A mapping and synthesis of tools for stakeholder and community engagement in quality improvement initiatives for reproductive, maternal, newborn, child and adolescent health.

BACKGROUND: Stakeholder and community engagement promotes collaboration and gives service users an opportunity to actively participate in the care they receive. Recognizing this potential, The Network for Improving Quality of Care for maternal, newborn and child health aimed to identify tools and operational guidance to integrate stakeholder and community engagement into quality improvement (QI) implementation. METHODS: A mapping, consisting of a literature review and an open call through email and listservers, for implementation tools was conducted. Materials were included if they provided guidance on stakeholder and community engagement aligned to the Network's QI framework comprising seven phases. Screening of tools was done by two reviewers. RESULTS: The literature search and the call for tools returned 197 documents with 70 tools included after screening. Most included tools (70%) were published after 2010. International organizations were the most frequently cited authors of tools. Only 15 tools covered all seven phases of the QI framework; few tools covered the more 'technical' phase of the QI framework: adapting standards and refining strategies. CONCLUSION: The quantity of tools and their varied characteristics including types of stakeholder and community engagement processes across the QI framework confirms that engagement cannot be captured in a 'one-size-fits-all' formula. Many tools were designed with a generic focus to allow for adaption and use in different settings and sectors. Country programmes looking to strengthen engagement approaches can take advantage of available tools through an online portal on the WHO website and adapt them to meet their specific needs and context. PUBLIC INVOLVEMENT: Programme implementers provided tools and resources during data collection.

"We come as friends": approaches to social accountability by health committees in Northern Malawi.

BACKGROUND: In 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. METHODS: Documentary 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. RESULTS: The 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. CONCLUSIONS: Policymakers 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.

Gendered norms of responsibility: reflections on accountability politics in maternal health care in Malawi.

BACKGROUND: This paper aims to provide insights into the role of traditional authorities in two maternal health programmes in Northern Malawi. Among strategies to improve maternal health, these authorities issue by-laws: local rules to increase the uptake of antenatal and delivery care. The study uses a framework of gendered institutions to critically assess the by-law content, process and effects and to understand how responsibilities and accountabilities are constructed, negotiated and reversed. METHODS: Findings are based on a qualitative study in five health centre catchment areas in Northern Malawi. Data were collected using meeting observations and document search, 36 semi-structured individual interviews and 19 focus group discussions with female maternal health service users, male community members, health workers, traditional leaders, local officials and health committee members. A gender and power sensitive thematic analysis was performed focusing on the formulation, interpretation and implementation process of the by-laws as well as its effects on women and men. RESULTS: In the study district, traditional leaders introduced three by-laws that oblige pregnant women to attend antenatal care; bring their husbands along and; and to give birth in a health centre. If women fail to comply with these rules, they risk being fined or denied access to maternal health services. The findings show that responsibilities and accountabilities are negotiated and that by-laws are not uniformly applied. Whereas local officials support the by-laws, lower level health cadres' and some community members contest them, in particular, the principles of individual responsibility and universality. CONCLUSIONS: The study adds new evidence on the understudied phenomenon of by-laws. From a gender perspective, the by-laws are problematic as they individualise the responsibility for maternal health care and discriminate against women in the definition and application of sanctions. Through the by-laws, supported by national policies and international institutions, women bear the full responsibility for failures in maternal health care, suggesting a form of 'reversed accountability' of women towards global maternal health goals. This can negatively impact on women's reproductive health rights and obstruct ambitions to achieve gender inequality and health equity. Contextualised gender and power analysis in health policymaking and programming as well as in accountability reforms could help to identify these challenges and potential unintended effects.

Informal social accountability in maternal health service delivery: A study in Northern Malawi.

Despite the expansion of literature on social accountability in low-and middle-income countries, little is known about how health providers experience daily social pressure and citizen feedback. This study used a narrative inquiry approach to explore the function of daily social accountability relations among maternal health care workers in rural Malawi. Through semi-structured interviews with 32 nurses and 19 clinicians, we collected 155 feedback cases allowing the identification of four main strategies social actors use to express their opinion and concerns about maternal health services. We found that women who used delivery care express their appreciation for successful deliveries directly to the health worker but complaints, such as on absenteeism and poor interpersonal behaviour, follow an indirect route via intermediaries such as the health workers' spouse, co-workers or the health committee who forward some cases of misbehaviour to district authorities. The findings suggest that citizen feedback is important for the socialization, motivation and retention of maternal healthcare workers in under resourced rural settings. Practitioners and external development programmes should understand and recognize the value of already existing accountability mechanisms and foster social accountability approaches that allow communities as well as health workers to challenge the systemic obstacles to quality and respectful service delivery.

Social accountability in primary health care in West and Central Africa: exploring the role of health facility committees.

BACKGROUND: Social accountability has been emphasised as an important strategy to increase the quality, equity, and responsiveness of health services. In many countries, health facility committees (HFCs) provide the accountability interface between health providers and citizens or users of health services. This article explores the social accountability practices facilitated by HFCs in Benin, Guinea and the Democratic Republic of Congo. METHODS: The paper is based on a cross-case comparison of 11 HFCs across the three countries. The HFCs were purposefully selected based on the (past) presence of community participation support programs. The cases were derived from qualitative research involving document analysis as well as interviews and focus group discussions with health workers, citizens, committee members, and local authorities. RESULTS: Most HFCs facilitate social accountability by engaging with health providers in person or through meetings to discuss service failures, leading to changes in the quality of services, such as improved health worker presence, the availability of night shifts, the display of drug prices and replacement of poorly functioning health workers. Social accountability practices are however often individualised and not systematic, and their success depends on HFC leadership and synergy with other community structures. The absence of remuneration for HFC members does not seem to affect HFC engagement in social accountability. CONCLUSIONS: Most HFCs in this study offer a social accountability forum, but the informal and non-systematic character and limited community consultation leave opportunities for the exclusion of voices of marginalised groups. More inclusive, coherent and authoritative social accountability practices can be developed by making explicit the mandate of HFC in the planning, monitoring, and supervision of health services; providing instruments for organising local accountability processes; strengthening opportunities for community input and feedback; and strengthening links to formal administrative accountability mechanisms in the health system.

Health provider responsiveness to social accountability initiatives in low- and middle-income countries: a realist review.

Social accountability in the health sector has been promoted as a strategy to improve the quality and performance of health providers in low- and middle-income countries. Whether improvements occur, however, depends on the willingness and ability of health providers to respond to societal pressure for better care. This article uses a realist approach to review cases of collective citizen action and advocacy with the aim to identify key mechanisms of provider responsiveness. Purposeful searches for cases were combined with a systematic search in four databases. To be included in the review, the initiatives needed to describe at least one outcome at the level of frontline service provision. Some 37 social accountability initiatives in 15 countries met these criteria. Using a realist approach, retroductive analysis and triangulation of methods and sources were performed to construct Context-Mechanism-Outcome configurations that explain potential pathways to provider responsiveness. The findings suggest that health provider receptivity to citizens' demands for better health care is mediated by health providers' perceptions of the legitimacy of citizen groups and by the extent to which citizen groups provide personal and professional support to health providers. Some citizen groups activated political or formal bureaucratic accountability channels but the effect on provider responsiveness of such strategies was more mixed. Favourable contexts for health provider responsiveness comprise socio-political contexts in which providers self-identify as activists, health system contexts in which health providers depend on citizens' expertise and capacities, and health system contexts where providers have the self-perceived ability to change the system in which they operate. Rather than providing recipes for successful social accountability initiatives, the synthesis proposes a programme theory that can support reflections on the theories of change underpinning social accountability initiatives and interventions to improve the quality of primary health care in different settings.

A realist synthesis of the effect of social accountability interventions on health service providers' and policymakers' responsiveness.

BACKGROUND: Accountability has center stage in the current post-Millennium Development Goals (MDG) debate. One of the effective strategies for building equitable health systems and providing quality health services is the strengthening of citizen-driven or social accountability processes. The monitoring of actions and decisions of policymakers and providers by citizens is regarded as a right in itself but also as an alternative to weak administrative accountability mechanisms, in particular in settings with poor governance. The effects of social accountability interventions are often based on assumptions and are difficult to evaluate because of their complex nature and context sensitivity. This study aims to review and assess the available evidence for the effect of social accountability interventions on policymakers' and providers' responsiveness in countries with medium to low levels of governance capacity and quality. For policymakers and practitioners engaged in health system strengthening, social accountability initiatives and rights-based approaches to health, the findings of this review may help when reflecting on the assumptions and theories of change behind their policies and interventions. METHODS/DESIGN: Little is known about social accountability interventions, their outcomes and the circumstances under which they produce outcomes for particular groups or issues. In this study, social accountability interventions are conceptualized as complex social interventions for which a realist synthesis is considered the most appropriate method of systematic review. The synthesis is based on a preliminary program theory of social accountability that will be tested through an iterative process of primary study searches, data extraction, analysis and synthesis. Published and non-published (grey) quantitative and qualitative studies in English, French and Spanish will be included. Quality and validity will be enhanced by continuous peer review and team reflection among the reviewers. DISCUSSION: The authors believe the advantages of a realist synthesis for social accountability lie in the possibility of overcoming disciplinary or paradigmatic boundaries often found in public health and development. In addition, they argue that this approach fills the knowledge gap left by conventional synthesis or evaluation exercises of participatory programs. Finally, the authors describe the practical strategies adopted to address methodological challenges and validity.

Devolution and human resources in primary healthcare in rural Mali.

Devolution, as other types of decentralization (e.g. deconcentration, delegation, privatization), profoundly changes governance relations in the health system. Devolution is meant to affect performance of the health system by transferring responsibilities and authority to locally elected governments. The key question of this article is: what does devolution mean for human resources for health in Mali?This article assesses the key advantages and dilemmas associated with devolution such as responsiveness to local needs, downward accountability and health worker retention. Challenges of politics and capacities are also addressed in relation to human resources for health at the local level. Examples are derived from experiences in Mali with a capacity development programme and from case studies of other countries. It is not research findings that are presented, but highlights of key issues at stake aimed at inspiring the debate in Mali and elsewhere.A first lesson from the discussion suggests that in the context of human resources for health, decentralization of authority and resources is not the main issue. The challenge is to develop or strengthen accountability of those who decide and act, whether they are local politicians, bureaucrats or community representatives. If decentralization policies do not address public accountability, they will not fundamentally change human resource management, quality and equity of staffing. A second lesson is that successful devolution requires innovations in capacity development of all actors involved and in designing effective incentive measures. A final key conclusion is that the topic of devolution policy and its effects on human resources for health, and vice versa, merit more attention. A better understanding may lead to more appropriate policy designs and better preparation for the actors involved in countries that are embarking on decentralization, as is the case in Mali.