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Abstract
BackgroundThere are several studies from different geographical settings and levels on maternal health, but none analyzes how accountability problems may contribute to the maternal health outcomes. This study aimed to analyze how accountability problems in public health system lead to maternal deaths and inequities in India.MethodsA conceptual framework was developed bringing together accountability process (in terms of standard setting, performance assessment, accountability (or answerability, and enforceability) —an ongoing cyclical feedback process at different levels of health system) and determinants of maternal health to analyze the influence of the process on the determinant leading to maternal health outcomes. A scoping review of qualitative and mixed-methods studies from public health sector in India was conducted. A narrative and interpretive synthesis approach was applied to analyze data.ResultsAn overarching influence of health system-related factors over non-health system-related factors leading to maternal deaths and inequities was observed. A potential link among such factors was identified with gaps in accountability functions at all levels of health system pertaining to policy gaps or conflicting/discriminatory policies and political commitment. A large number of gaps were also observed concerning performance or implementation of existing standards. Inherent to these issues was potentially a lack of proper monitoring and accountability functions. A critical role of power was observed influencing the accountability functions.ConclusionThe narrative and interpretive synthesis approach allowed to integrate and reframe the relevant comparable information from the limited empirical studies to identify the hot spots of systemic flaws from an accountability perspective. The framework highlighted problems in health system beyond health service delivery to wider areas such as policy or politics justifying their relevance and importance in such analysis. A crucial message from the study pertains to a need to move away from the traditional concept of viewing accountability as a blame-game approach and a concern of limited frontline health workers towards a constructive and systemic approach.
Highlights
There are several studies from different geographical settings and levels on maternal health, but none analyzes how accountability problems may contribute to the maternal health outcomes
To support our analysis and interpretation, we developed a conceptual framework integrating the two aspects, accountability and maternal health, based on the assumption that accountability potentially influences the performance of the health system, which could lead to poor health outcomes [17–19]
Nine studies explored factors contributing to maternal deaths [17, 18, 52, 38, 42, 54–57], eight were related to factors influencing access to use of maternal health services [19, 58–64], two explored policy contexts [3, 65], and two were related to the implementation of maternal death review (MDR) [66, 67]
Summary
There are several studies from different geographical settings and levels on maternal health, but none analyzes how accountability problems may contribute to the maternal health outcomes. This study aimed to analyze how accountability problems in public health system lead to maternal deaths and inequities in India. Even if maternal deaths have decreased at the global level, many women continue to die due to pregnancy- and childbirth-related causes, especially in low- and middle-income countries (LMICs). The World Health Organization (WHO) estimated that in 2015, about 99% of maternal deaths worldwide were in developing countries [1]. Direct obstetric causes account for about 73% of all maternal deaths globally, the most common being hemorrhage, hypertensive disorders, sepsis, abortions, complications of delivery, and obstructed labor [2]. Global strategies to achieve the Sustainable Development Goals (SDGs) have explicitly emphasized accountability in health systems and as a part of governance as a core principle to attain the SDG in relation to maternal and perinatal health [4, 5]. Accountability has been variously defined [6, 7], the most common definition in the health sector [8–12] pertains to Schedler’s [13] two-dimensional concept: an obligation for answerability—to provide information about and/or justification for the actions of the bodies accountable to accounting bodies—and enforceability—to be the subject to some form of sanction for failure to comply with and/or engage in appropriate action by accountable bodies
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