Accountability and equity in primary health care: co-creating user-centered evaluation systems for public-private...

Brazil's Unified Health System (SUS) is one of the world's largest universal health systems and operates through a plural governance arrangement involving public, philanthropic, and community actors under public coordination. In Primary Health Care (PHC), non-profit Social Health Organizations (OSS) are increasingly responsible for managing public healthcare facilities in large urban municipalities. However, evaluation systems used by public managers remain largely focused on service delivery indicators, with limited consideration of equity and user experience.

To examine how participatory approaches can broaden the informational foundations of evaluation, strengthen social accountability in contractual governance, and support more equity-oriented primary health care.

We conducted a comparative cross-sectional qualitative study embedded in a multi-stage participatory research process in two large urban Brazilian municipalities. Data collection included a review of policy documents and literature, semi-structured interviews with public officials, OSS managers, health professionals, health council representatives, and focus group discussions with users and health council representatives. Findings from these stages informed an iterative co-creation process to develop a user-centered questionnaire.

Documentary analysis and key informant interviews showed that evaluation systems in both municipalities had developed substantial capacities for monitoring service production, coverage, operational performance and contractual compliance, while user experience, responsiveness and equity remained less systematically incorporated. Drawing on these materials, we developed an equity framework organized around three broad evaluative dimensions-Responsiveness to Population Needs and Territorial Conditions, Sociocultural Dimensions of Care, and Comprehensive Care for the Person. Focus group discussions further showed how these gaps were experienced in practice, particularly through barriers related to access, communication, continuity, respect and responsiveness to diverse needs. Finally, findings from the documentary analysis, interviews and focus group discussions were integrated with the equity framework and translated into a proposed user-centered questionnaire.

Co-creation broadens the informational foundations of evaluation by translating users' experiential knowledge into actionable measures for performance assessment and quality improvement. This has the potential to strengthen accountability by incorporating forms of knowledge that are typically absent from conventional performance frameworks.