Social accountability for maternal health services in Muanda and Bolenge Health Zones, Democratic Republic of Congo: a situation analysis

Background

The Democratic Republic of the Congo is one of the countries in Sub-Saharan Africa with the highest maternal mortality ratio estimated at 846 deaths per 100,000 live births. Innovative strategies such as social accountability are needed to improve both health service delivery and utilization. Indeed, social accountability is a form of citizen engagement defined as the ‘extent and capability of citizens to hold politicians, policy makers and providers accountable and make them responsive to their needs.’ This study explores existing social accountability mechanisms through which women’s concerns are expressed and responded to by health providers in local settings.

Methods

An exploratory study was conducted in two health zones with purposively sampled respondents including twenty-five women, five men, five health providers, two health zone officers and eleven community stakeholders. Data on women’s voice and oversight and health providers’ responsiveness were collected using semi-structured interviews and analysed using thematic analysis.

Results

In the two health zones, women rarely voiced their concerns and expectations about health services. This reluctance was due to: the absence of procedures to express them, to the lack of knowledge thereof, fear of reprisals, of being misunderstood as well as factors such as age-related power, ethnicity backgrounds, and women’s status.

The means most often mentioned by women for expressing their concerns were as individuals rather than as a collective. They did not use them instead; instead they looked to intermediaries, mostly, trusted health providers, community health workers and local leaders. Their perceptions of health providers’ responsiveness varied. For women, there were no mechanisms for oversight in place. Individual discontent with malpractice was not shown to health providers. In contrast, health providers mentioned community health workers, health committee, and community based organizations as formal oversight mechanisms. All respondents recognized the lack of coalition around maternal health despite the many local associations and groups.

Conclusions

Social accountability is relatively inexistent in the maternal health services in the two health zones. For social accountability to be promoted, efforts need to be made to create its mechanisms and to open the local context settings to dialogue, which appears structurally absent.

Maternal mortality remains a major health issue in developing countries such as the Democratic Republic of the Congo (DRC) [1]. A recent survey estimated the maternal mortality ratio at 846 deaths per 100,000 live births [2], indicating that the DRC has not reached the MDG 5’s target[2], [3]. Interventions to reduce maternal morbidity and mortality emphasize the health service utilization through facility-based childbirth and skilled attendance at birth with timely referral for emergency obstetric care if complications occur [4], [5].

Skilled providers, appropriate equipment and services are important but there is no guarantee for responsive services. Service quality as perceived by its patients can improve the health service utilization by changing the behaviour of healthcare providers towards their patients and by improving their responsiveness to needs and expectations of patients [6]–[9]. One way of assessing and improving the behaviour of providers towards patients is through the use of social accountability mechanisms [10], [11].

Social accountability is defined as, ‘accountability that relies on civic engagement, i.e. in which citizens and/or civil society organizations participate directly or indirectly in exerting accountability’ [12] and holding politicians, policy makers and service providers responsible for their performance [13]–[15]. Functioning social accountability mechanisms should result in responsive services, defined as changes made to the service on the basis of ideas or concerns raised by users [16], [17]. Responsiveness also corresponds to the capacity of the service to limit abusive behaviour or inappropriate treatment by providers as well as to mitigate the fears and the shame which are associated with problems [13]. In the health sector, a responsive health service favours health by impacting the choice of persons and encouraging the use of health care by the population [18]. It is argued that, under certain conditions, social accountability mechanisms can trigger the responsiveness of health service providers and policymakers. Increased responsiveness is ultimately expected to result in a stronger health, such as an increase in user satisfaction or service utilization, or a decrease in the prevalence of disease, in our case maternal mortality.

Some examples of successful community participation projects with accountability mechanisms come from rural Nepal and rural Cambodia, where respectively Manandhar et al. (2004) and Skinner and Rathavy (2009) showed that when the citizens, are empowered to express their views and discuss the quality of health facility performance, when their views are taken into account in the decision making process, that could contribute to change, i.e. maternal health services could be adapted to their needs and might contribute better to the reduction of maternal mortality [19], [20]. In Nepal, for example, at the end of the project, the maternal mortality ratio was about 80 % lower within the intervention areas compared to the controls clusters [19]. Involving citizens could be an important strategy to improve the relationship between providers and clients particularly in fragile states, which are characterized by weak government systems and poor health indicators [16]. To date, we have not identified studies exploring social accountability for maternal health services performance and responsiveness in the DRC.

This paper presents some of the perceived realities of the current situation regarding social accountability in maternal health services in one health zone in the province of Bas-Congo and one health zone in the province of Equateur in the DRC.

Research question and conceptual framework

We aimed at answering the following question: What mechanisms and experiences exist regarding social accountability in maternal health services in Bas-Congo and Equateur?

In order to answer this question, we implemented an exploratory study in two Health Zones using the conceptual framework of social accountability proposed by Lodenstein et al. [21], refer to Fig. 1. This model distinguishes three elements in a social accountability mechanism:

1. Citizen engagement, includes individual participation and voice or collective expression of one’s expectations and concerns without formal ways of enforcement;

2. Citizen oversight, which includes involving citizens in collective monitoring and evaluation of health services and the performance of health service providers, sanctioning when the poor performance occurs and rewarding when the performance is perceived as of quality;

3. Both might result in a higher degree of responsive health services, thus contributing to improve health.

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