Devolution and human resources in primary healthcare in rural Mali

Devolution, as other types of decentralization (e.g. deconcentration, delegation, privatization), profoundly changes governance relations in the health system. Devolution is meant to affect performance of the health system by transferring responsibilities and authority to locally elected governments. The key question of this article is: what does devolution mean for human resources for health in Mali

The Challenges of Institutionalizing Community-Level Social Accountability Mechanisms for Health and Nutrition: a Qualitative Study in Odisha, India

Background: India has been at the forefront of innovations around social accountability mechanisms in improving the delivery of public services, including health and nutrition. Yet little is known about how such initiatives are faring now that they are incorporated formally into government programmes and implemented at scale. This brings greater impetus to understand their effectiveness. This formative qualitative study focuses on how such mechanisms have sought to strengthen community-level nutrition and health services (the Integrated Child Development Services and the National Rural Health Mission) in the state of Odisha. It fills a gap in the literature on considering how such initiatives are running when institutionalised at scale. The primary research questions were ‘what kinds of community level mechanisms are functioning in randomly selected villages in 3 districts of state of Odisha' and 'how are they perceived to function by their members and frontline workers’

Negotiating Access to Health Care for All through Social and Political Accountability: A Qualitative Study in Rural Nigeria

Social accountability is an important strategy towards ensuring that political leaders and actors implement the right policies in the interest of the entire society. In 2007, a community-based health insurance programme was implemented in selected rural communities in Kwara State, Nigeria, through collaboration between the Dutch Health Insurance Fund, PharmAccess Foundation, the Kwara State Government, and Hygeia Nigeria Limited to provide access to basic healthcare for the people. After operating for 9 years, the programme stopped in 2016. This paper describes how social and political accountability shaped the introduction, functioning, and stoppage of the CBHI programme. The study adopted a qualitative approach for data collection, particularly in-depth (n = 22) and key informant interviews (n = 32). Findings indicate that the community-based health insurance programme was proposed by the foreign agency and that the state government was instrumental in the stoppage of the programme. Also, the change in government (via voting against a political bloc that had been in power since 2003) in Kwara State during the 2019 general elections was among the accountability measures employed by the citizenry in reaction to the stoppage of the Community-Based Health Insurance programme. The implication of this is that the current government, expectedly, will not only draw up a more robust healthcare policy for implementation but will also ensure that the people are carried along through adequate social and political accountability mechanisms

Negotiating Access to Health Care for All through Social and Political Accountability: A Qualitative Study in Rural Nigeria

Abstract Social accountability is an important strategy towards ensuring that political leaders and actors implement the right policies in the interest of the entire society. In 2007, a community-based health insurance programme was implemented in selected rural communities in Kwara State, Nigeria, through collaboration between the Dutch Health Insurance Fund, PharmAccess Foundation, the Kwara State Government, and Hygeia Nigeria Limited to provide access to basic healthcare for the people. After operating for 9 years, the programme stopped in 2016. This paper describes how social and political accountability shaped the introduction, functioning, and stoppage of the CBHI programme. The study adopted a qualitative approach for data collection, particularly in-depth (n = 22) and key informant interviews (n = 32). Findings indicate that the community-based health insurance programme was proposed by the foreign agency and that the state government was instrumental in the stoppage of the programme. Also, the change in government (via voting against a political bloc that had been in power since 2003) in Kwara State during the 2019 general elections was among the accountability measures employed by the citizenry in reaction to the stoppage of the Community-Based Health Insurance programme. The implication of this is that the current government, expectedly, will not only draw up a more robust healthcare policy for implementation but will also ensure that the people are carried along through adequate social and political accountability mechanisms

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

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

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

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

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

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

Frequencies of cases and actors per type of feedback.

<p>Frequencies of cases and actors per type of feedback.</p