality, and non-discrimination. In all three countries, awareness efforts have helped reduce stigma and violence in care settings while strengthening trust between patients and providers. This has enhanced the holistic acceptance of patients regardless of beliefs or identity, and lowered barriers to care-seeking. A health provider in Niger confirmed: "The system helped raise awareness among healthcare workers about issues of discrimination and stigma" (Nig4).

A service user in Guinea added: "Aside from the doctor and a few people living with HIV, no one knows my status" (Gui8). Such efforts have led to increased patient involvement in care planning and a positive shift in attitudes, both among providers and within communities.

Quality of health services: OCASS interventions have contributed to improved quality of care. Monitoring, awareness-raising, and advocacy efforts have led to better organization within health facilities, reduced patient waiting times, improved patient reception, and overall increased satisfaction with services received. As a monitor in Guinea explained: "Reception and waiting time are key OCASS indicators... We even used video materials and images to raise awareness. Things really got changed" (Gui5). Community sensitization prompted efforts to improve hygiene and sanitation in health facilities. As a data collector in Burkina Faso observed: "Through rights-and-duties education, patients are encouraged to keep their care environments clean and to take steps to maintain hygienic facilities" (Bur5). OCASS advocacy also helped improve other aspects of quality, including the installation of signage in facilities and adherence to health standards.

Key challenges faced by the OCASS CLM programs: the OCASS programs in Burkina Faso, Guinea, and Niger face several common challenges that hinder their implementation and effectiveness. These include inadequate logistical support for data collectors, insufficient and unpredictable funding, dependence on external financing, and insufficient qualified human resources. Together, these factors limit the programs' ability to ensure robust monitoring, optimal site coverage, effective data analysis, and evidence generation. For instance, although OCASS operates in all health districts in Burkina Faso, data collectors typically make only one visit per facility per year, limiting their capacity to monitor changes over time. In Guinea and Niger, the program covers a smaller proportion of health facilities and relies on fixed-site data collection without community outreach, as is done in Burkina Faso. This restricts community ownership and limits the program's local anchoring.

Additionally, mistrust or reluctance from some health system actors, sometimes linked to poor communication, undermines the cooperation necessary for effective implementation. The lack or obsolescence of technological tools, such as tablets and computers used for data collection and processing, also hampers OCASS performance. Moreover, the low standardization of data collection and analysis methods, coupled with the limited involvement of health system actors in selecting monitoring indicators, raises concerns about the acceptability and uptake of OCASS-generated data.

Another challenge is the limited structuring of advocacy efforts at all levels, stemming from the low capacity of actors to conduct sustained advocacy over the long term. In Burkina Faso and Niger, security concerns in certain regions further threaten the continuity of OCASS activities.

Beyond these shared challenges, country-specific obstacles also affect implementation. In Burkina Faso, poor road conditions during the rainy season in remote areas complicate fieldwork, especially as data collectors often lack appropriate means of transportation. Frequent turnover among data collectors also affects data quality and hampers sustained capacity-building activities. In Niger, coordination issues between OCASS and health providers reduce the program's overall reach. In Guinea, the program faces more significant difficulties with acceptance and governance. OCASS is sometimes perceived not as a tool for improvement but as an adversarial mechanism, leading to resistance and threats against program actors, thereby undermining its overall impact.

Discussion     

This study highlights the contributions of the OCASS CLM initiative to the improvement of health services, while also revealing key challenges encountered in its implementation in Burkina Faso, Guinea, and Niger. The analysis demonstrates that OCASS has contributed significantly to strengthening health systems, particularly in the areas of HIV, tuberculosis, malaria, and maternal and child health services. Findings show that OCASS CLM improved the availability, accessibility, acceptability, and quality of health services through mechanisms such as community monitoring, the reporting of service delivery issues, advocacy to health authorities, support for the supply of medications to patients with chronic conditions, and awareness-raising on rights and responsibilities among users and providers. These efforts enhanced patient-provider relationships and helped reduce the incidence of violence in care settings.

These findings add to the growing evidence on the potential of community initiatives to strengthen the response to chronic and stigmatizing diseases such as HIV and TB, as well as acute conditions like malaria, which carry a heavy burden [14,22]. More broadly, the results support the claim that CLM contributes substantially to reinforcing fragile health systems, particularly in terms of accountability and equity [10,15,23]. Moreover, the OCASS model combines several CLM approaches described in the literature, including monitoring, data collection and analysis from both health providers and communities, public education, advocacy, and treatment monitoring, making it potentially well-suited to contexts where health systems face multifaceted challenges, such as in West Africa [15].

The collaboration and engagement of local stakeholders have played a crucial role in the success of OCASS activities [24]. Being members of the communities they serve, these actors are familiar with local realities and cultural norms, facilitating meaningful interaction and the effective implementation of OCASS interventions. Data collection and monitoring conducted by actors external to the health service structures have also proven vital, enabling the identification of service delivery dysfunctions in an impartial manner and facilitating the resolution of issues. Ultimately, this led to improvements in the management of diseases and the implementation of public policies, such as fee exemption measures [23].

A notable innovation in Burkina Faso's OCASS model is the collection of data at the community level, which may enhance data quality by allowing people to speak more confidently in their familiar environment, away from the potential pressure of health providers. This could also strengthen community ownership and the social acceptability of OCASS. Furthermore, it is well established in the literature that the use of information and communication technologies in data collection and analysis contributes to improving the implementation environment for CLM initiatives and, more broadly, the quality of health services [13,25].

Despite its successes, OCASS faces substantial challenges that limit its scale-up and impact. Financial constraints, logistical difficulties, lack of qualified personnel, and resistance from some health system actors were reported in all three countries. These challenges affect the quality of activities and hinder the expansion of OCASS coverage, particularly in Guinea and Niger. Previous studies on CLM in low- and middle-income countries have emphasized the importance of sufficient financial and human resources to maximize the success of such initiatives [16,24,26,27]. This study confirms these findings and reveals that OCASS data collectors often rely on their own transportation and communication tools such as motorcycles and mobile phones, that are not suited to the program's operational requirements. This situation raises concerns about both the efficiency and long-term sustainability of the initiative.

While resistance from health system actors to external accountability mechanisms is well known, the study uncovered instances of intimidation and direct threats against OCASS staff in Guinea, illustrating the politically sensitive nature of transparency efforts in the health sector [23]. Other challenges identified include seasonal variations, leadership and governance disputes [28], and political pressures exerted on program personnel. These findings highlight the complex and dynamic nature of implementing community-led monitoring in resource-constrained settings.

Additionally, the lack of standardized tools and methods for data collection, coupled with the limited involvement of health system actors in selecting monitoring indicators, may undermine trust, already fragile in some contexts, between healthcare workers and OCASS personnel. This could further reduce the acceptance and use of the reports produced by the program [23].

Limitations and research perspectives: this study has some limitations. First, the results are mainly based on qualitative data, which limits the ability to quantify the impact reported by stakeholders and restricts the generalizability of the findings. Second, the low standardization of data collection tools and methodologies limited the use of quantitative data from OCASS reports to track the evolution of key indicators over time.

Future research could include quantitative evaluations of OCASS's impact to provide a more comprehensive analysis. Additionally, a comparative analysis with other community-led monitoring models in West Africa could help identify best practices that are transferable to the OCASS context.

Conclusion     

The study showed that the OCASS program has contributed to improving health services in all three countries, but with varying levels of impact. Burkina Faso stands out for its better-structured implementation, good collaboration with health authorities, and extensive geographical coverage, despite restrictions linked to the security situation. Niger, although also facing security challenges, has also made notable progress. In Guinea, on the other hand, despite appreciable achievements, the system still faces major challenges in terms of acceptance, integration into the healthcare system, and governance. To enhance the impact of CLM OCASS, it is essential to build the capacity of the players involved, improve logistics, diversify funding sources, and better integrate the program into national health systems.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

The study was designed by Joël Arthur Kiendrébéogo, Issa Kaboré and Yamba Kafando; Issa Kaboré and Yamba Kafando conducted document review and data analysis under the supervision of Joël Arthur Kiendrébéogo; the article was drafted by Issa Kaboré, then Joël Arthur Kiendrébéogo, Yamba Kafando, Hamidou Ouédraogo, Christian Lamy, and Simon Kaboré revised the sections. All the authors read and approved the final version of this manuscript.

Acknowledgments     

We would first like to thank the International AIDS Society (IAS) and RAME for their support in carrying out this capitalization. Our sincere thanks also go to all the key informants in Burkina Faso, Niger and Guinea who took part in the interviews to enable us to carry out this analysis, as well as to the participants in the Ouagadougou amendment workshop for their contribution to improving this report.

References