Susan A. Papp, Aparajita Gogoi, and Catherine Campbell present a case study of efforts to improve service accountability in Odisha, India, focusing on the role of local women, intermediary groups, health providers and elected politicians

Campbell, Catherine

Gogoi, Aparajita

Papp, Susan A.

LSE Research Online

2013-11-6Can social accountability initiatives improve maternal healthin India?blogs.lse.ac.uk /southasia/2013/11/06/can-social-accountability-initiatives-improve-maternal-health-in-india/Susan A. Papp, Aparajita Gogoi, and Catherine Campbell present a case study of efforts to improve serviceaccountability in Odisha, India, focusing on the role of local women, intermediary groups, health providers andelected politicians. Millennium Development Goal Five (MDG5a) – the reduction of maternal  mortality by 75 per cent from 1990 to 2015– remains one of the MDG’s toughest targets. The number of women who die annually from pregnancy and labourcomplications is 287,000, and 99 per cent of these deaths occur in the developing world. While decades ofadvocacy are yielding improvements in mothers’ health in some settings, policy implementation lags in others.Drivers of poor maternal health include low awareness of the dangers of childbirth and how to avoid them, lack ofvalue given to women’s health in many settings, women’s lack of confidence and power to assert their needs,economic inequalities and poor health care provider commitment to women’s well-being. These problems areparticularly acute in India, which has the highest absolute number of maternal deaths (56,000) globally.Public and private entities in India often have weak capabilities to self-regulate and enforce accountability.Consequently, ‘social accountability’ – citizen-led, hybrid forms of accountability – has been identified as a keypathway to improved health, development and governance. ‘Social accountability planning’, emphasising communitymobilisation, potentially empowers women to assert their entitlements to health and creates environments wherepolicymakers and service providers recognise the urgency of policy implementation, interventions and services.We provide a case study of a social accountability initiative in the state of Odisha, India : in 2006, the White RibbonAlliance for Safe Motherhood in India embarked on a social accountability programme to address high maternalmortality and the inadequate implementation of maternal health programmes, using three tools: (1) maternal deathaudits via verbal autopsies, (2) health facility checklists and (3) public hearings and rallies to bring women togetherwith government officials and service providers to address grievances around maternal care. Our study seeks toidentify the processes and psycho-social pathways through which social accountability is mediated in an effort tocontribute to understandings of its potential in improving policy implementation and quality of care.The study is framed by Asha George’s conceptualisation of social accountability  “as a referee of the dynamics in1/2two-way relationships, between often unequal partners”. George asserts that three key elements of socialaccountability – information, dialogue and negotiation – support marginalised groups in confronting disempoweringrelations, generating actionable representations of the drivers of neglect and strategies for tackling them andtransforming the way dominant and marginalised participants view themselves and their inter-relationships. Thisstudy aims to expand on the empirical base for George’s framework by identifying three new complementaryprocesses, as demonstrated through the alliance’s work: (1) generating demand for rights and better services viainformation, (2) leveraging intermediaries to legitimise the demands of poor and marginalised women via dialogueand (3) sensitising leaders and health providers to the needs of women through external and internal levers vianegotiation.At a programmatic and systemic level, social accountability efforts in Odisha are generating a positive impact onwomen, intermediaries, service providers and government leaders. Social accountability efforts, such as the publichearing, are providing new ways for women to collectively voice their concerns and demands in a supported space.These demands are being reinforced and legitimised by intermediary partners such as local elected officials and themedia, leading to an enhanced receptivity to women’s needs on the part of the leaders. Among the service providersand government leaders, the alliance’s social accountability efforts are catalysing new levels of understandingaround the gaps in the system. This new understanding opens up many opportunities for improved service delivery.Perhaps the most significant finding of the study was the discovery that subtle mindsets – among both marginalisedwomen as well as leaders and service providers – play as much of a role in the success or failure of socialaccountability as any manifest factors and structural barriers. Informants were unanimous in noting that a change ofmindset and the ability to generate a sense of concern were essential for realising a system that is more sociallyaccountable. This discovery has implications that could impact the government’s response to maternal health. Inaddition to working to improve infrastructure and increase the number of skilled health workers, our findings suggestthe parallel need for government officials to further explore and scale up community monitoring efforts to facilitate achange in the mindset of providers, patients and local leaders alike.While public hearings provide a critical forum and can promote accountability, it is one step and one tool of manyneeded to achieve sustainable social change. This type of long-term change can only be achieved through acombination of top-down (checklists, verbal autopsies, public interest litigation and special rapporteur visits) andbottom-up (public hearings, report cards and community monitoring) accountability tools that challenge the ingrainedsocio-cultural norms that perpetuate health disparities in the first place.For more information on this topic, see: Susan A. Papp , Aparajita Gogoi, and Catherine Campbell (2013) Improvingmaternal health through social accountability: A case study from Orissa, India, Global Public Health: An InternationalJournal for Research, Policy and Practice, 8:4, 449-464.Copyright © 2016 London School of Economics2/2

Can social accountability initiatives improve maternal health in India?

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