Abstract
ABSTRACTBackground: There is a gap in knowledge about how citizen participation impacts governance of free healthcare policies for universal health coverage in low- and middle-income countries.Objective: This study provides evidence about how social accountability initiatives influenced revenue generation, pooling and fund management, purchasing and capacity of health facilities implementing the free maternal and child healthcare programme (FMCHP) in Enugu State, Nigeria.Methods: The study adopted a descriptive, qualitative case-study design to explore how social accountability influenced implementation of the FMCHP at the state level and in two health districts (Isi-Uzo and Enugu Metropolis) in Enugu State. Data were collected from policymakers (n = 16), providers (n = 16) and health facility committee leaders (n = 12) through in-depth interviews. We also conducted focus-group discussions (n = 4) with 42 service users and document review. Data were analysed using thematic analysis.Results: It was found that health facility committees (HFCs) have not been involved in the generation of funds, fund management and tracking of spending in FMCHP. The HFCs did not also seem to have increased transparency of benefits and payment of providers. The HFCs emerged as the dominant social accountability initiative in FMCHP but lacked power in the governance of free health services. The HFCs were constrained by weak legal framework, ineffectual FMCHP committees at the state and district levels, restricted financial information disclosure, distrustful relationships with policymakers and providers, weak patient complaint system and low use of service charter.Conclusion: The HFCs have not played a significant role in health financing and service provision in FMCHP. The gaps in HFCs’ participation in health financing functions and service delivery need to be considered in the design and implementation of free maternal and child healthcare policies that aim to achieve universal health coverage.
Highlights
There is a gap in knowledge about how citizen participation impacts governance of free healthcare policies for universal health coverage in low- and middle-income countries
Policymakers explained that free maternal and child healthcare programme (FMCHP) preceded the formation of health facility committees (HFCs), the HFC Alliance had so far not engaged with decision makers effectively
Some HFC leaders even thought, wrongly, that FMCHP was being funded by health development partners, as illustrated by the words of one HFC leader, who demonstrated a lack of information on which level of government has been funding FMCHP: ‘It seems that some donors are funding free MCH program and not just the state government
Summary
There is a gap in knowledge about how citizen participation impacts governance of free healthcare policies for universal health coverage in low- and middle-income countries. In the current era of sustainable development goals, with a huge focus on UHC, citizen participation in implementing health financing policies may promote service use relative to the need for care, responsiveness of providers and financial protection [9] Social accountability initiatives, such as patient complaints procedures, health facility committees (HFCs), provider report cards and patients’ rights charters [10,11,12,13], may inspire users to participate in management of health facilities, complement government-led supervision and regulation, and improve the quality of healthcare decisions by government [4,6,14]. These accountability initiatives may improve the capacity of policymakers and providers to make changes to services based on citizens’ expectations [12,15], promote
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