Improving maternal health services Improving maternal health services performance and responsiveness performance and responsiveness through social accountability through social accountability mechanisms in DRC : mechanisms in DRC : implementing participatory action implementing participatory action research with a realist perspectiveresearch with a realist perspective

Therese Mambu, Eric Mafuta (KSPH)Therese Mambu, Eric Mafuta (KSPH)Patrick Kayembe (KSPH) Patrick Kayembe (KSPH) Tjard de Cock Buning (VU) Tjard de Cock Buning (VU) Marjolein Dieleman (KIT)Marjolein Dieleman (KIT)

IntroductionIntroduction

Reducing maternal mortality ratios and morbidity rates requires among others that maternal health services are responsive to citizens’ needs. Citizen engagement in decision processes for health services and policies can improve responsiveness.

One way to achieve this is through the establishment of political accountability mechanisms, which intend to measure performance in relation to civil society’s stated needs and demands of health services.

IntroductionIntroduction

Citizen engagement is particularly important in fragile states, because of weak government systems.

Research objectivesResearch objectives

This research program assesses whether, and how, political accountability mechanisms increase responsiveness and performance of maternal health services in Burundi and the Democratic Republic of (DR) Congo.

It is expected that lessons drawn from it will provide policy advice on use of political accountability to improve maternal health services in fragile states.

Research objectivesResearch objectives

Specific objectives in terms of: a) Scientific quality: 1. Identify and analyze existing mechanisms

through which interests of citizens are expressed and integrated into maternal health service standards, policy and planning and human resource performance management in Burundi/Congo

2. Assess whether specific SAMs result in improved performance of maternal health service delivery and its use in Burundi/Congo

3. Develop conceptual framework for political accountability incorporating contextual factors, enabling change in maternal health service performance in fragile states

Research objectivesResearch objectives

b) Development relevance 1. Facilitate the development of evidence-

informed policy-making on maternal health service performance in fragile states

2. Develop capacity among stakeholders to establish practical and measurable SAMs in maternal healthcare in fragile states

3. Develop capacity among citizens, particularly women, to actively engage in policy dialogues for maternal health

Research objectivesResearch objectives

c) International multi-stakeholder collaboration:

1. Create a multi-stakeholder learning network for exchange of knowledge and experiences on maternal health service performance and SAMs in Burundi/Congo;

2. Share experiences through South-South and North–South learning among researchers and relevant stakeholders;

3. Communicate evidence for SAMs in maternal healthcare to the international research community.

AssumptionAssumption

When maternal health services are responsive to perceived needs:

Uptake and quality of maternal service

Reduction in risks of maternal morbidity and

mortality

Interactive learning and action on social accountability in Burundi and DR Congo

Research frameworkResearch framework

In-country research programIn-country research program

The research is action-oriented and uses a transdisciplinary approach, involving different types of actors. It covers a 5-years period and is organised as follows:

1. Preparation and exploration (6 months): Selection and training of PhD students and researchers, stakeholder analysis in each intervention area, insight in current situation concerning maternal health and accountability mechanisms, networking, capacity development

2. In-depth study (12 months): Situational analysis of existing political accountability mechanisms for maternal health services

In-country research programIn-country research program

3. Integration and intervention planning (6 months): Integration of results of the situational analysis, selection and planning political accountability interventions in Burundi/Congo, and development of monitoring and evaluation framework

4a. Implementation and assessment of the intervention (24 months): Implementation, monitoring and evaluation of interventions

Related research programRelated research program

4b. Descriptive case studies in other fragile states (24 months): Identification and analysis of experiences on political accountability mechanisms for maternal health services in four selected fragile states, so as to complement the country-level intervention studies

5. Reflexive learning and developing policy advice (48 months): Comparative analysis of results in

Burundi/Congo and other fragile states, translation of results in policy advice, development of

conceptual framework for political accountability for maternal health in fragile state

ApproachApproach

1. Dialogue with wide group of stakeholders

2. Partnership with 2 NGOs in Burundi and in DR Congo:◦ Researchers- baseline◦ Joint discussion:

Expectations of current interventions = program theory Include learning-action cycles

3. Implementation and research and document: What works for who and under which circumstances Joint organization of policy dialogues Joint article writing

•

Implementation ILAImplementation ILA

Action-learning cycles:

Base line results-Start constructive dialogue And adapt social accountability

Experience, discuss and Explain results in context

Use results to adapt againthe intervention

Achievement 1Achievement 1

1. Dialogue with a wide range of stakeholders A workshop was organized in the beginning of

the program aiming to discuss with stakeholders and involve them in research.

All national offices and health partners involved in maternal health were present (Health Zones, Health committee members, Health services providers, NGO, Professionnal groups, MoH Programs and Directorate, Partners)

They sign a MOU to support research application to NOW

Achievement 2Achievement 2

2. Stakeholders analysis A small scale research was carried out to analyze

accountability mechanisms used by selected health providers and health sector partners involved in providing or supporting maternal health provision (ABF-ND, MM,…) and planning.

Findings : financial and performance accountability

mechanisms exist, but few social accountability (suggestion box, interviews….)

Existence of multi-years program which can integrate research intervention

Achievements 3Achievements 3

Research partners selection and inceptive workshops (Bujumbura I)

Discussion on maternal mortality issues and accountability concepts;

Planning of context and baseline studies

Achievement 4Achievement 4

Context study : Is the context supportive

As part of community participation, social accountability is viewed as a process of empowerment and a social practice. It has to be necessarily configured according to the social and political context and change as the context changes .

As a dynamic process, accountability can take different forms in different settings and will impact in the sustainability of the intervention and can vary according to the social context.

Achievement 4Achievement 4

Context study : Aims : to explore contextual factors that could

be incorporated in a conceptual framework for accountability,

It consisted in collecting data about political, social, economic and cultural contexts in which an intervention that aims to introduce community accountability mechanisms will be implemented;

Methods: In-depth interviews of key informants and documentary reviews

Achievement 4Achievement 4

Context study (Main findings): Community groups, association and network :

Contexts are similar with several types of community associations and groups, with little social activism antecedent; related to socio-economic contexts; existence of community participation through health committee, low involvement of other community groups, Inexistence of coalition;

Socio-economic contexts : subsistance activities, based on agriculture and farming, very low salary paid employment, Some oil firms in one site; Relative friction sometimes between natives and non natives

Achievement 4Achievement 4 Cultural contexts: multiple tribes and cultures, low

women’s status related to male dominance tradition; low participation of women in decision making. Potential impact of education, resources possession, employement position in women statutes

Political contexts: No effectiveness of decentralization, Relative non resistance to community grouping and

assocation, But Identification of community association

committed to demand rights even basic rights to « political activities »,

Relative support to community participation in health

Achievement 4Achievement 4

Media: inexistence of local media such as radio, newspapers or TV.

Conclusion: The local contexts are supportive to the

implementation of accountability mechanisms considering considering certain factors and not for other.

Achievement 5Achievement 5

Baseline study : local existing social accountability mechanisms

Methods : in depth interviews of key informants, community members (women, men, mother-in law) and health providers

Achievement 5Achievement 5

Findings: Relative good experiences of maternal health

services; Few expectations, needs and concerns; Women Engagement: Very few declared complaints about

inappropriate care; No reporting of complaints and concerns,

because of inexistence of formal reporting systems and of fear of reprisals

Use of intermediairies for bringing complaints forward: community health workers, community leaders…

Achievement 5Achievement 5

Use of informal accountability mechanims : rutless, gossips, rumors,

Use of exit strategies or abandon

Community oversight: Inexistence of community involvement according to

women Existence of health committee and community based

organizations for others key informants Existence of some mechanims which can support

social accountability: health committee, community based association involved in PBF scheme

Health providers responsiveness: Mitigated perception of health providers

responsiveness

Example Example • Engagement: Women feel inferior, fear reprisals

“Health providers are complicated, if you have a problem against them. They can get angry and abuse you “(Woman, village RDC)

• M&E/oversight: no formal processes• Intermediate approached but does not act as broker

“The last time, I told them [CHW] what I had found in the center. I reported to them because they can have the ease and the courage to go to speak to the health providers… However, I do not know if they delivered my message” (Woman, village RDC)

Achievement 5Achievement 5

Conclusion:Relative inexistence of social accountability

mechanisms in local level

Achievement 5Achievement 5

1. Joint writing of scientific papers (in internal revue : 3 papers)

2. Presentation of poster during the 3rd Global Health Systems research Symposium;

3. Joint preparation of intervention protocol and fieldworks

4. Linkage of the research program to existing health program

Next stepsNext steps

Intergration phase : dissemination meetings and workshops in different

levels (Knowlegde translation):

Reserch team: Joint preparation of social accountability intervention

National: Involvement of decision makers and health partners: Discussion of findings and implications for health policy (with media, writing of policy brief)

Provincial level: Involvement of health zones management team and implication for operational level : community participation

Local level: community members, community associations and health providers: Joint vision

Next stepsNext steps

Implementation :

To be carried out in research sites by health partners following joint research protocol;

Monitoring and evaluation :

using realist evaluation approach

Opportunities and challengesOpportunities and challenges

Discussing the logic of the intervention Joining research to existing health program Measuring and adapting the research progress Ownership and initiative Institutional language Bringing research closer to practice

◦ Contextualising practice and understanding its workings- some interventions are scalable, others not?

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