"We come as friends": approaches to social accountability by health committees in Northern Malawi

Unsung heroes in Ghana's healthcare system: the case of community health volunteers and community health management committee

BACKGROUND

In Ghana, the community-based health planning and services (CHPS) policy highlights the significance of both community health management committees (CHMCs) and community health volunteers (CHVs) in the Ghanaian health system. However, research into their specific effects on health system improvement is scarce. Some research has focussed on the roles of the CHMCs/CHVs in implementing specific targeted health interventions but not on improving the overall health system. Therefore, this research aims to examine the role of the CHMCs and CHVs in improving the Ghanaian health system.

METHODS

The study was conducted in three districts in the Ashanti region of Ghana. A total of 35 participants, mainly health service users and health professionals, participated in the study. Data were collected using semi-structured individual in-depth interviews. Participants were selected according to their patient-public engagement or community health activity roles. Data were transcribed and analysed descriptively using NVIVO 12 Plus.

RESULTS

We found that the effectiveness of CHMCs and CHVs in health systems improvement depends largely on how members are selected. Additionally, working through CHMC and CHVs improves resource availability for community health services, and using them in frontline community health activities improves health outcomes.

CONCLUSIONS

Overall, we recommend that, for countries with limited healthcare resources such as Ghana, leveraging the significant role of the CHMCs and CHVs is key in complementing government's efforts to improve resource availability for healthcare services. Community health management committees and CHVs are key in providing basic support to communities with limited healthcare personnel. Thus, there is a need to strengthen their capacities to improve the overall health system.

Social Accountability in Health System Governance: A Scoping Review

Background

Social accountability is an important element in health system governance, which is necessary for health system reform and reaching Universal Health Coverage. Understanding the social accountability mechanism and tools will help policymakers to design policies according to the context. We aimed to explore the extent of the application of social accountability in health system governance, its results, challenges, and tools.

Methods

We conducted a scoping review study, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping review. An inclusive search in bibliographic databases and search engines was done to identify peer review articles and grey literatures, published in English in the range of 2010 to 2021. Search terms were (social accountability), (public accountability), AND (health system).

Results

Thirty-one records met inclusion criteria from 286 potentially relevant sources, which included 25 peer-review articles and 6 grey literatures. Maternal and child health was the main health subject for social accountability interventions. We identified some social accountability tools to apply at the health facility and community levels. Social accountability has some benefits for the health system and for the community and some challenges to the implementation of social accountability were listed.

Conclusion

Social accountability improves health system performance. It contains different tools and strategies applied at different levels of the health system. Successful social accountability initiatives that are strategic, multi-interventional, and context-specific can produce good results in health services and social domains.

Community engagement in maternal and perinatal death surveillance and response (MPDSR): Realist review protocol

Background: While there has been a decline in maternal and perinatal mortality, deaths remain high in sub-Saharan Africa and Asia. With the sustainable development goals (SDGs) targets to reduce maternal and perinatal mortality, more needs to be done to accelerate progress and improve survival. Maternal and perinatal death surveillance and response (MPDSR) is a strategy to identify the clinical and social circumstances that contribute to maternal and perinatal deaths. Through MPDSR, an active surveillance and response cycle is established by bringing together different stakeholders to review and address these social and clinical factors. Community engagement in MPDSR provides a strong basis for collective action to address social factors and quality of care issues that contribute to maternal and perinatal deaths. Studies have shown that community members can support identification and reporting of maternal and/or perinatal deaths. Skilled care at birth has been increasing globally, but there are still gaps in quality of care. Through MPDSR, community members can collaborate with health workers to improve quality of care. But we do not know how community engagement in MPDSR works in practice; for whom it works and what aspects work (or do not work) and why. This realist review answers the question: which strategies of community engagement in MPDSR produce which outcomes in which contexts? Methods : For this realist review, we will identify published and grey literature by searching relevant databases for articles. We will include papers published from 2004 in all languages and from all countries. We have set up an advisory group drawn from academia, international organizations, and practitioners of both MPDSR and community engagement to guide the process. Conclusion: This protocol and the subsequent realist review will use theoretical approaches from the community engagement literature to generate theory on community engagement in MPDSR. Prospero registration number:  CRD42022345216.

Facilitators for and Barriers to the Implementation of Performance Accountability Mechanisms for Quality Improvement in the Delivery of Maternal Health Services in a District Hospital in Pwani Region, Tanzania

Tanzania experiences a burden of maternal mortality and morbidity. Despite the efforts to institute accountability mechanisms, little is known about quality improvement in the delivery of maternal health services. This study aimed at exploring barriers and facilitators to enforcing performance accountability mechanisms for quality improvement in maternal health services. A case study design was used to conduct semi-structured interviews with thirteen key informants. Data were analyzed using thematic analyses. The findings were linked to two main performance accountability mechanisms: maternal and perinatal death reviews (MPDRs) and monitoring and evaluation (M&E). Prioritization of the maternal health agenda by the government and the presence of maternal death review committees were the main facilitators for MPDRs, while negligence, inadequate follow-up, poor record-keeping, and delays were the main barriers facing MPDRs. M&E was facilitated by the availability of health management information systems, day-to-day ward rounds, online ordering of medicines, and the use of biometrics. Non-use of data for decision-making, supervision being performed on an ad hoc basis, and inadequate health workforce were the main barriers to M&E. The findings underscore that barriers to the performance accountability mechanisms are systemic and account for limited effectiveness in the improvement of quality of care.

Social accountability in primary health care facilities in Tanzania: Results from Star Rating Assessment

Background

Star Rating Assessment (SRA) was initiated in 2015 in Tanzania aiming at improving the quality of services provided in Primary Healthcare (PHC) facilities. Social accountability (SA) is among the 12 assessment areas of SRA tools. We aimed to assess the SA performance and its predictors among PHC facilities in Tanzania based on findings of a nationwide reassessment conducted in 2017/18.

Methods

We used the SRA database with results of 2017/2018 to perform a cross-sectional secondary data analysis on SA dataset. We used proportions to determine the performance of the following five SA indicators: functional committees/boards, display of information on available resources, addressing local concerns, health workers’ engagement with local community, and involvement of community in facility planning process. A facility needed four indicators to be qualified as socially accountable. Adjusted odds ratios (AOR) with 95% confidence intervals (CI) were used to determine facilities characteristics associated with SA, namely location (urban or rural), ownership (private or public) and level of service (hospital, health centre or dispensary).

Results

We included a total of 3,032 PHC facilities of which majority were dispensaries (86.4%), public-owned (76.3%), and located in rural areas (76.0%). On average, 30.4% of the facilities were socially accountable; 72.0% engaged with local communities; and 65.5% involved communities in facility planning process. Nevertheless, as few as 22.5% had functional Health Committees/Boards. A facility was likely to be socially-accountable if public-owned [AOR 5.92; CI: 4.48–7.82, p = 0.001], based in urban areas [AOR 1.25; 95% CI: 1.01–1.53, p = 0.038] or operates at a level higher than Dispensaries (Health centre or Hospital levels)

Conclusion

Most of the Tanzanian PHC facilities are not socially accountable and therefore much effort in improving the situation should be done. The efforts should target the lower-level facilities, private-owned and rural-based PHC facilities. Regional authorities must capacitate facility committees/boards and ensure guidelines on SA are followed.

The quest for accountability of Health Facility Governing Committees implementing Direct Health Facility Financing in Tanzania: A supply-side experience

User committees, such as Health Facility Governing Committees, are popular platforms for representing communities and civil society in holding service providers accountable. Fiscal decentralization via various arrangements such as Direct Health Facility Financing is thought to strengthen Health Facility Governing Committees in improving accountability in carrying out the devolved tasks and mandates. The purpose of this study was to analyze the status of accountability of Health Facility Governing Committees in Tanzania under the Direct Health Facility Financing setting as perceived by the supply side. In 32 different health institutions, a cross-sectional design was used to collect both qualitative and quantitative data at one point in time. Data was collected through a closed-ended questionnaire, an in-depth interview, and a Focus Group Discussion. Descriptive statistics, multiple logistic regression, and theme analysis were used to analyze the data. According to the findings, Health Facility Governing Committees' accountability is 78%. Committees have a high level of accountability in terms of encouraging the community to join community health funds (91.71%), receiving medicines and medical commodities (88.57%), and providing timely health services (84.29%). The health facility governance committee's responsibility was shown to be substantially connected with the health planning component (p = 0.0048) and the financial management aspect (p = 0.0045). This study found that the fiscal decentralization setting permits Committees to be accountable for carrying out their obligations, resulting in improved health service delivery in developing nations.

Health workforce governance for compassionate and respectful care: a framework for research, policy and practice

The progressive realisation of universal health coverage requires that health services are not only available and accessible, but also that they are rendered to the population in an acceptable, compassionate and respectful manner to deliver quality of care. Health workers’ competencies play a central role in the provision of compassionate and respectful care (CRC); but health workers’ behaviour is also influenced by the policy and governance environment in which they operate. The identification of relevant policy levers to enhance CRC therefore calls for actions that enable health workers to optimise their roles and fulfil their responsibilities.

This paper aims at exploring the health workforce policy and management levers to enable CRC. Through an overview of selected country experiences, concrete examples are provided to illustrate the range of available policy options. Relevant interventions may span the individual, organisational, or system-wide level. Some policies are specific to CRC and may include, among others, the inclusion of relevant competencies in preservice and in-service education, supportive supervision and accountability mechanisms. Other relevant actions depend on a broader workforce governance approach, including policies that target health workforce availability, distribution and working conditions, or wider system -level factors, including regulatory and financing aspects.

The selection of the appropriate system-wide and CRC-specific interventions should be tailored to the national and operational context in relation to its policy objectives and feasibility and affordability considerations. The identification of performance metrics and the collation and analysis of required data are necessary to monitor effectiveness of the interventions adopted.

Participation in primary health care through community-level health committees in Sub-Saharan Africa: a qualitative synthesis

Background

Health committees are key mechanisms for enabling participation of community members in decision-making on matters related to their health. This paper aims to establish an in-depth understanding of how community members participate in primary health care through health committees in sub-Saharan Africa (SSA).

Methods

We searched peer-reviewed English articles published between 2010 and 2019 in MEDLINE, Popline and CINAHL databases. Articles were eligible if they involved health committees in SSA. Our search yielded 279 articles and 7 duplicates were removed. We further excluded 255 articles following a review of titles and abstracts by two authors. Seventeen abstracts were eligible for full text review. After reviewing the full-text, we further excluded two articles that did not explicitly describe the role of health committees in community participation. We therefore included 15 articles in this review. Two authors extracted data on how health committees contributed to community participation in SSA using a conceptual framework for assessing community participation in health. We derived our themes from five process indicators in this framework, namely, leadership, management and planning, resource mobilization from external sources, monitoring and evaluation and women involvement.

Findings

We found that health committees work well in voicing communities’ concerns about the quality of care provided by health facility staff, day-to-day management of health facilities and mobilizing financial and non-financial resources for health activities and projects. Health committees held health workers accountable by monitoring absenteeism, quality of services and expenditures in health facilities. Health committees lacked legitimacy because selection procedures were often not transparent and participatory. Committee members were left out in planning and budgeting processes by health workers, who perceived them as insufficiently educated and trained to take part in planning. Most health committees were male-dominated, thus limiting participation by women.

Conclusion

Health committees contribute to community participation through holding primary health workers accountable, voicing their communities’ concern and mobilizing resources for health activities and projects. Decision makers, health managers and advocates need to fundamentally rethink how health committees are selected, empowered and supported to implement their roles and responsibilities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12730-y.

Assessing Facilitators and Barriers to Referral of Children Under the Age of Five Years at Ndirande Health Centre in Blantyre, Malawi

Patient referrals among health facilities are initiated to maximize receipt of quality care at a proper level within the health system. This study explored the processes, factors that influence, and strategies for referral of children from Ndirande Health Centre to Queen Elizabeth Central Hospital in Blantyre, Malawi. We drew a purposive sample comprising health care workers, mothers, fathers, ambulance drivers, and Health Center Advisory Committee (HCAC) members and held 19 in-depth interviews and 1 focus group discussion in August 2020. The referral process is influenced by the availability of motor and bicycle ambulances that are well equipped with medical equipment, delay in seeking health services, uptake of referral, and community support. Education and communication with the community and parents respectively optimize the process of referral. There is a need to improve the referral system of under-five children by instituting a policy that is functional while addressing the main barriers.