The views and opinions expressed in this document are those of the author(s) and do not necessarily reflect the official policy or position of any organisation, employer, client, or affiliated institution.

Correspondence: aloysius.odii@unn.edu.ng

Corruption in the health sector is a persistent and life-threatening problem. It weakens service delivery, undermines public trust, and hampers progress towards health goals. Evidence indicates that it takes many forms (e.g., absenteeism, informal payments, drug theft, inflated procurement costs, and ghost workers). For communities relying on primary health centres (PHCs) as their primary and often only point of contact with the health system, corruption can lead to impoverishment, denied access, suffering, and death.

Over the last decade, research into corruption in Nigerian healthcare has revealed that no single solution is sufficient. It was also learned that social accountability, citizen-led efforts to hold public service providers to account, has gained traction as a response to health sector corruption. However, to be genuinely effective, we must stop viewing it as a single-event intervention. Social accountability should be regarded as a multi-component ecosystem comprising various tools, people, and steps that all collaborate to reduce corruption in the health sector.

What are these components?

An effective social accountability system must include the following interconnected elements:

• Community oversight structures – community-led committees that assist in overseeing activities at health centres.

• Citizen awareness and empowerment – enabling people to identify and report corruption

• Information transparency – public access to service entitlements and pricing.

• Accessible, secure reporting channels – such as toll-free lines or complaint boxes.

• State-level institutional response – Government agencies authorised to investigate complaints and take action.

• Feedback loops – methods for informing citizens about actions taken in response to their complaints.

Oversight structures matter, but they aren’t enough

Community health governance structures are helpful because they offer localised oversight and act as a pathway for community voices to be heard. However, they are often underfunded, subject to political manipulation, or lack clear mandates. Without genuine authority, they tend to serve more as symbols than as effective entities. Therefore, for accountability to be meaningful, it is essential to bolster these structures with broader support systems.

Active citizens: the frontline of accountability

The most overlooked component of anti-corruption efforts is the role of citizens. In a study in Nigeria, some patients believed that paying for immunisations or accessing free maternal services was normal because no one informed them otherwise. To foster active citizens’ participation in the fight against healthcare corruption, public education campaigns should reveal corruption within healthcare. Patients need to understand what is genuinely free, which costs are justified, and who they should contact if something feels wrong. Ultimately, citizens must be able to:

• Recognise corruption (e.g., when asked to pay for free services)

• Know what to do about it

• Feel protected enough to report it

Transparency is not accountability

There is a recent push for transparency in service provision. For example, it involves displaying a list of free services and the official prices of drugs and procedures. Besides the fact that it could reduce informal payments, it might also help patients incur lower healthcare costs. Additionally, it includes showing the names of staff on duty to reveal who is present or absent at their post. However, while transparency is important, it alone is not enough.

Transparency provides information, but accountability requires action. Displaying the prices of drugs and those on duty has little impact if patients cannot report extortion, and if their complaints are ignored. Without mechanisms to act on what is revealed, transparency risks becoming ineffective.

This is why social accountability should include accessible and safe reporting channels. It should also incorporate strategies that allow citizens, especially service users, to monitor and influence the behaviour of healthcare providers without risking their safety, and sometimes, without exposing their identities. Therefore, it must be integrated into a wider social accountability framework that empowers patients and safeguards whistleblowers. This is one reason why complaint systems should be externally overseen, and why community actors must act as safe intermediaries.

Therefore, based on our experiences in Nigeria, we propose that every health facility should:

• Post a toll-free number or SMS code for making complaints – anonymously if needed.

• Ensure these mechanisms are connected to a state-level anti-corruption unit with authority to investigate and report actions taken.

• Indicate who to contact locally in case of corruption.

The State’s Role Is Irreplaceable

Even the most informed citizen cannot hold a corrupt health worker accountable without official backing from the state. Therefore, local government health authorities, state ministries of health, and state primary healthcare development agencies must:

• Establish and finance social accountability units to manage complaints.

• Collaborate with community organisations to oversee the implementation of transparency measures at the PHC level,

• Act on credible reports of corruption,

• Provide regular public updates on the number of reports received, investigated and resolved.

For these units to be effective, they must be integrated with facility-level reporting systems (such as toll-free lines, SMS codes, community complaints) and have a clear protocol for receiving, verifying, escalating, and acting on reports. A responsive state system should also ensure prompt feedback is carefully given to complainants and the public.

Conclusion

The solution to corruption in PHCs is citizen voice, supported by systems that listen and act. Social accountability should not be viewed as a standalone committee or slogan. We believe that it is a system of interconnected actions and actors. Reducing corruption in PHCs requires us to see social accountability not as a silver bullet but as a system—one that is transparent, inclusive, safe, and enforceable. Only then can we start to shift from normalising corruption to dismantling it.