Social Accountability and Legal Empowerment for Quality Maternal Health Care

Unacceptably high rates of maternal morbidity and mortality affect the Global North and the Global South. Among many challenges, policy-makers and researchers cite concerns about quality of care, respectful maternity care, and implementation of evidence-based strategies and national guidelines at the frontlines of the health system. Informal payments are one concern that cut across these three challenges; they represent poor quality care; they are often experienced as disrespect by patients; and, health care worker demands for such payments by definition conflict with national policy. Social accountability and legal empowerment are two approaches that are increasingly used to address quality of care concerns in maternal health and poor implementation at the frontlines of the health system. This dissertation is comprised of three chapters (papers), all of which focus on these challenges in maternal health in low and middle income countries (LMICs). They apply concepts and methods from health policy and systems research (HPSR) to undertake theoretically-informed analyses that straddle two fields: (1) accountability, and, (2) global maternal health. The first chapter is a critical interpretive synthesis that summarizes the evidence base on the prevalence, drivers, and impact of informal payments in maternal health care; critically interrogates the paradigms that are used to describe informal payments; and, finally, synthesizes the policy and funding debates directly related to informal payments. The paper finds that though assessing the true prevalence of informal payments is difficult given measurement challenges, quantitative and qualitative studies have identified widespread informal payments in health care in many low and middle income countries in Asia, Africa, and Latin America. Studies and conceptual papers identified both proximate, immediate drivers of informal payments, as well as broader systemic causes. These causes include norms of gift giving, health workforce scarcity, inadequate health systems financing, the extent of formal user fees, structural adjustment and the marketization of health care, and patient willingness to pay for better care. Similarly, there are both proximate and distal impacts, including on household finances, patient satisfaction and demand for health care, and provider morale. Despite the ground level relevance of informal payments, they are generally not adequately addressed in global policy frameworks and strategies, or in standard metrics of health system performance. Though this absence does not necessarily imply lack of financial or other attention to informal payments, it makes inattention more likely, and regardless, represents a notable silence. Informal payments have been studied and addressed from a variety of different perspectives, including anti-corruption, ethnographic and other in-depth qualitative approaches, and econometric modeling. Synthesizing data from these and other paradigms illustrates the value of an inter-disciplinary approach. Each lens adds value and has blind spots. These attributes in turn affect the solutions proposed. The paper concludes that the same tacit, hidden attributes that make informal payments hard to measure also make them hard to discuss and address. A multi-disciplinary health systems approach that leverages and integrates positivist, interpretivist, and constructivist tools of social science research can lead to better insight and policy critiques. The second chapter is a descriptive case study of a social accountability project seeking to decrease health provider demands that women make informal payments in Uttar Pradesh (UP), India. Women in UP are often asked to make informal payments for maternal health care services that the central or state government has mandated to be free. The chapter is a descriptive, contextualized case study of a social accountability project undertaken by SAHAYOG, an NGO based in UP. The study methods included document review; interviews and focus group discussions of program implementers, governmental stakeholders, and community activists; and participant observation in health facilities. The study found that SAHAYOG adapted their strategy over time to engender greater empowerment and satisfaction among program participants, as well as greater impact on the health system. Participants gained resources and agency; they learned about their entitlements, had access to mechanisms for complaints, and, despite risk of retaliation, many felt capable of demanding their rights in a variety of fora. However, only program participants seemed able to avoid making informal payments to the health sector; they largely were unable to effect this change for women in the community at large. Several features of the micro and macro context shaped the trajectory of SAHAYOG’s efforts, including caste dynamics, provider commitment to ending informal payments, the embeddedness of informal payments in the health system, human resource scarcity, the overlapping private interests of pharmaceutical companies and providers, and the level of regional development. Though changes were manifest in certain health facilities, as a group, providers did not necessarily embraced the notion of low caste, tribal, or Muslim women as citizens with entitlements, especially in the context of free government services for childbirth. SAHAYOG assumed a supremely difficult task. Project strategy changes may have made the task somewhat less difficult, but given the population making the rights claims and the rights they were claiming, widespread changes in demands for informal payments may require a much larger and stronger coalition. The third paper is an explanatory case study of a hybrid legal empowerment and social accountability effort led by the Mozambican NGO, Namati Moçambique. Established in 2013, Namati Moçambique runs a multi—pronged health paralegal and policy advocacy program that employs community paralegals as Health Advocates and trains Village Health Committees (VHCs). The study sought to uncover how the program affected the relationship between citizens and the health sector, how the health sector and citizens responded, and what role contextual factors played. The case study had two components: 1) a retrospective review of 24 cases 2) qualitative investigation of the Namati program and program context. The cases came from a total of 6 sites in 3 districts. Program implementers, clients, Village Health Committee (VHC) members, and health providers were interviewed or participated in focus groups as part of the research. The study found that though they are unable to address some deeply embedded national challenges, Health Advocates successfully solved a variety of cases affecting poor Mozambicans in both urban and rural areas. Health Advocates took a variety of steps to resolve these cases, some of which entailed interactions with multiple levels of the government. We identified three key mechanisms, or underlying processes of change that Namati’s work engendered, including: bolstered administrative capacity within the health sector, reduced transaction and political costs for health providers, and provider fear of administrative sanction. In addition to case resolution, stakeholders highlighted individual satisfaction at having one’s complaint remedied and individual empowerment among clients and Health Advocates as stemming from the project. Health Advocates and VHCs developed functional working relationships with providers, in part because they addressed issues that providers felt were important, and engendered community satisfaction with the Health Advocate, and ultimately, trust in the health system. The case resolution focus of legal empowerment brought procedural teeth, helping to ensure that new relationships result in immediate improvements, thus instigating a circle of relationship building and health system improvements

Ending preventable maternal mortality: phase II of a multi-step process to develop a monitoring framework, 2016–2030

Background In February 2015, the World Health Organization (WHO) released “Strategies toward ending preventable maternal mortality (EPMM)” (EPMM Strategies), a direction-setting report outlining global targets and strategies for reducing maternal mortality in the Sustainable Development Goal (SDG) period. In May 2015, the EPMM Working Group outlined a plan to develop a comprehensive monitoring framework to track progress toward the achievement of these targets and priorities. This monitoring framework was developed in two phases. Phase I, which focused on identifying indicators related to the proximal causes of maternal mortality, was completed in October 2015. This paper describes the process and results of Phase II, which was completed in November 2016 and aimed to build consensus on a set of indicators that capture information on the social, political, and economic determinants of maternal health and mortality. Findings A total of 150 experts from more than 78 organizations worldwide participated in this second phase of the process to develop a comprehensive monitoring framework for EPMM. The experts considered a total of 118 indicators grouped into the 11 key themes outlined in the EPMM report, ultimately reaching consensus on a set of 25 indicators, five equity stratifiers, and one transparency stratifier. Conclusion The indicators identified in Phase II will be used along with the Phase I indicators to monitor progress towards ending preventable maternal deaths. Together, they provide a means for monitoring not only the essential clinical interventions needed to save lives but also the equally important political, social, economic and health system determinants of maternal health and survival. These distal factors are essential to creating the enabling environment and high-performing health systems needed to ensure high-quality clinical care at the point of service for every woman, her fetus and newborn. They complement and support other monitoring efforts, in particular the “Survive, Thrive, and Transform” agenda laid out by the Global Strategy for Women’s, Children’s and Adolescents’ Health (2016-2030) and the SDG3 global target on maternal mortality

Community health workers and accountability: reflections from an international “think-in”

Community health workers (CHWs) are frequently put forward as a remedy for lack of health system capacity, including challenges associated with health service coverage and with low community engagement in the health system, and expected to enhance or embody health system accountability. During a ‘think in’, held in June of 2017, a diverse group of practitioners and researchers discussed the topic of CHWs and their possible roles in a larger “accountability ecosystem.” This jointly authored commentary resulted from our deliberations. While CHWs are often conceptualized as cogs in a mechanistic health delivery system, at the end of the day, CHWs are people embedded in families, communities, and the health system. CHWs’ social position and professional role influence how they are treated and trusted by the health sector and by community members, as well as when, where, and how they can exercise agency and promote accountability. To that end, we put forward several propositions for further conceptual development and research related to the question of CHWs and accountability

Power analysis in health policy and systems research: A guide to research conceptualisation

Power is a growing area of study for researchers and practitioners working in the field of health policy and systems research (HPSR). Theoretical development and empirical research on power are crucial for providing deeper, more nuanced understandings of the mechanisms and structures leading to social inequities and health disparities; placing contemporary policy concerns in a wider historical, political and social context; and for contributing to the (re)design or reform of health systems to drive progress towards improved health outcomes. Nonetheless, explicit analyses of power in HPSR remain relatively infrequent, and there are no comprehensive resources that serve as theoretical and methodological starting points. This paper aims to fill this gap by providing a consolidated guide to researchers wishing to consider, design and conduct power analyses of health policies or systems. This practice article presents a synthesis of theoretical and conceptual understandings of power; describes methodologies and approaches for conducting power analyses; discusses how they might be appropriately combined; and throughout reflects on the importance of engaging with positionality through reflexive praxis. Expanding research on power in health policy and systems will generate key insights needed to address underlying drivers of health disparities and strengthen health systems for all

Posting and transfer: key to fostering trust in government health services

Appropriate deployment or posting and transfer (P&T) of health workers – placing the right people in the right positions at the right time – lies at the heart of fostering communities’ faith in government health services and cementing the role of the health system as a core social institution. The authors of this paper have been involved in an ongoing transnational dialogue about P&T practices and determinants. This dialogue seeks to call attention to the importance of P&T as a health system function; to urge donors and policy-makers working in health systems, HRH and public administration governance to consider how to address issues around P&T; and to suggest avenues and approaches to research. P&T is a vexed and unresolved issue in many low- and middle-income countries that requires, above all, political commitment to improving public sector services and to new thinking and research. It holds promise as a focal point for inter-disciplinary collaboration in research and implementation that can inform other areas in HRH and health systems strengthening. Innovative social science and management theorizing, and iterative, locally driven interventions that focus on establishing transparent professional norms and building the credibility of government administration, including the health services, are likely the way forward

Power Analysis in Health Policy and Systems Research: a Guide to Research Conceptualisation

Power is a growing area of study for researchers and practitioners working in the field of health policy and systems research (HPSR). Theoretical development and empirical research on power are crucial for providing deeper, more nuanced understandings of the mechanisms and structures leading to social inequities and health disparities; placing contemporary policy concerns in a wider historical, political and social context; and for contributing to the (re)design or reform of health systems to drive progress towards improved health outcomes. Nonetheless, explicit analyses of power in HPSR remain relatively infrequent, and there are no comprehensive resources that serve as theoretical and methodological starting points. This paper aims to fill this gap by providing a consolidated guide to researchers wishing to consider, design and conduct power analyses of health policies or systems. This practice article presents a synthesis of theoretical and conceptual understandings of power; describes methodologies and approaches for conducting power analyses; discusses how they might be appropriately combined; and throughout reflects on the importance of engaging with positionality through reflexive praxis. Expanding research on power in health policy and systems will generate key insights needed to address underlying drivers of health disparities and strengthen health systems for all

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570