Abstract
BackgroundIn Malawi, as in many low-and middle-income countries, health facility committees (HFCs) are involved in the governance of health services. Little is known about the approaches they use and the challenges they face. This study explores how HFCs monitor the quality of health services and how they demand accountability of health workers for their performance.MethodsDocumentary analysis and key informant interviews (7) were complemented by interviews with purposefully selected HFC members (22) and health workers (40) regarding their experiences with HFCs. Data analysis was guided by a coding scheme informed by social accountability concepts complemented by inductive analysis to identify participants’ perceptions and meanings of processes of social accountability facilitated by HFCs.ResultsThe results suggest that HFCs address poor health worker performance (such as absenteeism, poor treatments and informal payments), and report severe misconduct to health authorities. The informal and constructive approach that most HFCs use is shaped by formal definitions and common expectations of the role of HFCs in service delivery as well as resource constraints. The primary function of social accountability through HFCs appears to be co-production: the management of social relations around the health facility and the promotion of a minimum level of access and quality of services.ConclusionsPolicymakers and HFC support programs should take into account the broad task description of HFCs and integrate social accountability approaches in existing quality of care programs. The study also underscores the need to clarify accountability arrangements and linkages with upward accountability approaches in the system.
Highlights
In Malawi, as in many low-and middle-income countries, health facility committees (HFCs) are involved in the governance of health services
Participants’ accounts of how Health Centre Advisory Committee (HCAC) identify and address poor health worker performance are presented in terms of three major themes generated by the analysis: monitoring performance, “sitting down” and mediation, and reporting
The other 50% of the HCACs hold their meetings without the presence of a Statutory meetings HCACs formally meet once a month on average, but the frequency of their meetings is influenced by climatic conditions, social events, public health events, training, emergencies or campaigns organised by the health centre, the Ministry of Health or NGOs
Summary
In Malawi, as in many low-and middle-income countries, health facility committees (HFCs) are involved in the governance of health services. The role of HFCs in the governance of health services and the monitoring of health workers is receiving increased attention, little empirical evidence is available on how they perform this role in low-and middleincome countries [4]. It assumes that HFCs, through their formal intermediary position between the community and health workers, constitute an essential channel through which citizens can provide feedback to health workers and demand service improvements or explanations for actions and service delivery failures. The paper provides a lens for reflection for health workers, managers and policymakers on the expectations regarding the role of HFCs in governance and accountability and for targeting improvement efforts in Malawi and elsewhere. It starts with a brief overview of HFC characteristics in Malawi, followed by a conceptual framework to assess HFCs role as social accountability interfaces
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