International Journal of Health Policy and Management

International Journal of Health Policy and Management

Social Accountability in Maternal Health Services in the Far-Western Development Region in Nepal: An Exploratory Study

Document Type : Original Article

Authors
Mukesh Hamal 1, 2, 3
Kalina Heiter 1
Lian Schoenmakers 1
Myonne Smid 1
Tjard de Cock Buning 1
Vincent De Brouwere 2
Azucena Bardají 3
Chiranjibi Nepal 4
Marjolein Dieleman 1, 5
1 Athena Institute for Research on Innovation and Communication in Health and Life Sciences (VU University), Amsterdam, The Netherlands
2 Maternal and Reproductive Health, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
3 ISGlobal, Hospital Clínic-Universitat de Barcelona, Barcelona, Spain
4 CARE, Lalitpur, Nepal
5 KIT Health, Amsterdam, The Netherlands
10.15171/ijhpm.2019.05
Abstract
Background
Social accountability or citizen-led accountability has been promoted in many low- and middle-income countries to improve the quality, access to and use of maternal health services. Experiences with social accountability in maternal health services in Nepal have not yet been documented. This study identifies existing social accountability structures and activities in maternal health services in two districts of Far-Western Nepal and explores their functions, implementation and gaps/challenges.
 
Methods
An exploratory study was conducted that included in-depth interviews with purposively selected policy advisors (8), healthcare officials (11), healthcare providers (12) and non-governmental staff (3); and focus group discussions (FGDs) with 54 women. Data analysis was conducted using thematic content analysis based on George’s information, dialogue and negotiation framework.
 
Results
Social accountability in maternal health existed in terms of structures such as mothers’ groups (MGs), female community health volunteers (FCHVs) and Health Facility Operation and Management Committees (HFOMCs); and activities such as social audits and community health score board (CHSB). MGs and FCHVs were perceived as trusted intermediaries, but their functioning was limited to information. HFOMCs were not fully functional. Social audits and CHSBs were implemented in limited sites and with poor participation by women. Health-sector responses were mainly found at the local level. Factors contributing to these challenges were the absence of a mandate and limited capacity, including resources.
 
Conclusion
Formal structures and activities existed for social accountability in maternal health services in the Far-Western Development Region of Nepal, but there were limitations pertaining to their implementation. The main recommendations are: for clear policy mandates on the social accountability roles of MGs and FCHVs; wider implementation of social audits and CHSBs, with emphasis on the participation of women from disadvantaged groups; improved capacity of HFOMCs; and improved engagement of the health sector at all levels to listen and respond to women’s concerns.

Highlights

 

Watch the Video Summary here.

 

Keywords
Social Accountability
Governance
Maternal Health
Health Services
Nepal
Subjects

 

 

  1. World Health Organization (WHO). Trends in Maternal Mortality: 1990 to 2015: Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. http://apps.who.int/iris/bitstream/10665/194254/1/9789241565141_eng.pdf?ua=1.  Accessed May 5, 2016. Published 2015.
  2. Souza J, Tunçalp Ö, Vogel J, et al. Obstetric transition: The pathway towards ending preventable maternal deaths. BJOG. 2014;121(Suppl 1):1-4. doi:10.1111/1471-0528.12735.
  3. Mehata S, Baral SC, Chand PB, Singh DR, Poudel P, Barnett S. Nepal Household Survey 2012: Nepal Health Sector Programme ll; 2013. https://www.mohp.gov.np/downloads/Household%20Survey%202012.pdf.  Accessed December 4, 2017.
  4. Suvedi BK, Pradhan A, Barnett S, et al. Nepal Maternal Mortality and Morbidity Study 2008/2009: Summary of Preliminary Findings. http://library.nhrc.gov.np:8080/nhrc/bitstream/handle/123456789/45/604.pdf?sequence=1. Accessed December 5, 2017. Published 2009.
  5. Pradhan A, Suvedi BK, Barnett S, et al. Nepal Maternal Mortality and Morbidity Study 2008/2009. http://nhsp.org.np/wp-content/uploads/2016/08/MMMS-Final-Report.pdf.  Accessed July 9, 2018. Published 2010.
  6. Onta S, Choulagai B, Shrestha B, Subedi N, Bhandari GP, Krettek A. Perceptions of users and providers on barriers to utilizing skilled birth care in mid- and far-western Nepal: A qualitative study. Glob Health Action. 2014;7(1). doi:10.3402/gha.v7.24580
  7. Baral Y, Lyons K, Skinner J, Van Teijlingen E. Determinants of skilled birth attendants for delivery in Nepal. Kathmandu Univ Med J. 2010;8(31):325-332. doi:10.3126/kumj.v8i3.6223
  8. Mafuta EM, Dieleman MA, Hogema LM, et al. Social accountability for maternal health services in Muanda and Bolenge Health Zones, Democratic Republic of Congo: A situation analysis. BMC Health Serv Res. 2015;15(1):514. doi:10.1186/s12913-015-1176-6
  9. George A. Using accountability to improve reproductive health care. Reprod Health Matters. 2003;11(21):161-170.
  10. Papp SA, Gogoi A, Campbell C. Improving maternal health through social accountability: A case study from Orissa, India. Glob Public Health. 2013;8(4):449-464. doi:10.1080/17441692.2012.748085
  11. Joshi A, Houtzager PP. Widgets or watchdogs? Public Manag Rev. 2012;14(2):145-162. doi:10.1080/14719037.2012.657837
  12. Schedler A. Conceptualizing accountability. In: Schelder A, Diamond L, Plattner MF, eds. The Self-Restraining State: Power and Accountability in New Democracies. London: Lynne Reinner Publishers; 1999:13-28.
  13. Lodenstein E, Dieleman M, Gerretsen B, Broerse JE. Health provider responsiveness to social accountability initiatives in low- and middle-income countries: A realist review. Health Policy Plan. 2017;32(1):125-140. doi:10.1093/heapol/czw089
  14. CARE Nepal. Strengthening approaches for maximizing maternal, neonatal and reproductive health (SAMMAN)/GSKII Project- Community Health Score Board (CHSB). http://www.carenepal.org/uploads/pdf/publication/_CHSB_final%20document.pdf.     Accessed December 6, 2017. Published 2013.
  15. Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ). Making Local Health Services Accountable: Social Auditing in Nepal’s Health Sector. http://health.bmz.de/ghpc/case-studies/Making_local_health_services_accountable/index.html.  Accessed November 20, 2017. Published 2015.
  16. Neupane BD. A Review of Social Audit Guidelines and Practices in Nepal (Draft). Available at: http://nhsp.org.np/wp-content/uploads/2016/08/Social-Audit-Review-Final-Draft-Report-10-Oct-2011-5.pdf.  Accessed November 20, 2017. Published 2011.
  17. Dasgupta J. Ten years of negotiating rights around maternal health in Uttar Pradesh, India. BMC Int Health Hum Rights. 2011;11(Suppl 3):S4. doi:10.1186/1472-698X-11-S3-S4
  18. Gullo S, Galavotti C, Altman L. A review of CARE’s community score card experience and evidence. Health Policy Plan. 2016;31(10):1467-1478. doi:10.1093/heapol/czw064
  19. Ministry of Health (MoH). Nepal Demographic and Health Survey 2016. Available at: https://www.dhsprogram.com/pubs/pdf/fr336/fr336.pdf.  Accessed December 5, 2017. Published 2017.
  20. Department of Health Services (DoHS). Annual Report 2072/73 (2015/2016). http://dohs.gov.np/wp-content/uploads/2017/06/DoHS_Annual_Report_2072_73.pdf.  Accessed December 5, 2017. Published 2015.
  21. Ministry of Health and Population (MOHP). Nepal Demographic and Health Survey 2011. https://dhsprogram.com/pubs/pdf/fr257/fr257%5B13april2012%5D.pdf.  Accessed December 5, 2017. Published 2012.
  22. Central Bureau of Statistics (CBS). Population District Level, 2017 (National Population and Housing Census 2011). https://cbs.gov.np/wp-content/upLoads/2018/12/Population_District_Level.pdf.  Accessed December 18, 2017. Published 2011.
  23. Central Bureau of Statistics (CBS). National Population and Housing Census 2011 (Village Development Committee/Municipality), Volume 06-Doti. 2014; 6:1-278. https://cbs.gov.np/wp-content/upLoads/2018/12/70-Doti_VDCLevelReport.pdf.  Accessed December 18, 2017.
  24. Ministry of Foreign Affairs and Local Development (MoFALD). GIS District Map. Available at: http://lgcdp.gov.np/GIS_district.  Accessed February 20, 2018. Published 2014.
  25. Local Nepal Today. Draft constitution: Whats the change for local Nepal? http://localnepaltoday.com/draft-constitution-whats-the-change-for-local-nepal/.  Accessed February 20, 2018. Published 2015.
  26. The World Bank. Making Services Work for Poor People. World Development Report 2004. Washington, DC: the World Bank; 2004. http://documents.worldbank.org/curated/en/832891468338681960/pdf/268950WDR00PUB0ces0work0poor0people.pdf.  Accessed August 18, 2016.
  27. Green J, Thorogood N. Qualitative Methods for Health Research. London: SAGE Publications Ltd; 2004. doi:10.1007/s13398-014-0173-7.2
  28. Patton MQ. Enhancing the quality and credibility of qualitative analysis. Health Serv Res. 1999;34(5 Pt 2):1189-1208. doi:10.4135/9781412985727
  29. Ministry of Health and Population (MOHP). National Female Community Health Volunteer Program Strategy (Unofficial Translation). https://www.advancingpartners.org/sites/default/files/nepal_national_female_chv_program_strategy.pdf.  Accessed November 11, 2017. Published 2010.
  30. Nepal Family Health Program (NFHP). Female Community Health Volunteers (Technical brief #1). https://www.jsi.com/JSIInternet/Inc/Common/_download_pub.cfm?id=12140&lid=3.  Accessed April 16, 2018. Published 2012.
  31. Morrison J, Tumbahangphe KM, Budhathoki B, et al. Community mobilisation and health management committee strengthening to increase birth attendance by trained health workers in rural Makwanpur, Nepal: Study protocol for a cluster randomised controlled trial. Trials. 2011;12(1):128. doi:10.1186/1745-6215-12-128
  32. Hada J. Effectiveness of health facility management strengthening program: A case study of Surkhet district [thesis report]. http://www.academia.edu/7247890/Health_facility_management_strengthening_program_A_case_study_of_surkhet_district-Nepal.  Accessed November 14, 2017. Published 2013.
  33. Gurung G, Tuladhar S. Fostering good governance at peripheral public health facilities: An experience from Nepal. Rural Remote Health. 2013;13(2):2042.
  34. Ministry of Health and Population (MOHP). Health Facility Operation and Management Committee Guideline, 2063 [Nepali]. https://publichealthupdate.com/health-facility-operation-and-management-committees-hfomc-guideline-nepal/.  Accessed November 2, 2017.
  35. District Development Committee (Kailali). Periodic District Development Plan (Fiscal Year 2072/073-2076/077), District Profile (Translated Version). http://ddckailali.gov.np/wp-content/uploads/2015/09/2.2-PDDP-_-Kailali-_-English-_-Final-_-23-March.pdf.  Accessed December 18, 2017. Published 2015.
  36. Brinkerhoff DW. Accountability and health systems: Toward conceptual clarity and policy relevance. Health Policy Plan. 2004;19(6):371-379. doi:10.1093/heapol/czh052
  37. Scott K, George AS, Harvey SA, et al. Beyond form and functioning: Understanding how contextual factors influence village health committees in northern India. PLoS One. 2017;12(8):e0182982. doi:10.1371/journal.pone.0182982
  38. Schaaf M, Topp SM, Ngulube M. From favours to entitlements: Community voice and action and health service quality in Zambia. Health Policy Plan. 2017;32(6):847-859. doi:10.1093/heapol/czx024
  39. Lodenstein E, Mafuta E, Kpatchavi AC, et al. Social accountability in primary health care in West and Central Africa: Exploring the role of health facility committees. BMC Health Serv. Res. 2017;17(1):403. doi:10.1186/s12913-017-2344-7
  40. Katahoire AR, Henriksson DK, Ssegujja E, et al. Improving child survival through a district management strengthening and community empowerment intervention: Early implementation experiences from Uganda. BMC Public Health. 2015;15:797. doi:10.1186/s12889-015-2129-z
  41. Gullo S, Galavotti C, Kuhlmann AS, Msiska T, Hastings P, Marti CN. Effects of a social accountability approach, CARE’s Community Score Card, on reproductive health-related outcomes in Malawi: A cluster-randomized controlled evaluation. PLoS One. 2017;12(2):e0171316. doi:10.1371/journal.pone.0171316
  42. Saprii L, Richards E, Kokho P, Theobald S. Community health workers in rural India: Analysing the opportunities and challenges Accredited Social Health Activists (ASHAs) face in realising their multiple roles. Hum Resour Health. 2015;13(1):95. doi:10.1186/s12960-015-0094-3
  43. Scott K, Shanker S. Tying their hands? Institutional obstacles to the success of the ASHA community health worker programme in rural north India. AIDS Care 2010;22(2):1606-1612. doi:10.1080/09540121.2010.507751
  44. Brinkerhoff DW, Wetterberg A. Gauging the effects of social accountability on services, governance, and citizen empowerment. Public Adm Rev. 2016;76(2):274-286. doi:10.1111/puar.12399
  45. Hamal M, Dieleman M, Brouwere V De, Buning TDC. How do accountability problems lead to maternal health inequities? A review of qualitative literature from Indian public sector. Public Health Rev. 2018;39(9):1-27. doi:10.1186/s40985-018-0081-z.
  46. O’Meally SC. Mapping Context for Social Accountability: A Resource Paper. Washington, DC: Social Development Department, World Bank; 2013. http://siteresources.worldbank.org/EXTSOCIALDEVELOPMENT/Resources/244362-1193949504055/Context_and_SAcc_RESOURCE_PAPER.pdf.  Accessed August 18, 2016.
International Journal of Health Policy and Management
Volume 8, Issue 5
May 2019
Pages 280-291

  • Received Date 25 February 2018
  • Revised Date 02 February 2019
  • Accepted Date 02 February 2019
  • First Published Date 01 May 2019
  • Published Date 01 May 2019