Social accountability interventions in maternal health services in Nepal
Community engagement
In Nepal, it is found that different social accountability tools have been used and tested either by government or development partners to ensure community engagement in social accountability interventions in maternal health services. The common tools used in maternal health services are described below.
- Social Audit
The social audit has been initiated by the GoN since 2009 to ensure the quality implementation of Aama program [22, 23]. The main aim of this initiation is to increase women’s and community awareness, promote transparency in the decision process of health facility, make the health workers and decision-makers accountable and responsive for quality maternal health services, set a culture of demand for information from the health facility as well as strengthen mutual accountability between service providers and users [23].
The programme has been implemented through the local non-government organization (NGO) who are identified through a competitive process [23, 24]. The NGOs facilitate the process of social audit where community and local stakeholders are invited to review the performance, identify existing problems and challenges of the health facility as well as develop an action plan for improving quality of services. The process takes 5-6 days to complete in one health facility in the initial stage. However, time implication is less in the follow-up programme [24].
The outcomes of social audit are supposed to be reviewed in district as well as regional level programme review meeting and provide necessary feedback to the concerned district and health facility on their action plan. However, the meetings usually limited to compiling the reports, rather than analysis of the results and quality of the process [22, 24]. Up to fiscal year 2016/17, the program has been scaled up to 70 districts out of 77. The social audit was done in 1752 health facilities the up to 25 bed in the last fiscal year. The Government has a plan to scale up the program into all 77 districts by 2020 [7, 24].
- Maternal Perinatal Death Surveillance and Response (MPDSR)
The WHO has recognized the Maternal Death Review (MDR) as a relevant accountability tool for improved quality of the maternal and neonatal health (MNH) services which are based on the concept of the monitor-review-act cycle [25–27]. The process involves national-level monitoring and oversight of the results, multi-stakeholder analysis and action and all components of surveillance and responses systems [26].
The GoN firstly initiated the program in 1990 at the tertiary level hospital with the support of the WHO. Since then it has been scaled up at different levels of care at different phases with improvisation from the learnings of the programs. [27]. Recently, the government merged this MDR program with Maternal Perinatal Death Review (MPDR) program and developed a comprehensive surveillance system named ‘Maternal Perinatal Death Surveillance and Response’ (MPDSR). There are two types of MPDSR; facility-based and community-based in Nepal [3, 27]. It is a supply-side accountability intervention initiated to improve quality of maternal health services which is focused on routine identification and notification of maternal and perinatal deaths, determinants of death causes and use of the information to improve quality of care as well as management of the program to avoid future deaths [27]. The community-based intervention has been implemented in 6 districts whereas facility-based intervention has been expanded in 65 hospitals in 38 districts [3]. For the implementation, the committee is formed at district, hospital and local health facilities level. At the local level committee, there is a separate verbal autopsy and cause of death assignment team [3]. Fig 2 shows the process of the MPDSR.
Despite the effort, the implementation of the intervention is challenged by underreporting, delay reporting and incomplete reporting of death from peripheral health facilities, geographical difficulties and resources constraints [3].
Fig 3 Process of MPDSR at community and health facility level [3].
- Community Score Card/Community Health Score Board
Both community scorecard (CSC) and community health scoreboard (CHSB) are introduced at the same time in Nepal to promote health sector accountability. CSC is a tool designed to promote participation, transparency, and accountability among service providers, service users and decision-makers. The tool provides an opportunity for the community to evaluate the quality of services, express their dissatisfaction and voice health rights [28, 29]. It is a process-oriented tool, where community people along with service providers and stakeholders monitor and evaluate health service against agreed indicators. With the support of indicators, quality of services, health facility performance, and health governance are monitored using define scale or score. At the end of the process, people along with service providers develop an action plan and prioritize the activities based on the given score for further improvement [29]. The tool was piloted in 16 health posts by the Government with support of World Bank in 2011 [28, 29] which was found effective for promoting direct feedback mechanism and efficient use of resources at a health facility. However, due to high implementation cost and lack of competent human resources for the facilitation of the process the government could not scale-up further [22, 28, 29].
As a hybrid form of participatory rural appraisal (PRA), social audit and CSC, community health scoreboard (CHSB) has been introduced in maternal, neonatal and child health (MNCH) services with the support of CARE-Nepal [22, 30]. The tool is based on the value and principle of community participation. The tool creates an environment for tri-party dialogue among service providers, beneficiaries and decision-makers which facilitates monitoring and performance of MNCH services [30, 31]. The dialogue is based on the indicators developed with the consultation with the district health office/district public health office (DHO/DPHO) [30]. Similar to the CSC, community people, service providers, and decision-makers jointly discuss the MNCH issues and then provide mutually agreed scores on the performance indicators and develop action plans for further improvement. The action plans are reviewed semi-annually following the same process. It provides an opportunity for immediate feedback to services provider and decision-makers and respond toward raised concerns [22, 30].
- Citizen Charter
Citizen charter is an information board, displayed at all public service centres. It is a tool to ensure the constitutional right of the Nepali citizen to the information as well as express the government commitment for providing quality services in a transparent and accountable way [29]. The citizen charter includes the information about the availability of services, essential requirement to get services, name of the contact person, required time and name of the person to redress the grievances if any. The board also includes the information about the day, time and duration of services; fee/charges of services like lab-test, x-ray; list of free health services and drugs; incentives information; terms and procedure; responsible health workers, etc. [22, 29]. Since 2007, GoN has made it mandatory to display it at clearly visible premises of all public office/facilities and this applied in the health sector as well [29, 32].
The tool has been promoted in the health sector to ensure transparency, improve service providers’ accountability, make the service users informed about the services and address the concern/grievances of citizen about the services [33], however, many gaps have been identified in posting information about the availability of essential drugs and services in the health facilities [33]. A report in social accountability in the health sector [22] stated that 29% of health facilities do not have citizen charter at their premises. And if the health facilities have, it hasn’t been displaying properly [22]. Eventually, the weak enforceability mechanism in the health sector is one of the reason for it [22, 33].
- Grievance/Complaint handling tool
The GoN has enforced to establish a grievance/complain handling mechanism in every public sector including health [29]. In the health facility, suggestion or complaint box is the widely used tool for handling the grievances/complaints [22]. The box is placed in the premises of health facilities to receive the complaints and/or grievances from service users, communities as well as other stakeholders about the health services. Most of the time verbal grievances are likely to be addressed, hence, the complaints boxes in the health facilities are underutilized [22].
Moreover, MoHP Nepal has established the digital system to receive complaints via email and twitter [34]. Similarly, the MoHP has instructed hospitals, district public/ health offices to have their own website which includes information regarding organization, program, activities including budget and also has Facebook and Twitter account in order to foster accountability and transparency and improve access to the information [22]. Apart from that, MOH has initiated a digital monitoring campaign called ‘Smart Health Nepal’ via its website: www.mohp.gov.np [35]. It includes web-based information about the progress and achievement of NHSS-IP, information about the health facilities and available human resources as well as health sector planning, budget, expenditures, and progress [35].
Community oversight
In the health system, there is a different established structure that facilitates community oversight in social accountability interventions in maternal health services. The structures are presented below.
- Health Facility Operation Management Committee
In line with the objective of Local Self-Governance Act 1999, MoHP devolved its power and responsibilities to the local body i.e. health facility operation and management committee (HFOMC) for the overall management of their respective health facility in 2000 [36, 37]. The committee is chaired by an elected representative; ward chairperson. The other members include; headteacher of the local school, one representative from the local business association, one FCHVs, ward secretary and one woman nominated by the chairperson. In-charge of health facility act as a member secretary of the committee [38]. Recently, the Constitution of Nepal 2015, has empowered the HFOMC with necessary responsibility for planning, implementation, and monitoring of the services of the health facility [38, 39].
According to the HFOMC guideline, the committee is required to meet once in a month to discuss the health facility issues and review the previous action plans, however, this is limited in practice [22, 38]. A national survey conducted in 2015 [37], reported that only 35% of health facilities had management meetings with community participation and only half of the committee members were engaged in the social audit process in six months preceding the survey. However, the survey was held in 2015, at that time the committee did not have locally elected chairperson which could be one of the factor non-functional committee. Eventually, with the local level election in 2017, all the committees are being chaired by the locally elected chief, hopefully, this will bring an improvement [36].
The committee plays an influential role in raising resources for maternal health services in the community. They are the strong voice mechanism of the community in social accountability interventions as the committee constitute inclusive members [31, 38, 40]. In Nepal, the HFOMC found to more functional and also responsive toward addressing maternal health issues where social accountability interventions have been promoted [24, 36, 41].
A review by Shakya et al. [42] reported increased numbers of birthing centres providing 24-hour services, availability of SBA at health facility, improved infection prevention practices and management of labour and delivery in rural health facilities where active engagement of HFOMC in accountability interventions is existed [42]. The findings are similar to other studies, done in Nepal. Conclusively, the health facility having active management committee are more likely to manage the resources and accountable to operate the birthing 24/7 so as to improve the access to the services [24, 31, 41, 43].
- Female Community Health Volunteers (FCHVs)
The female community health volunteer (FCHV) programme was initiated from in 1988 in Nepal. Initially, they were assigned to promote Family Planning (FP) services in the community. With a notable outcome of the programme, their role and responsibilities were gradually expanded to the continuum of care [44]. FCHVs are known for their remarkable contribution to the reduction of maternal and child morbidity and mortality in Nepal [3, 45]. Similarly, they are a responsive member of the HFOMC [38]. Currently, 51,470 FCHVs (47,328 in rural and 4,142 in urban areas) are working across the country [3].
As a promoter of maternal and child health (MCH) in community, they create awareness regarding birth preparedness to pregnant women and their family members and mothers’ group through behaviour change communication (BCC) and other discussions held at the community [3, 44]. The FCHVs liaison the Mothers’ group and HFOMC in community level [46]. Moreover, they are initial reporting system in community-based MPDSR and voice mechanism of the marginalized and disadvantaged women in social accountability interventions [3, 22]. Being an important stakeholder of the community, they also monitor and evaluate the performance and quality of health services [44]. Recognizing their closeness with community people and their contribution in MCH sector, along with MoHP different development partners and government line agencies have mobilized them in health system strengthening programs [22, 41].
- Mothers’ Group for Health
The mothers’ group for health refers to the group of reproductive age women formed at the community with the initiation of the local health facility. The mothers’ group have been recognized as an innovative strategy of community participation particularly women’s participation that have been introduced to improve the MCH outcomes in Nepal [44]. The group members are responsible to select FCHV for their group [41, 44]. Every month, the group members meet to discuss various MCH issues and best practices. Similarly, they are responsible to establish and maintain an emergency fund for obstetric services for their fellow group members [44]. In addition, they also monitor and evaluate the performances of FCHV on regular basis and make the FCHV accountable towards them [22, 44]. The health mothers’ group is the voice mechanism to raise maternal health concerns in social accountability interventions [22].
A randomized controlled trial (RCT) in a rural part of Nepal, maternal mortality rate (MMR) decreased by 80% [adjusted odds ratio (0.22, 95% CI 0.05-0.90)] in the women’s group where community participation project with social accountability interventions was implemented in compare to the control group [47]. In addition infection prevention practice improved by twice among the birth attendees where the interventions were implemented and also improved maternal health service utilization among the trail groups [47].
Meanwhile, the meta-analysis of RCTs of the same intervention in four countries i.e. Bangladesh, India, Nepal, and Malawi [48] reported no significant differences in reduction of maternal mortality [OR 0.77, 95% CI 0.48-1.23] [48]. The variation in the outcomes of each country led to further analysis of the trails. Eventually, subgroup analysis of the RCTs concluded, at least with 30% of women participation in the accountability intervention can reduce almost half (49%) of the maternal mortality [OR 0.51, 95% CI 0.29-0.89] [48]. The analysis evident inverse relationship between women participation in social accountability intervention and MMR. The intervention is also concluded as a cost-effective strategy to save women’s life as per as WHO standard [48].
- Civil Society Organization
In this review, the Civil Society Organizations (CSO) refer to the national and local NGOs working in the maternal health sector in Nepal. The CSOs have been identified as a strong community engagement and oversight mechanism in the accountability and governance process in Nepal’s health sector [22, 49]. In regards to maternal health, they have played a vital role in advocacy for addressing maternal health problems and promoting accountability from centre to community level [41]. The local NGOs are mostly involved in implementing social accountability interventions either initiated by the government or development agencies. However, they themselves are a robust oversight system existed in the community in Nepal [22]. Some of the NGOs also provide preventive and promotive maternal health services and in some cases care too [3, 22]. Meanwhile, INGOs provide technical and financial support to the government for the policy and guideline development and to implement social accountability interventions and strategies in the health sector [3, 22, 24, 50].
Contextual factors influencing social accountability interventions in Nepal
Social-cultural context
- Gender Norms
Nepalese society is a typically patriarchal society where strong gender norms existed. Traditionally, men are privileged with power and position, as a result, women participation in the governance system is considerably low [51]. Therefore, to address the issue and empower women for their meaningful participation in each sector of development, GoN has made provision of reservation for women. [39, 49]. Women’s participation also has been ensured in the management committee of health facility through the mandatory provision of at least three women out of seven members in the committee, however, this is still restricted to the paper [38].
In one hand government has emphasized on women’s and marginalized groups participation in each level of governance to enhance gender equality and social inclusion (GESI), while on another hand, due to unequal power relationship, low education, overloaded with household, productive and reproductive works, women tend to show less interest in participatory activities [51] like social audit, health management committee meetings etc. [22, 51, 52]. In most cases, women’s presence in the meetings are just for token and they speak only if explicitly requested [51]. Hence women roles are confined only up to their physical presence at the programmes, while men are the ultimate decision-makers. [51]. However, evidence has shown that the increased women’s involvement in participatory decision-making process results in a notable improvement in maternal health services which ultimately reduces maternal mortality and morbidity [47, 48, 53].
- Social structure
The country has a complex caste system with diverse ethnic groups [54] where the Brahman/Chhetri refers to upper caste and are most privileged group while the Dalit as disadvantaged caste and Janjati: indigenous group are the underprivileged groups in the country [54, 55]. This caste-based social structure in Nepal has hindered the effective participation of the marginalized groups in the social accountability interventions [51]. Earlier there was mandatory reservation for a marginalized and disadvantaged member in the HFOMC, however, in 2019, the provision is abolished form the system. Now, they (one member from Dalit, disable and adolescent) are invitee member of the committee, who will not have an influencing role as a core member in the decision-making process [38].
“In the committee, most of the members are from higher castes. When we have meetings of the committee or any other programme, and when there is time for taking snacks, the other committee members sit a short distance away from me. There is thus still discrimination in our society. It [untouchability issue] is not in all places, but still exists with some people in some places. Due to this, it causes me stress inside. Then, how can I speak in the meeting or any events without hesitation?” [58].
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There is a hegemony of the so-called higher caste group in the Nepalese society, still, major decision-making positions are held by them [32, 51]. Similarly, in the health sector, 50% of the health workers belong to the Brahman/Chhetri caste [56]. This caste hierarchy often produces unequal power relation between the service providers and service users where service users from the marginalized community have less power to negotiate for change in the health service providers attitude and behaviour [32, 56, 57]. In a qualitative study by Gurung et al, a Dalit member of the health management committee has stated how caste hierarchy system has suppressed their voice and participation in the accountability process [58].
Any form of discrimination is prohibited by law in Nepal, however, the issue of caste-based discrimination is still deeply deep-rooted in the community [39, 58, 59]. Hence, the existing informal power relationship and the dynamics of social structures needed to taken into consideration to ensure the effectiveness of the social accountability process.
- Awareness, value, beliefs, and practices
The effectiveness of social accountability interventions is often influenced by the level of people’s awareness about their rights and entitlements, the existing governance mechanism to protect it and their role in it [14]. In Nepal, the majority of people are unaware of the concept of accountability and governance that makes difficult to hold service providers accountable for their action [22, 32]. Although, access to the information is a constitutional right of every Nepali citizen; women, poor and disadvantaged groups are less likely aware of their rights to get quality health services [39]. Meanwhile, literacy level, perception, and cultural beliefs are hindering factors for it [32, 60]. A study in Nepal [61] has reported, citizen charter is not useful for illiterate people as they cannot read the information in it. Similarly, the list of free medicines written in English and displayed in the health facility is also useless as most people cannot read English. In both cases, the language is the barrier to access the information. The study also identified that people prefer television, radio or FCHV to get information about the health services which indicates changing preferences of people in accessing health information [61].
In Nepal, health belief and practices of people also influence the level of community participation in social accountability process [62]. In addition engaging youth and marginalized people in the social accountability interventions are difficult, as youth often hesitate to share their opinion in front of elders and mass respectively while marginalized people think their issues are irrelevant to be addressed. [62, 63]. A study was done by Gurung et al. identified despite having grievances and complaints regarding the quality of health services and provider’s performance, in most cases, people have a tendency to stay silent and they are generally women, poor and marginalized group [64]. Eventually, those who complain they prefer/use informal channels like verbal complain mechanism such as direct talk to the person or via phone calls, through health management committee or FCHVs [22, 64]. Similarly, in Nepalese society, the culture of raising questions and providing feedback to the power holders and prompt respond toward feedback is not properly established which also affect the community participation in the social accountability interventions [64].
Political and economic context
Nepal has gone through various political and structural transitions in the last two decades which had resulted in the unstable political situation in the country. The unstable political context created huge governance challenges in the country [32, 36]. Similarly, the issue of political interference in the health sector has been also well reported. Often politic acts as a driving force in the formation and functioning of the health management committee [58] that interfere with the social accountability process [24, 36]. The decisions are often made on the political ground by the leaders rather than the community’s concerns. The bureaucracy of health facility, kinship and health worker’s power tend to determine the level of community participation in the accountability interventions [36, 58, 65].
An evaluation study of the social accountability interventions has reported the issue of political pressure in the selection and retention of competent NGO to facilitate the social audit process in the health facilities. [24]. The political pressure generally comes through DHO/DPHO and LDO and sometimes intense pressure result in the replacement of experienced NGO with the favoured one which directly affects the quality implementation of social accountability interventions [24]. This kind of political influences tends to increase conflict of interest in social accountability interventions, process, and outcomes.
In Nepal, most of the health workers are associated with trade union and sister organization of political parties. They are often protected by associated political leadership for their actions. The health workers often use this nexus for their deployment and retention at well-facilitated places which have resulted in a persistent vacant post of regular and skilled staff in the remote health facilities, as the health workers prefer to stay in urban areas [65, 66]. On the other hand, access to information, level of participation and ability to influence the responsiveness or decision making process in the health management committee are also determined by the economic status of the individual [36, 51, 64].
The business group have greater influence over the political infiltration and often resist the political intervention in the sphere of the economy in Nepal and they have been able to make the health sector a profit-making investment [32, 67]. The running private and teaching hospitals becoming one of the lucrative areas to get the best benefits out of the investment for business groups and politician [67]. This might potentially influence the responsiveness of policymaker toward community concerns. Therefore, it is essential to analyse and consider the influence of political-economic dynamics in social accountability interventions.
Health system context
- Client-provider relationship
The health workers are recognized as an intellectual and respected personality in the community and their profession is perceived as a highly prestigious profession in Nepal [64]. Hence, the community hardly think that health workers commit any mistakes while providing and managing services. This perception often imbalances the power-relation between service users and providers, this, therefore, affect the dialogue processes in social accountability interventions [64]. On the other hand, the power relationship between service providers and service users particularly in remote areas where there are no choices for health services, the community often hesitate to complain or to provide feedback to the health workers in order to avoid unnecessary conflict and in the fear of getting poor quality of services in the next visit. A quote in the below box from a study of rural health facility reflects the perception of
“How can Dalit, women, and the marginalized speak their minds with service providers? They think what the government does is all right. Health is the matter related to life and death. If you or your family member becomes ill, you have to go to the same place. Then, how could you take issue with the service providers? In villages, there is no option”- (Qualitative interview, staff, NGO) [64].
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the community toward accountability interventions [64].
Sometimes, the health workers and health facility committee members also tend to skip the interface with the community due to fear of being criticized in accountability interventions. [36, 68]. Furthermore, the people do not have access to have an interface with policy-level people as it is provisioned which has weakened the influence of social accountability interventions in the policy-level decision-making process [36].
- Resource availability
Persistent resource deficiencies in the health sector are also identified factor limiting the health workers’ and policymaker’s responsiveness towards the community [24, 68]. The management of the health facility has been handed to the local authority, however, human resource and logistics management are still being performed centrally which has undoubtedly made demand-supply procedure complex [22]. This has resulted in the frequent stock-outs of drugs and supplies and scarcity of human resources at health facilities level [33]. Moreover, in the federal government system, the line of accountability between Ministry of Health and Population, provincial and the local government has not been explicitly defined and also not properly guided which has further created responsibility dilemma among local authorities to manage health facilities under their responsibility [22, 59]. As per new government structure, the local government has only provided with a budget for staff salaries and basic operation cost for health facility management which may be insufficient to fulfil the relevant health needs and priorities of the community raised up during social accountability interventions [22]. Additionally, due to the human resources gap at community level health facility, the FCHVs are overwhelmed with community-based health interventions like Safe Motherhood, FP, Immunization, Nutrition, MPDSR, mother groups meetings etc. They are also being used by other several sectors such as education, forest groups, micro-credit finance groups etc. for their own accountability purpose in the community [45]. In the end, they are a volunteer and only get event-based incentives, therefore, the increased volume of responsibilities with minimal incentive has resulted in a decrease in their motivation to work [44, 45]. This might affect the quality service delivery and their responsiveness toward the community concerns.
In another argument, it has been said that organizational institutional capacity is equally important with the evidence of cases where allocated resources could not be mobilized and utilized properly due to lack of management capacity for improving the quality of health services [65].
- Monitoring and evaluation
In Nepal, the low responsiveness health system is often caused by the lack of proper monitoring and evaluation mechanism [7, 37]. Very few facilities, in fact, those facilities located at feasible geographic locations are frequently visited and receive regular supervision by the lined authorities [22, 65]. The district supervisors are often busy in conducting training and workshops which leave them with less time for supervision and monitoring at community-level health facilities [65]. This has weakened the effectiveness of established social accountability interventions in health facilities. The regular follow-up and analysis of audit action plans from the district and/or central level are almost non-existent in the health system [22, 24].
Evidence shows that demand-side social accountability interventions involve dialogue process which usually put soft pressure to the health workers to be accountable for their action and responsibility. It is argued that in the long run, without threat of sanction from the state, the interventions likely to address only surface level service delivery issues and affect the sustainability of the interventions [15]. Thus, the health system needs to strengthen the monitoring and supervision mechanism for effective and sustained outcomes of social accountability interventions.
Evidence on the outcomes of social accountability interventions in maternal health services
Social audit
There was no scientific research found examining the outcomes of social audit in Nepal, neither in other LMICs. Therefore, the findings from the evaluation and review study of social audit in Nepal has been presented as evidence.
Initiating the social audit intervention in health facilities has evident improved quality of maternal health services in Nepal. An evaluation study undertaken in health facilities of four districts of Nepal i.e. Palpa, Rupandehi, Jhapa and Ilam found overall improvement in the health provider’s behaviour and attitude as well regularity of health service providers. The clients and patients received more equitable treatment and with dignity. Similarly, the ANC and institutional delivery incentives were timely provided to the beneficiaries. The interventions also improved the dialogue between the community, health service providers and health facility committee. Community concerns were incorporated with the health facility action plan. However, the impact level of the interventions was different in each study district [24]. It was more effective in Palpa and Rupandehi where the social audit was conducted on regular basis for a long time with the technical support of external development agency compared to Jhapa and Ilam where it was solely implemented by the Government without any support from development partners. [24]. Therefore, the result indicated the regular practice of social accountability interventions improves the outcomes.
Another review conducted to examine the effectiveness of social audit in rural health facilities in far-western region one of the remotest regions in the country has identified social audit as an innovative and cost-effective strategy to improve health services quality. It is reported that social audit provides an opportunity for health workers and community leaders to be heard by policymakers. However, the sustainability of the intervention is still a question [68]. It depicted that specific attention is needed from policymakers to ensure enough budget allocation for the sustainability of the intervention, particularly for the facilities where intervention is supported by external development partners (EDPs).
Maternal death review
The maternal death review has been practised in Nepal for a long time and has also been scaled up in the different level of the health facilities [3, 27]. However, no research has been carried out to examine the effectiveness and outcomes of the intervention in the context of Nepal, therefore, evidence from other LMICs having similar context has been presented.
A study in Bangladesh regarding MDR intervention reported the intervention helps to recognize the causes of maternal deaths in the community and bring the attention of decision-makers to respond and addressing the issues appropriately. The analysis of the cause of the maternal death resulted in deploying competent human resource such as MBBS doctor, SBA at birthing centres to manage complications, all necessary equipment and supplies were ensured that ultimately improved the QoC and provider-user satisfaction which resulted in the increased uptake of maternal health services in Bangladesh. Increased uptake of maternal health services led to reduction in maternal death [69].
A similar finding was reported in Nigeria where MDR played an influential role in improving health service provider’s and policymaker’s responsiveness toward addressing causes of maternal deaths. Due to the intervention, the state government of Nigeria showed a high level of political commitment to evidence-based strategy and interventions to improve the maternal health services [26].
Since, MoHP has already established a web-based system to capture maternal deaths, however, getting the data from health facilities is still an issue. With the available data, MoHP has able to identify the causes of death and action plans have been developed by MPDSR committee for a different level of care, however, implementation of those action plans are still a challenge. [3]. Nigeria also encountered a similar problem in death reporting and implementation of developed action plans in earlier days. However, they incorporate the scorecard to monitor whether the plan of action is developed and if recommendations are acted upon accordingly [26]. The intervention supported to improve the reporting and triggered the system to respond accordingly [26]. Taking into consideration of the experiences from Nigeria having similar health system context; this example can be applied in Nepal as well to overcome the challenges and improve the outcomes of the MDR/MPDSR intervention.
Community scorecard/Community health scoreboard
Based on the successful experience of CSC implemented in Malawi CARE-International has brought that concept customized tool; community health scoreboard (CHSB) and applied in Nepal to improve the maternal health outcomes [30, 70]. As no studies were found for analysis about the effectiveness of the tool for improved maternal health outcomes in Nepal; evidence from other LMICS has been presented to show the relationship between tool and maternal health outcomes.
In Malawi, the intervention supported to increase interaction between the health service providers, members of the health committee and community, this improved accountability of health worker as well as improved the quality ANC and PNC services. As women were treated better at health facilities, the maternal service utilization trend increased [70]. Improved quality of maternal health services, access to and utilization of the maternal health services were achieved through mutually developed action plans [70]. The intervention particularly had more impact on the indicators that required little or no resources from the government [70]. As it was implemented at the community level health facility, the tool no significant impact on the indicators which needed the attention of higher-level government authorities [70]. This finding is similar to findings of an evaluation of social audit done in Nepal [24].
A mixed-method study performed in 2016 in Ghana to examine the effectiveness of CSC for improved maternal and newborn health services reported improved quality of emergency obstetric and newborn care (EmONC) in intervention piloted health facilities while the intervention improved engagement of stakeholders and community in the process [71]. The process also supported to develop a shared responsibility also termed ‘horizontal accountability' and created ownership among the community and stakeholders for both challenges and solutions, ultimately improved management of equipment and infrastructure in majority of health facilities [71].
Looking at the contextual similarities of Malawi and Ghana, Nepal can also expect similar outcomes of the CSC and/or CHSB in maternal health services. However, the sustainability of the interventions in Nepal is a major challenge as the interventions are promoted by the donor with minimal involvement of government [36]. Meanwhile, the government can integrate the CSC/CHSB in the social audit for efficiency and sustainability purpose. As an example in Zambia, CSC was combined with a social audit to enhance the responsiveness of the service providers and improve the coordination between state and community [72]. In the country, the social audit is used to assess the service performance against the national standard and the CSC is to rate the health facility against the perception-based indicators [72]. Taking the best practice from Zambia, Nepal can also adopt similar modality to sustain the intervention.
Citizen charter and complain/grievances handling interventions
No evidence is found on the contribution/effectiveness in the maternal health services in Nepal as well as in the other LMICs. Eventually, a study mapping awareness and factor influencing the implementation of citizen charter in health facility concluded it promotes the transparency of health facility and accountability of health workers towards service users if well implemented [61]. The similar conclusion was drawn in a study conducted in Kenya [73].
Although the complaint/grievances box contributes to enhancing accountability and transparency their uses are limited in practice and no specific attention has been given by the state. Many health facilities were found not to have citizen charter in the place and the complaint boxes often go unused and found to be filling with dust and spider webs [22, 61, 64]. The statement in the below box from a study in Nepal highlights the attitude of health worker on the usefulness of complaint box [64].
“… not only at the health facility level but even at the district level, the situation is that suggestion boxes are filled up with ‘spider webs’. As far as I know the suggestion box is not in use. No one puts their complaints or suggestions [into the suggestion box] by writing onto a piece of paper. Many do not know about its existence. So I do not see any importance of it”- PHC clinic manager [64].
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A report by Commissions for the Investigation of Abuse of Authority (CIAA, the health sector in Nepal is in 5th place amongst 9 sectors for the highest number of complaint about power abuse which indicated potential corruption vulnerabilities in the health system [74]. In such cases, poor information dissemination mechanism might result in information asymmetry between providers and users ultimately affect the quality of the service delivery. In addition, without informing the community could not evaluate the components of QoC in maternal health services and also unable to claim their rights entitlements ultimately lead to superficial community participation and produce suboptimal outcomes [75].
In Nepal, 20% of the estimated population is using the internet to access information and the trend is increasing, therefore, this indicates the possibility to use the digital media to improve information access so as to create the demand for quality health services [76]. A digital campaign has already been practising in sub-Saharan African countries with the support of the Evidence for Action (E4A) programme i.e. ‘Mama Ye!’ public engagement campaign [77]. The campaign is to create pressure on policymakers for their commitment and respond in prioritizing quality maternal and neonatal health services through digital media approaches [77]. The strategy could be relevant to the Nepalese context to create demand of quality maternal health service and make service providers accountable toward their actions and responsibility, while people’s preference for accessing health information and providing feedback is changing accordingly to the advancement of the technology in Nepal [22, 36, 64].
Social accountability interventions in maternal health services in Nepal
Community engagement
In Nepal, it is found that different social accountability tools have been used and tested either by government or development partners to ensure community engagement in social accountability interventions in maternal health services. The common tools used in maternal health services are described below.
- Social Audit
The social audit has been initiated by the GoN since 2009 to ensure the quality implementation of Aama program [22, 23]. The main aim of this initiation is to increase women’s and community awareness, promote transparency in the decision process of health facility, make the health workers and decision-makers accountable and responsive for quality maternal health services, set a culture of demand for information from the health facility as well as strengthen mutual accountability between service providers and users [23].
The programme has been implemented through the local non-government organization (NGO) who are identified through a competitive process [23, 24]. The NGOs facilitate the process of social audit where community and local stakeholders are invited to review the performance, identify existing problems and challenges of the health facility as well as develop an action plan for improving quality of services. The process takes 5-6 days to complete in one health facility in the initial stage. However, time implication is less in the follow-up programme [24].
The outcomes of social audit are supposed to be reviewed in district as well as regional level programme review meeting and provide necessary feedback to the concerned district and health facility on their action plan. However, the meetings usually limited to compiling the reports, rather than analysis of the results and quality of the process [22, 24]. Up to fiscal year 2016/17, the program has been scaled up to 70 districts out of 77. The social audit was done in 1752 health facilities the up to 25 bed in the last fiscal year. The Government has a plan to scale up the program into all 77 districts by 2020 [7, 24].
- Maternal Perinatal Death Surveillance and Response (MPDSR)
The WHO has recognized the Maternal Death Review (MDR) as a relevant accountability tool for improved quality of the maternal and neonatal health (MNH) services which are based on the concept of the monitor-review-act cycle [25–27]. The process involves national-level monitoring and oversight of the results, multi-stakeholder analysis and action and all components of surveillance and responses systems [26].
The GoN firstly initiated the program in 1990 at the tertiary level hospital with the support of the WHO. Since then it has been scaled up at different levels of care at different phases with improvisation from the learnings of the programs. [27]. Recently, the government merged this MDR program with Maternal Perinatal Death Review (MPDR) program and developed a comprehensive surveillance system named ‘Maternal Perinatal Death Surveillance and Response’ (MPDSR). There are two types of MPDSR; facility-based and community-based in Nepal [3, 27]. It is a supply-side accountability intervention initiated to improve quality of maternal health services which is focused on routine identification and notification of maternal and perinatal deaths, determinants of death causes and use of the information to improve quality of care as well as management of the program to avoid future deaths [27]. The community-based intervention has been implemented in 6 districts whereas facility-based intervention has been expanded in 65 hospitals in 38 districts [3]. For the implementation, the committee is formed at district, hospital and local health facilities level. At the local level committee, there is a separate verbal autopsy and cause of death assignment team [3]. Fig 2 shows the process of the MPDSR.
Despite the effort, the implementation of the intervention is challenged by underreporting, delay reporting and incomplete reporting of death from peripheral health facilities, geographical difficulties and resources constraints [3].
Fig 3 Process of MPDSR at community and health facility level [3].
- Community Score Card/Community Health Score Board
Both community scorecard (CSC) and community health scoreboard (CHSB) are introduced at the same time in Nepal to promote health sector accountability. CSC is a tool designed to promote participation, transparency, and accountability among service providers, service users and decision-makers. The tool provides an opportunity for the community to evaluate the quality of services, express their dissatisfaction and voice health rights [28, 29]. It is a process-oriented tool, where community people along with service providers and stakeholders monitor and evaluate health service against agreed indicators. With the support of indicators, quality of services, health facility performance, and health governance are monitored using define scale or score. At the end of the process, people along with service providers develop an action plan and prioritize the activities based on the given score for further improvement [29]. The tool was piloted in 16 health posts by the Government with support of World Bank in 2011 [28, 29] which was found effective for promoting direct feedback mechanism and efficient use of resources at a health facility. However, due to high implementation cost and lack of competent human resources for the facilitation of the process the government could not scale-up further [22, 28, 29].
As a hybrid form of participatory rural appraisal (PRA), social audit and CSC, community health scoreboard (CHSB) has been introduced in maternal, neonatal and child health (MNCH) services with the support of CARE-Nepal [22, 30]. The tool is based on the value and principle of community participation. The tool creates an environment for tri-party dialogue among service providers, beneficiaries and decision-makers which facilitates monitoring and performance of MNCH services [30, 31]. The dialogue is based on the indicators developed with the consultation with the district health office/district public health office (DHO/DPHO) [30]. Similar to the CSC, community people, service providers, and decision-makers jointly discuss the MNCH issues and then provide mutually agreed scores on the performance indicators and develop action plans for further improvement. The action plans are reviewed semi-annually following the same process. It provides an opportunity for immediate feedback to services provider and decision-makers and respond toward raised concerns [22, 30].
- Citizen Charter
Citizen charter is an information board, displayed at all public service centres. It is a tool to ensure the constitutional right of the Nepali citizen to the information as well as express the government commitment for providing quality services in a transparent and accountable way [29]. The citizen charter includes the information about the availability of services, essential requirement to get services, name of the contact person, required time and name of the person to redress the grievances if any. The board also includes the information about the day, time and duration of services; fee/charges of services like lab-test, x-ray; list of free health services and drugs; incentives information; terms and procedure; responsible health workers, etc. [22, 29]. Since 2007, GoN has made it mandatory to display it at clearly visible premises of all public office/facilities and this applied in the health sector as well [29, 32].
The tool has been promoted in the health sector to ensure transparency, improve service providers’ accountability, make the service users informed about the services and address the concern/grievances of citizen about the services [33], however, many gaps have been identified in posting information about the availability of essential drugs and services in the health facilities [33]. A report in social accountability in the health sector [22] stated that 29% of health facilities do not have citizen charter at their premises. And if the health facilities have, it hasn’t been displaying properly [22]. Eventually, the weak enforceability mechanism in the health sector is one of the reason for it [22, 33].
- Grievance/Complaint handling tool
The GoN has enforced to establish a grievance/complain handling mechanism in every public sector including health [29]. In the health facility, suggestion or complaint box is the widely used tool for handling the grievances/complaints [22]. The box is placed in the premises of health facilities to receive the complaints and/or grievances from service users, communities as well as other stakeholders about the health services. Most of the time verbal grievances are likely to be addressed, hence, the complaints boxes in the health facilities are underutilized [22].
Moreover, MoHP Nepal has established the digital system to receive complaints via email and twitter [34]. Similarly, the MoHP has instructed hospitals, district public/ health offices to have their own website which includes information regarding organization, program, activities including budget and also has Facebook and Twitter account in order to foster accountability and transparency and improve access to the information [22]. Apart from that, MOH has initiated a digital monitoring campaign called ‘Smart Health Nepal’ via its website: www.mohp.gov.np [35]. It includes web-based information about the progress and achievement of NHSS-IP, information about the health facilities and available human resources as well as health sector planning, budget, expenditures, and progress [35].
Community oversight
In the health system, there is a different established structure that facilitates community oversight in social accountability interventions in maternal health services. The structures are presented below.
- Health Facility Operation Management Committee
In line with the objective of Local Self-Governance Act 1999, MoHP devolved its power and responsibilities to the local body i.e. health facility operation and management committee (HFOMC) for the overall management of their respective health facility in 2000 [36, 37]. The committee is chaired by an elected representative; ward chairperson. The other members include; headteacher of the local school, one representative from the local business association, one FCHVs, ward secretary and one woman nominated by the chairperson. In-charge of health facility act as a member secretary of the committee [38]. Recently, the Constitution of Nepal 2015, has empowered the HFOMC with necessary responsibility for planning, implementation, and monitoring of the services of the health facility [38, 39].
According to the HFOMC guideline, the committee is required to meet once in a month to discuss the health facility issues and review the previous action plans, however, this is limited in practice [22, 38]. A national survey conducted in 2015 [37], reported that only 35% of health facilities had management meetings with community participation and only half of the committee members were engaged in the social audit process in six months preceding the survey. However, the survey was held in 2015, at that time the committee did not have locally elected chairperson which could be one of the factor non-functional committee. Eventually, with the local level election in 2017, all the committees are being chaired by the locally elected chief, hopefully, this will bring an improvement [36].
The committee plays an influential role in raising resources for maternal health services in the community. They are the strong voice mechanism of the community in social accountability interventions as the committee constitute inclusive members [31, 38, 40]. In Nepal, the HFOMC found to more functional and also responsive toward addressing maternal health issues where social accountability interventions have been promoted [24, 36, 41].
A review by Shakya et al. [42] reported increased numbers of birthing centres providing 24-hour services, availability of SBA at health facility, improved infection prevention practices and management of labour and delivery in rural health facilities where active engagement of HFOMC in accountability interventions is existed [42]. The findings are similar to other studies, done in Nepal. Conclusively, the health facility having active management committee are more likely to manage the resources and accountable to operate the birthing 24/7 so as to improve the access to the services [24, 31, 41, 43].
- Female Community Health Volunteers (FCHVs)
The female community health volunteer (FCHV) programme was initiated from in 1988 in Nepal. Initially, they were assigned to promote Family Planning (FP) services in the community. With a notable outcome of the programme, their role and responsibilities were gradually expanded to the continuum of care [44]. FCHVs are known for their remarkable contribution to the reduction of maternal and child morbidity and mortality in Nepal [3, 45]. Similarly, they are a responsive member of the HFOMC [38]. Currently, 51,470 FCHVs (47,328 in rural and 4,142 in urban areas) are working across the country [3].
As a promoter of maternal and child health (MCH) in community, they create awareness regarding birth preparedness to pregnant women and their family members and mothers’ group through behaviour change communication (BCC) and other discussions held at the community [3, 44]. The FCHVs liaison the Mothers’ group and HFOMC in community level [46]. Moreover, they are initial reporting system in community-based MPDSR and voice mechanism of the marginalized and disadvantaged women in social accountability interventions [3, 22]. Being an important stakeholder of the community, they also monitor and evaluate the performance and quality of health services [44]. Recognizing their closeness with community people and their contribution in MCH sector, along with MoHP different development partners and government line agencies have mobilized them in health system strengthening programs [22, 41].
- Mothers’ Group for Health
The mothers’ group for health refers to the group of reproductive age women formed at the community with the initiation of the local health facility. The mothers’ group have been recognized as an innovative strategy of community participation particularly women’s participation that have been introduced to improve the MCH outcomes in Nepal [44]. The group members are responsible to select FCHV for their group [41, 44]. Every month, the group members meet to discuss various MCH issues and best practices. Similarly, they are responsible to establish and maintain an emergency fund for obstetric services for their fellow group members [44]. In addition, they also monitor and evaluate the performances of FCHV on regular basis and make the FCHV accountable towards them [22, 44]. The health mothers’ group is the voice mechanism to raise maternal health concerns in social accountability interventions [22].
A randomized controlled trial (RCT) in a rural part of Nepal, maternal mortality rate (MMR) decreased by 80% [adjusted odds ratio (0.22, 95% CI 0.05-0.90)] in the women’s group where community participation project with social accountability interventions was implemented in compare to the control group [47]. In addition infection prevention practice improved by twice among the birth attendees where the interventions were implemented and also improved maternal health service utilization among the trail groups [47].
Meanwhile, the meta-analysis of RCTs of the same intervention in four countries i.e. Bangladesh, India, Nepal, and Malawi [48] reported no significant differences in reduction of maternal mortality [OR 0.77, 95% CI 0.48-1.23] [48]. The variation in the outcomes of each country led to further analysis of the trails. Eventually, subgroup analysis of the RCTs concluded, at least with 30% of women participation in the accountability intervention can reduce almost half (49%) of the maternal mortality [OR 0.51, 95% CI 0.29-0.89] [48]. The analysis evident inverse relationship between women participation in social accountability intervention and MMR. The intervention is also concluded as a cost-effective strategy to save women’s life as per as WHO standard [48].
- Civil Society Organization
In this review, the Civil Society Organizations (CSO) refer to the national and local NGOs working in the maternal health sector in Nepal. The CSOs have been identified as a strong community engagement and oversight mechanism in the accountability and governance process in Nepal’s health sector [22, 49]. In regards to maternal health, they have played a vital role in advocacy for addressing maternal health problems and promoting accountability from centre to community level [41]. The local NGOs are mostly involved in implementing social accountability interventions either initiated by the government or development agencies. However, they themselves are a robust oversight system existed in the community in Nepal [22]. Some of the NGOs also provide preventive and promotive maternal health services and in some cases care too [3, 22]. Meanwhile, INGOs provide technical and financial support to the government for the policy and guideline development and to implement social accountability interventions and strategies in the health sector [3, 22, 24, 50].
Contextual factors influencing social accountability interventions in Nepal
Social-cultural context
- Gender Norms
Nepalese society is a typically patriarchal society where strong gender norms existed. Traditionally, men are privileged with power and position, as a result, women participation in the governance system is considerably low [51]. Therefore, to address the issue and empower women for their meaningful participation in each sector of development, GoN has made provision of reservation for women. [39, 49]. Women’s participation also has been ensured in the management committee of health facility through the mandatory provision of at least three women out of seven members in the committee, however, this is still restricted to the paper [38].
In one hand government has emphasized on women’s and marginalized groups participation in each level of governance to enhance gender equality and social inclusion (GESI), while on another hand, due to unequal power relationship, low education, overloaded with household, productive and reproductive works, women tend to show less interest in participatory activities [51] like social audit, health management committee meetings etc. [22, 51, 52]. In most cases, women’s presence in the meetings are just for token and they speak only if explicitly requested [51]. Hence women roles are confined only up to their physical presence at the programmes, while men are the ultimate decision-makers. [51]. However, evidence has shown that the increased women’s involvement in participatory decision-making process results in a notable improvement in maternal health services which ultimately reduces maternal mortality and morbidity [47, 48, 53].
- Social structure
The country has a complex caste system with diverse ethnic groups [54] where the Brahman/Chhetri refers to upper caste and are most privileged group while the Dalit as disadvantaged caste and Janjati: indigenous group are the underprivileged groups in the country [54, 55]. This caste-based social structure in Nepal has hindered the effective participation of the marginalized groups in the social accountability interventions [51]. Earlier there was mandatory reservation for a marginalized and disadvantaged member in the HFOMC, however, in 2019, the provision is abolished form the system. Now, they (one member from Dalit, disable and adolescent) are invitee member of the committee, who will not have an influencing role as a core member in the decision-making process [38].
“In the committee, most of the members are from higher castes. When we have meetings of the committee or any other programme, and when there is time for taking snacks, the other committee members sit a short distance away from me. There is thus still discrimination in our society. It [untouchability issue] is not in all places, but still exists with some people in some places. Due to this, it causes me stress inside. Then, how can I speak in the meeting or any events without hesitation?” [58].
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There is a hegemony of the so-called higher caste group in the Nepalese society, still, major decision-making positions are held by them [32, 51]. Similarly, in the health sector, 50% of the health workers belong to the Brahman/Chhetri caste [56]. This caste hierarchy often produces unequal power relation between the service providers and service users where service users from the marginalized community have less power to negotiate for change in the health service providers attitude and behaviour [32, 56, 57]. In a qualitative study by Gurung et al, a Dalit member of the health management committee has stated how caste hierarchy system has suppressed their voice and participation in the accountability process [58].
Any form of discrimination is prohibited by law in Nepal, however, the issue of caste-based discrimination is still deeply deep-rooted in the community [39, 58, 59]. Hence, the existing informal power relationship and the dynamics of social structures needed to taken into consideration to ensure the effectiveness of the social accountability process.
- Awareness, value, beliefs, and practices
The effectiveness of social accountability interventions is often influenced by the level of people’s awareness about their rights and entitlements, the existing governance mechanism to protect it and their role in it [14]. In Nepal, the majority of people are unaware of the concept of accountability and governance that makes difficult to hold service providers accountable for their action [22, 32]. Although, access to the information is a constitutional right of every Nepali citizen; women, poor and disadvantaged groups are less likely aware of their rights to get quality health services [39]. Meanwhile, literacy level, perception, and cultural beliefs are hindering factors for it [32, 60]. A study in Nepal [61] has reported, citizen charter is not useful for illiterate people as they cannot read the information in it. Similarly, the list of free medicines written in English and displayed in the health facility is also useless as most people cannot read English. In both cases, the language is the barrier to access the information. The study also identified that people prefer television, radio or FCHV to get information about the health services which indicates changing preferences of people in accessing health information [61].
In Nepal, health belief and practices of people also influence the level of community participation in social accountability process [62]. In addition engaging youth and marginalized people in the social accountability interventions are difficult, as youth often hesitate to share their opinion in front of elders and mass respectively while marginalized people think their issues are irrelevant to be addressed. [62, 63]. A study was done by Gurung et al. identified despite having grievances and complaints regarding the quality of health services and provider’s performance, in most cases, people have a tendency to stay silent and they are generally women, poor and marginalized group [64]. Eventually, those who complain they prefer/use informal channels like verbal complain mechanism such as direct talk to the person or via phone calls, through health management committee or FCHVs [22, 64]. Similarly, in Nepalese society, the culture of raising questions and providing feedback to the power holders and prompt respond toward feedback is not properly established which also affect the community participation in the social accountability interventions [64].
Political and economic context
Nepal has gone through various political and structural transitions in the last two decades which had resulted in the unstable political situation in the country. The unstable political context created huge governance challenges in the country [32, 36]. Similarly, the issue of political interference in the health sector has been also well reported. Often politic acts as a driving force in the formation and functioning of the health management committee [58] that interfere with the social accountability process [24, 36]. The decisions are often made on the political ground by the leaders rather than the community’s concerns. The bureaucracy of health facility, kinship and health worker’s power tend to determine the level of community participation in the accountability interventions [36, 58, 65].
An evaluation study of the social accountability interventions has reported the issue of political pressure in the selection and retention of competent NGO to facilitate the social audit process in the health facilities. [24]. The political pressure generally comes through DHO/DPHO and LDO and sometimes intense pressure result in the replacement of experienced NGO with the favoured one which directly affects the quality implementation of social accountability interventions [24]. This kind of political influences tends to increase conflict of interest in social accountability interventions, process, and outcomes.
In Nepal, most of the health workers are associated with trade union and sister organization of political parties. They are often protected by associated political leadership for their actions. The health workers often use this nexus for their deployment and retention at well-facilitated places which have resulted in a persistent vacant post of regular and skilled staff in the remote health facilities, as the health workers prefer to stay in urban areas [65, 66]. On the other hand, access to information, level of participation and ability to influence the responsiveness or decision making process in the health management committee are also determined by the economic status of the individual [36, 51, 64].
The business group have greater influence over the political infiltration and often resist the political intervention in the sphere of the economy in Nepal and they have been able to make the health sector a profit-making investment [32, 67]. The running private and teaching hospitals becoming one of the lucrative areas to get the best benefits out of the investment for business groups and politician [67]. This might potentially influence the responsiveness of policymaker toward community concerns. Therefore, it is essential to analyse and consider the influence of political-economic dynamics in social accountability interventions.
Health system context
- Client-provider relationship
The health workers are recognized as an intellectual and respected personality in the community and their profession is perceived as a highly prestigious profession in Nepal [64]. Hence, the community hardly think that health workers commit any mistakes while providing and managing services. This perception often imbalances the power-relation between service users and providers, this, therefore, affect the dialogue processes in social accountability interventions [64]. On the other hand, the power relationship between service providers and service users particularly in remote areas where there are no choices for health services, the community often hesitate to complain or to provide feedback to the health workers in order to avoid unnecessary conflict and in the fear of getting poor quality of services in the next visit. A quote in the below box from a study of rural health facility reflects the perception of
“How can Dalit, women, and the marginalized speak their minds with service providers? They think what the government does is all right. Health is the matter related to life and death. If you or your family member becomes ill, you have to go to the same place. Then, how could you take issue with the service providers? In villages, there is no option”- (Qualitative interview, staff, NGO) [64].
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the community toward accountability interventions [64].
Sometimes, the health workers and health facility committee members also tend to skip the interface with the community due to fear of being criticized in accountability interventions. [36, 68]. Furthermore, the people do not have access to have an interface with policy-level people as it is provisioned which has weakened the influence of social accountability interventions in the policy-level decision-making process [36].
- Resource availability
Persistent resource deficiencies in the health sector are also identified factor limiting the health workers’ and policymaker’s responsiveness towards the community [24, 68]. The management of the health facility has been handed to the local authority, however, human resource and logistics management are still being performed centrally which has undoubtedly made demand-supply procedure complex [22]. This has resulted in the frequent stock-outs of drugs and supplies and scarcity of human resources at health facilities level [33]. Moreover, in the federal government system, the line of accountability between Ministry of Health and Population, provincial and the local government has not been explicitly defined and also not properly guided which has further created responsibility dilemma among local authorities to manage health facilities under their responsibility [22, 59]. As per new government structure, the local government has only provided with a budget for staff salaries and basic operation cost for health facility management which may be insufficient to fulfil the relevant health needs and priorities of the community raised up during social accountability interventions [22]. Additionally, due to the human resources gap at community level health facility, the FCHVs are overwhelmed with community-based health interventions like Safe Motherhood, FP, Immunization, Nutrition, MPDSR, mother groups meetings etc. They are also being used by other several sectors such as education, forest groups, micro-credit finance groups etc. for their own accountability purpose in the community [45]. In the end, they are a volunteer and only get event-based incentives, therefore, the increased volume of responsibilities with minimal incentive has resulted in a decrease in their motivation to work [44, 45]. This might affect the quality service delivery and their responsiveness toward the community concerns.
In another argument, it has been said that organizational institutional capacity is equally important with the evidence of cases where allocated resources could not be mobilized and utilized properly due to lack of management capacity for improving the quality of health services [65].
- Monitoring and evaluation
In Nepal, the low responsiveness health system is often caused by the lack of proper monitoring and evaluation mechanism [7, 37]. Very few facilities, in fact, those facilities located at feasible geographic locations are frequently visited and receive regular supervision by the lined authorities [22, 65]. The district supervisors are often busy in conducting training and workshops which leave them with less time for supervision and monitoring at community-level health facilities [65]. This has weakened the effectiveness of established social accountability interventions in health facilities. The regular follow-up and analysis of audit action plans from the district and/or central level are almost non-existent in the health system [22, 24].
Evidence shows that demand-side social accountability interventions involve dialogue process which usually put soft pressure to the health workers to be accountable for their action and responsibility. It is argued that in the long run, without threat of sanction from the state, the interventions likely to address only surface level service delivery issues and affect the sustainability of the interventions [15]. Thus, the health system needs to strengthen the monitoring and supervision mechanism for effective and sustained outcomes of social accountability interventions.
Evidence on the outcomes of social accountability interventions in maternal health services
Social audit
There was no scientific research found examining the outcomes of social audit in Nepal, neither in other LMICs. Therefore, the findings from the evaluation and review study of social audit in Nepal has been presented as evidence.
Initiating the social audit intervention in health facilities has evident improved quality of maternal health services in Nepal. An evaluation study undertaken in health facilities of four districts of Nepal i.e. Palpa, Rupandehi, Jhapa and Ilam found overall improvement in the health provider’s behaviour and attitude as well regularity of health service providers. The clients and patients received more equitable treatment and with dignity. Similarly, the ANC and institutional delivery incentives were timely provided to the beneficiaries. The interventions also improved the dialogue between the community, health service providers and health facility committee. Community concerns were incorporated with the health facility action plan. However, the impact level of the interventions was different in each study district [24]. It was more effective in Palpa and Rupandehi where the social audit was conducted on regular basis for a long time with the technical support of external development agency compared to Jhapa and Ilam where it was solely implemented by the Government without any support from development partners. [24]. Therefore, the result indicated the regular practice of social accountability interventions improves the outcomes.
Another review conducted to examine the effectiveness of social audit in rural health facilities in far-western region one of the remotest regions in the country has identified social audit as an innovative and cost-effective strategy to improve health services quality. It is reported that social audit provides an opportunity for health workers and community leaders to be heard by policymakers. However, the sustainability of the intervention is still a question [68]. It depicted that specific attention is needed from policymakers to ensure enough budget allocation for the sustainability of the intervention, particularly for the facilities where intervention is supported by external development partners (EDPs).
Maternal death review
The maternal death review has been practised in Nepal for a long time and has also been scaled up in the different level of the health facilities [3, 27]. However, no research has been carried out to examine the effectiveness and outcomes of the intervention in the context of Nepal, therefore, evidence from other LMICs having similar context has been presented.
A study in Bangladesh regarding MDR intervention reported the intervention helps to recognize the causes of maternal deaths in the community and bring the attention of decision-makers to respond and addressing the issues appropriately. The analysis of the cause of the maternal death resulted in deploying competent human resource such as MBBS doctor, SBA at birthing centres to manage complications, all necessary equipment and supplies were ensured that ultimately improved the QoC and provider-user satisfaction which resulted in the increased uptake of maternal health services in Bangladesh. Increased uptake of maternal health services led to reduction in maternal death [69].
A similar finding was reported in Nigeria where MDR played an influential role in improving health service provider’s and policymaker’s responsiveness toward addressing causes of maternal deaths. Due to the intervention, the state government of Nigeria showed a high level of political commitment to evidence-based strategy and interventions to improve the maternal health services [26].
Since, MoHP has already established a web-based system to capture maternal deaths, however, getting the data from health facilities is still an issue. With the available data, MoHP has able to identify the causes of death and action plans have been developed by MPDSR committee for a different level of care, however, implementation of those action plans are still a challenge. [3]. Nigeria also encountered a similar problem in death reporting and implementation of developed action plans in earlier days. However, they incorporate the scorecard to monitor whether the plan of action is developed and if recommendations are acted upon accordingly [26]. The intervention supported to improve the reporting and triggered the system to respond accordingly [26]. Taking into consideration of the experiences from Nigeria having similar health system context; this example can be applied in Nepal as well to overcome the challenges and improve the outcomes of the MDR/MPDSR intervention.
Community scorecard/Community health scoreboard
Based on the successful experience of CSC implemented in Malawi CARE-International has brought that concept customized tool; community health scoreboard (CHSB) and applied in Nepal to improve the maternal health outcomes [30, 70]. As no studies were found for analysis about the effectiveness of the tool for improved maternal health outcomes in Nepal; evidence from other LMICS has been presented to show the relationship between tool and maternal health outcomes.
In Malawi, the intervention supported to increase interaction between the health service providers, members of the health committee and community, this improved accountability of health worker as well as improved the quality ANC and PNC services. As women were treated better at health facilities, the maternal service utilization trend increased [70]. Improved quality of maternal health services, access to and utilization of the maternal health services were achieved through mutually developed action plans [70]. The intervention particularly had more impact on the indicators that required little or no resources from the government [70]. As it was implemented at the community level health facility, the tool no significant impact on the indicators which needed the attention of higher-level government authorities [70]. This finding is similar to findings of an evaluation of social audit done in Nepal [24].
A mixed-method study performed in 2016 in Ghana to examine the effectiveness of CSC for improved maternal and newborn health services reported improved quality of emergency obstetric and newborn care (EmONC) in intervention piloted health facilities while the intervention improved engagement of stakeholders and community in the process [71]. The process also supported to develop a shared responsibility also termed ‘horizontal accountability' and created ownership among the community and stakeholders for both challenges and solutions, ultimately improved management of equipment and infrastructure in majority of health facilities [71].
Looking at the contextual similarities of Malawi and Ghana, Nepal can also expect similar outcomes of the CSC and/or CHSB in maternal health services. However, the sustainability of the interventions in Nepal is a major challenge as the interventions are promoted by the donor with minimal involvement of government [36]. Meanwhile, the government can integrate the CSC/CHSB in the social audit for efficiency and sustainability purpose. As an example in Zambia, CSC was combined with a social audit to enhance the responsiveness of the service providers and improve the coordination between state and community [72]. In the country, the social audit is used to assess the service performance against the national standard and the CSC is to rate the health facility against the perception-based indicators [72]. Taking the best practice from Zambia, Nepal can also adopt similar modality to sustain the intervention.
Citizen charter and complain/grievances handling interventions
No evidence is found on the contribution/effectiveness in the maternal health services in Nepal as well as in the other LMICs. Eventually, a study mapping awareness and factor influencing the implementation of citizen charter in health facility concluded it promotes the transparency of health facility and accountability of health workers towards service users if well implemented [61]. The similar conclusion was drawn in a study conducted in Kenya [73].
Although the complaint/grievances box contributes to enhancing accountability and transparency their uses are limited in practice and no specific attention has been given by the state. Many health facilities were found not to have citizen charter in the place and the complaint boxes often go unused and found to be filling with dust and spider webs [22, 61, 64]. The statement in the below box from a study in Nepal highlights the attitude of health worker on the usefulness of complaint box [64].
“… not only at the health facility level but even at the district level, the situation is that suggestion boxes are filled up with ‘spider webs’. As far as I know the suggestion box is not in use. No one puts their complaints or suggestions [into the suggestion box] by writing onto a piece of paper. Many do not know about its existence. So I do not see any importance of it”- PHC clinic manager [64].
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A report by Commissions for the Investigation of Abuse of Authority (CIAA, the health sector in Nepal is in 5th place amongst 9 sectors for the highest number of complaint about power abuse which indicated potential corruption vulnerabilities in the health system [74]. In such cases, poor information dissemination mechanism might result in information asymmetry between providers and users ultimately affect the quality of the service delivery. In addition, without informing the community could not evaluate the components of QoC in maternal health services and also unable to claim their rights entitlements ultimately lead to superficial community participation and produce suboptimal outcomes [75].
In Nepal, 20% of the estimated population is using the internet to access information and the trend is increasing, therefore, this indicates the possibility to use the digital media to improve information access so as to create the demand for quality health services [76]. A digital campaign has already been practising in sub-Saharan African countries with the support of the Evidence for Action (E4A) programme i.e. ‘Mama Ye!’ public engagement campaign [77]. The campaign is to create pressure on policymakers for their commitment and respond in prioritizing quality maternal and neonatal health services through digital media approaches [77]. The strategy could be relevant to the Nepalese context to create demand of quality maternal health service and make service providers accountable toward their actions and responsibility, while people’s preference for accessing health information and providing feedback is changing accordingly to the advancement of the technology in Nepal [22, 36, 64].