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

Mukesh Hamal,Myonne Smid,Azucena Bardají,Tjard De Cock Buning,Kalina Heiter,Vincent De Brouwere,Chiranjibi Nepal,Lian Schoenmakers,Marjolein Dieleman

doi: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

Maternal mortality is still a major concern in low- and middle-income countries such as Nepal
Our study showed that women share their health service concerns in mothers’ groups (MGs) and with female community health volunteers (FCHVs), who have the potential to serve as intermediaries between the women and the health sector
Except for a few studies that focused on specific activities, such as social audits, citizen charters and a suggestions/complaints box,[3,15,16] we found no studies exploring social accountability mechanisms for maternal health services in Nepal, how they function, and their potential to address local concerns about health services

Summary

Introduction

Maternal mortality is still a major concern in low- and middle-income countries such as Nepal. Challenges related to access to and use of maternal health services persist, especially among ‘disadvantaged groups’ such as rural and socio-economically marginalized castes and ethnic groups in Nepal.[3,4] For example, in addition to the lack of transportation, long distance to health facilities, and difficult geographical terrain in rural areas, health facilities often lack round-the-clock maternal health services, trained healthcare providers, equipment and drugs.[3,5,6,7] Women have reported a lack of proper referral, unfriendly and discriminatory behaviours of healthcare providers, etc.[3]

Objectives

Methods

Results

Conclusion