The Contingent Payoff of Transparency: The Mediating Roles of Citizen Participation and Enforcement in Health Service Delivery Improvement

Background: How transparency reforms affect frontline health service delivery remains uncertain. Research presents a transparency paradox, where some studies report service improvements when transparency is combined with oversight, while others find minimal impact on outcomes such as staff absence or medicine availability. Objective: This article addresses the conditions under which transparency improves health services. We argue that inconsistent findings stem from construct slippage, where distinct reforms are grouped together. We propose an unbundled conceptualisation distinguishing three types: Passive Transparency (information only disclosure), VOICE Interventions (disclosure plus citizen participation), and TEETH Interventions (disclosure linked to credible sanctions). Methods: We conducted a scoping review of studies from 2000 to 2025 following PRISMA guidelines. Database searches yielded 6636 records, resulting in 49 included experimental, quasi experimental, and observational studies. Each intervention was coded as Passive Transparency, VOICE or TEETH based on its actual components rather than author labels. Results: The evidence shows that Passive Transparency alone rarely shifts health service outcomes, though it can modestly increase citizen knowledge. Interventions that combine disclosure with empowered VOICE mechanisms show more consistent gains, such as large mortality reductions found in Uganda and Malawi. Similarly, TEETH interventions with credible enforcement, such as centralised drug procurement, produced large price reductions. Where enforcement was weak, transparency had little effect. Conclusion: The impact of transparency on health service delivery is conditional rather than automatic. The transparency paradox is largely resolved when interventions are unbundled. Transparency functions as a diagnostic input whose effectiveness depends on being coupled with functional accountability arrangements: either empowered citizen VOICE or credible state TEETH.