| Summary: | Introduction: Historically in South Africa, civil society has played a key role within the health system, including advocating for equitable and quality health care services. The purpose of this research is to explore the implementation of a pilot health systems strengthening intervention in primary health facilities in Khayelitsha, South Africa. The study is built on Treatment Action Campaign, a civil society organization, which has recently implemented a health system monitoring tool within health care facilities in Khayelitsha. Specifically, this study considers the functioning and potential impact of the monitoring tool introduced as a community accountability mechanism at the local level. The development and implementation of the monitoring tool can also be seen as part of a policy implementation process. Methods: Using an action research approach, the researcher engaged with implementing actors in the development and implementation of the monitoring tool. Qualitative methods were used to explore: the understandings of various stakeholders about the tool, their interests or concerns, potential positions, power and influence on its implementation. Quantitative data allowed for the ability to track potential improvements in clinic performance in terms of operational research. The challenges during tool development and implementation and how these were overcome were also explored. Results: Analysis of the stakeholders demonstrated how actors exerted their power in various ways to influence the development and implementation of the tool. Results suggest it can be an empowering process for members of civil society and there is a role for civil society in improving health system performance. Findings have highlighted the need for civil society organization monitoring tools to be not only methodologically sound but, more importantly, accepted by the activist. If carefully considered and driven by civil society itself, rather than imposed, there does seem to be some tentative examples of service delivery improvement and scope for their engagement. Conclusions: The findings offer relevant and useful insights for understanding how this tool acts as an accountability mechanism at a local level within Khayelitsha sub-district. Such findings may have implications for further adaptations to the tool, potential scale-up by Treatment Action Campaign and for other low and middle income contexts.
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