Strengthening accountability for improved maternal and newborn health: A mapping of studies in Sub-Saharan Africa.

OBJECTIVE: To describe the types of maternal and newborn health program accountability mechanisms implemented and evaluated in recent years in Sub-Saharan Africa, how these have been implemented, their effectiveness, and future prospects to improve governance and MNH outcomes. METHOD: A structured review selected 38 peer-reviewed papers between 2006 and 2016 in Sub-Saharan Africa to include in the analysis. RESULTS: Performance accountability in MNH through maternal and perinatal death surveillance was the most common accountability mechanism used. Political and democratic accountability through advocacy, human rights, and global tracking of progress on indicators achieved greatest results when multiple stakeholders were involved. Financial accountability can be effective but depend on external support. Overall, this review shows that accountability is more effective when clear expectations are backed by social and political advocacy and multistakeholder engagement, and supported by incentives for positive action. CONCLUSION: There are few accountability mechanisms in MNH in Sub-Saharan Africa between decision-makers and those affected by those decisions with both the power and the will to enforce answerability. Increasing accountability depends not only on how mechanisms are enforced but also, on how providers and managers understand accountability.

Maternal Death Surveillance and Response Systems in driving accountability and influencing change.

Good progress has been made in reducing maternal deaths from 1990-2015 but accelerated progress is needed to achieve the Sustainable Development Goals (SDGs) in ending preventable maternal deaths through a renewed focus on accountability and actions. This paper looks at how Maternal Death Surveillance and Response (MDSR) systems are strengthening response and accountability for better health outcomes by analyzing key findings from the WHO and UNFPA Global MDSR Implementation Survey across 62 countries. It examines two concrete examples from Nigeria and Ethiopia to demonstrate how findings can influence systematic changes in policy and practice. We found that a majority of countries have policies in place for maternal death notification and review, yet a gap remains when examining the steps beyond this, including reviewing and reporting at an aggregate level, disseminating findings and recommendations, and involving civil society and communities. As more countries move toward MDSR systems, it is important to continue monitoring the opportunities and barriers to full implementation, through quantitative means such as the Global MDSR Implementation Survey to assess country progress, but also through more qualitative approaches, such as case studies, to understand how countries respond to MDSR findings.

Using advocacy and data to strengthen political accountability in maternal and newborn health in Africa.

Accountability mechanisms help governments and development partners fulfill the promises and commitments they make to global initiatives such as the Millennium Development Goals and the Global Strategy on Women's and Children's health, and regional or national strategies such as the Campaign for the Accelerated Reduction in Maternal Mortality in Africa (CARMMA). But without directed pressure, comparative data and tools to provide insight into successes, failures, and overall results, accountability fails. The analysis of accountability mechanisms in five countries supported by the Evidence for Action program shows that accountability is most effective when it is connected across global and national levels; civil society has a central and independent role; proactive, immediate and targeted implementation mechanisms are funded from the start; advocacy for accountability is combined with local outreach activities such as blood drives; local and national champions (Presidents, First Ladies, Ministers) help draw public attention to government performance; scorecards are developed to provide insight into performance and highlight necessary improvements; and politicians at subnational level are supported by national leaders to effect change. Under the Sustainable Development Goals, accountability and advocacy supported by global and regional intergovernmental organizations, constantly monitored and with commensurate retribution for nonperformance will remain essential.

Accountability for quality of care: Monitoring all aspects of quality across a framework adapted for action.

Quality of care is essential to maternal and newborn survival. The multidimensional nature of quality of care means that frameworks are useful for capturing it. The present paper proposes an adaptation to a widely used quality of care framework for maternity services. The framework subdivides quality into two inter-related dimensions-provision and experience of care-but suggests adaptations to reflect changes in the concept of quality over the past 15years. The application of the updated framework is presented in a case study, which uses it to measure and inform quality improvements in northern Nigeria across the reproductive, maternal, newborn, and child health continuum of care. Data from 231 sampled basic and comprehensive emergency obstetric and newborn care (BEmONC and CEmONC) facilities in six northern Nigerian states showed that only 35%-47% of facilities met minimum quality standards in infrastructure. Standards for human resources performed better with 49%-73% reaching minimum standards. A framework like this could form the basis for a certification scheme. Certification offers a practical and concrete opportunity to drive quality standards up and reward good performance. It also offers a mechanism to strengthen accountability.

Establishing a baseline to measure change in political will and the use of data for decision-making in maternal and newborn health in six African countries.

The Evidence for Action (E4A) program assumes that both resource allocation and quality of care can improve via a strategy that combines evidence and advocacy to stimulate accountability. The present paper explains the methods used to collect baseline monitoring data using two tools developed to inform program design in six focus countries. The first tool is designed to understand the extent to which decision-makers have access to the data they need, when they need it, and in meaningful formats, and then to use the data to prioritize, plan, and allocate resources. The second tool seeks the views of people working in the area of maternal and newborn health (MNH) about political will, including: quality of care, the political and financial priority accorded to MNH, and the extent to which MNH decision-makers are accountable to service users. Findings indicate significant potential to improve access to and use of data for decision-making, particularly at subnational levels. Respondents across all six program countries reported lack of access by ordinary citizens to information on the health and MNH budget, and data on MNH outcomes. In all six countries there was a perceived inequity in the distribution of resources and a perception that politicians do not fully understand the priorities of their constituents.

Using evidence to drive action: a "revolution in accountability" to implement quality care for better maternal and newborn health in Africa.

Introducing evidence-based accountability mechanisms at national and subnational levels into maternal newborn health programs can accelerate reductions in maternal and newborn mortality. Clearly packaged evidence has the potential to catalyze change, if it is communicated not only to the public but also to key policymakers. Evidence for Action (E4A) is a DFID-funded program that contributes to global efforts toward improving accountability in maternal and neonatal health. It uses evidence to drive action and accountability to improve maternal and newborn survival in six African countries: Ethiopia, Ghana, Malawi, Nigeria, Sierra Leone, and Tanzania. This paper introduces the E4A program, the rationale that underpins the program design, and presents initial findings on how information and data currently feed into accountability and implementation across the six E4A countries.

Applying a framework for assessing the quality of maternal health services in urban India.

This paper presents findings from the application of a framework for assessing the quality of care of institutional maternity services in an urban slum in India. The framework divides quality into two parts: the quality of users' experience of care and the quality of the provision of care. Data from public and private hospitals were collected via observation, exit interviews, provider interviews, review of hospital records, the mystery client approach and a household survey of 650 women in the immediate vicinity of the case study hospitals. Findings provide evidence that quality is far from optimal in both public and private facilities. Problems identified included a lack of essential drugs, women being left unsupported, evidence of physical and verbal abuse, and births occurring in hospitals without a health professional in attendance. The paper concludes that while many governments have explicit targets to increase institutional deliveries, many do not have explicit targets or even a commitment to assess and improve the quality of institutional services for childbirth.