Abstract
Background: Community-led governance can ensure that leaders are accountable to the populations they serve and strengthen health systems for maternal care. A key aspect of democratic accountability is electing respective governance bodies, in this case community boards, and holding public meetings to inform community members about actions taken on their behalf. After helping build and open 10 maternity waiting homes (MWHs) in rural Zambia as part of a randomized controlled trial, we assisted community governance committees to plan and execute annual meetings to present performance results and, where needed, to elect new board members. Methods: We applied a principally qualitative design using observation and analysis of written documentation of public meetings to answer our research question: how do governance committees enact inward transparency and demonstrate accountability to their communities. The analysis measured participation and stakeholder representation at public meetings, the types and purposes of accountability sought by community members as evidenced by questions asked of the governance committee, and responsiveness of the governance committee to issues raised at public meetings. Results: Public meetings were attended by 6 out of 7 possible stakeholder groups, and reports were generally transparent. Stakeholders asked probing questions focused mainly on financial performance. Governance committee members were responsive to questions raised by participants, with 59% of answers rated as fully or mostly responsive (showing understanding of and answering the question). Six of the 10 sites held elections to re-elect or replace governance committee members. Only 2 sites reached the target set by local stakeholder committees of 50% female membership, down from 3 at formation. To further improve transparency and accountability, community governance committees need to engage in advance preparation of reports, and should consult with stakeholders on broader measures for performance assessment. Despite receiving training, community-level governance committees lacked understanding of the strategic purpose of open public meetings and elections, and how these relate to democratic accountability. They were therefore not motivated to engage in tactics to manage stakeholders effectively. Conclusion: While open meetings and elections have potential to enhance good governance at the community level, continuous training and mentoring are needed to build capacity and enhance sustainability.
Highlights
Strengthening health systems to foster community engagement and empowerment can lead to improved maternal, neonatal and child health.[1,2,3] An important aspect of strengthening community participation is assuring good governance, systems of “shared control” and accountability.[1,4] Community-led governance helps ensure that leaders are answerable and accountable to the populations they serve.[5,6] Those in a position of authority—community leaders—are obligated to provide information about or justification for their actions to other community members, and should face consequences if they fail to respond to the needs and concerns of their constituencies.[7]
Our objective is to explore whether the governance committees practiced inward transparency and were held accountable through elections and open public meetings, and to examine the barriers and facilitators to open meetings and election processes as a strategy for good governance of the local committees
Background on the Intervention Governance Committee Structures and Initial Capacity Building To assure that we met Andrews and Shah’s first criteria for good governance, we made efforts to adhere to the formal rules for managing a collaborative in Zambia, as well as respecting the informal customs of starting a community-owned facility within a chiefdom
Summary
Strengthening health systems to foster community engagement and empowerment can lead to improved maternal, neonatal and child health.[1,2,3] An important aspect of strengthening community participation is assuring good governance, systems of “shared control” and accountability.[1,4] Community-led governance helps ensure that leaders are answerable and accountable to the populations they serve.[5,6] Those in a position of authority—community leaders—are obligated to provide information about or justification for their actions to other community members, and should face consequences if they fail to respond to the needs and concerns of their constituencies.[7]. Consulting widely to determine who was influential in the community,[23] project staff created short-term, district-level steering committees composed of traditional chiefs, health facility staff, ministry officials, local community leaders, and reproductive-aged women, and identified some decisions the committees should consider, such as establishing terms of reference for the governance committees and processes for member selection. Aligned with stakeholder steering committee recommendations, project staff facilitated the formation of the governance committees at each study site. Vian et al representation from villages in the health facility catchment area, community health workers, health facility staff, and traditional leadership; they emphasized a minimum of 50% female representation, in an effort to assure that structures meant to improve women’s health could have leadership representative of the target population. Project staff helped each governance committee to choose a management unit, usually an individual or several individuals in charge of day-to-day MWH management
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