Social accountability for maternal health services in Muanda and Bolenge Health Zones, Democratic Republic of Congo: a situation analysis

Abstract

BackgroundThe Democratic Republic of the Congo is one of the countries in Sub-Saharan Africa with the highest maternal mortality ratio estimated at 846 deaths per 100,000 live births. Innovative strategies such as social accountability are needed to improve both health service delivery and utilization. Indeed, social accountability is a form of citizen engagement defined as the ‘extent and capability of citizens to hold politicians, policy makers and providers accountable and make them responsive to their needs.’ This study explores existing social accountability mechanisms through which women’s concerns are expressed and responded to by health providers in local settings.MethodsAn exploratory study was conducted in two health zones with purposively sampled respondents including twenty-five women, five men, five health providers, two health zone officers and eleven community stakeholders. Data on women’s voice and oversight and health providers’ responsiveness were collected using semi-structured interviews and analysed using thematic analysis.ResultsIn the two health zones, women rarely voiced their concerns and expectations about health services. This reluctance was due to: the absence of procedures to express them, to the lack of knowledge thereof, fear of reprisals, of being misunderstood as well as factors such as age-related power, ethnicity backgrounds, and women’s status.The means most often mentioned by women for expressing their concerns were as individuals rather than as a collective. They did not use them instead; instead they looked to intermediaries, mostly, trusted health providers, community health workers and local leaders. Their perceptions of health providers’ responsiveness varied. For women, there were no mechanisms for oversight in place. Individual discontent with malpractice was not shown to health providers. In contrast, health providers mentioned community health workers, health committee, and community based organizations as formal oversight mechanisms. All respondents recognized the lack of coalition around maternal health despite the many local associations and groups.ConclusionsSocial accountability is relatively inexistent in the maternal health services in the two health zones. For social accountability to be promoted, efforts need to be made to create its mechanisms and to open the local context settings to dialogue, which appears structurally absent.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-015-1176-6) contains supplementary material, which is available to authorized users.

Implementation of free maternal and child healthcare policies: assessment of influence of context and institutional capacity of health facilities in South-east Nigeria

“…Our findings are consistent with low citizen participation found in other studies [9,22–24]. In contrast, in Nepal, Burkina Faso and Kenya, HFCs were actively involved in free care schemes including financial management [10–12].…”

“…Use of service charters to curb informal payments to service providers [9], active health facility committees (HFCs) including financial management [10–12], timely payment of providers [13], regular and uninterrupted drug supply [13], availability of clear guidelines on use of user fee replacement grants [14], an effective staff sanction framework, which reduces health worker absenteeism [15], have enabled health facilities to effectively implement free healthcare policies. In contrast, barriers to health facilities implementing free healthcare policies include weak decentralization [10,16–18]; poor supervision and monitoring [19,20]; weak referral systems [17]; absence of written implementation guidelines [14,21]; shortage of staff and inconsistent recording and reporting [10,20]; low social accountability and community involvement [9,22–24]; delayed payment of providers [12,21,25]; lack of adequate drug stock [17,18,24,26–31]; mistrust between providers and patients [19,32–34]; absenteeism [10,15,20]; poorly motivated health workers [18,24]; lack of financial incentives [35]; preference for urban postings [19,36]; funding inadequacy in health facilities [16]; inadequate physical infrastructure [18,24,36]; unavailability of guidelines for use of user fee replacement fund [37] and unclear procedures for targeting beneficiaries [3]. …”

The community is just a small circle: citizen participation in the free maternal and child healthcare programme of Enugu State, Nigeria

“…Even though users in Mexico had good knowledge of complaint systems, information gaps and limited collective action constrained the effectiveness of the complaint system [20]. The reasons adduced for low use of a complaint box included low literacy level of clients, fear of reprisal and insufficient client communication by providers, similar to the findings from studies in Democratic Republic of Congo and Tanzania [5,25]. Unfortunately, absence of complaint box limited users of the FMCHP from providing feedback to providers of the care process, who instead relied on the community being ‘just a small circle’ to share their complaints with the HFC members with whom they are familiar.…”

“…An advanced form of citizen participation termed social accountability [3] comprises strategies, processes or interventions used by citizens to ensure that politicians, policymakers and service providers respond to citizens and account for their actions and decisions [4,5]. Social accountability strives to improve institutional performance by bolstering both citizen participation in policies and service delivery, and the public responsiveness of state and organisations [6].…”

“…However, an information gap, collective action problems and lack of highly motivated citizens constrained the responsiveness of providers in Mexico’s Seguro Popular [24]. The use of complaint services was limited by an absence of complaint procedures, lack of knowledge of grievance redress and fear of reprisal or of being misunderstood in the Democratic Republic of the Congo and Tanzania [5,25]. In Kenya, the use of service charters was constrained by illegibility and language issues, lack of expenditure records, lack of time to read and understand them and socio-cultural limitations [26].…”