Table 5 Key findings of the social accountability interventions, its process and outcomes

i. Social Audit: The GoN initiated a social audit in 2009 to ensure the quality implementation of “Aama programme”^a. The intervention aimed to increase women’s and community awareness, promote transparency in the decision process of health facility, make the health workers and decision-makers accountable and responsive for quality maternal health services, set a culture of demand for information from the health facility as well as strengthen mutual accountability between service providers and users [20, 21].

The programme is implemented through the local non-government organizations (NGOs) which are identified through a competitive process [20, 22]. The NGOs facilitate the process of social audit where community and local stakeholders are invited to review the performance, identify existing problems and challenges of the health facility as well as develop an action plan for improving quality of services. The process takes 5-6 days to complete in one health facility in the initial stage. However, time implication is less in the follow-up programme [22].

An evaluation study [22] undertaken in health facilities of four districts of Nepal, namely Palpa, Rupandehi, Jhapa and Ilam, found that social audit resulted in the overall improvement in the health service providers’ behaviour, attitude and regularity. Clients and patients received more equitable and dignified treatment. Similarly, antenatal care (ANC) and institutional delivery incentives were timely provided to the beneficiaries. The intervention also improved the dialogue between the community, health service providers and health facility committee. Community concerns were incorporated in the health facility action plan.

ii. MPDSR: The GoN initiated the programme in 1990 at the tertiary level hospital with the support of WHO. Since then it has been scaling up at different levels of care at different phases with improvisation from the learnings of the programmes [23]. It is a supply-side intervention initiated to improve quality of maternal health services which is focused on routine identification and notification of maternal and perinatal deaths, determinants of death causes and use of the information to improve quality of care to avoid future deaths [23].

The MPDSR committee is formed at district, hospital and local health facility level. At the local level committee, there is a separate verbal autopsy and cause of death assignment team [23]. The community-based intervention has been implemented in 6 districts whereas facility-based intervention has been expanded in 65 hospitals in 38 districts [2].

No study could be found on the impact of MPDSR on maternal health in Nepal. Hence, the evidence from another similar context is presented. A study in Bangladesh reported that the MDR helped to recognize the causes of maternal deaths in the community and brought the attention of decision-makers to respond and address the issues appropriately. Further, it is observed to result in deploying competent human resource such as medical officer, SBA at birthing centres to manage complications, and ensuring an adequate supply of necessary equipment which ultimately improved the QoC and provider-user satisfaction and finally in the increased uptake of maternal health services and decreased maternal mortality in Bangladesh [24].

A similar finding was reported in Nigeria where MDR played an influential role in improving health service providers’ and policymakers’ responsiveness toward addressing causes of maternal deaths [25].

iii. CSC/CHSB: CSC is a tool designed to promote participation, transparency, and accountability among service providers, service users and decision-makers. The tool provides an opportunity for the community to evaluate the quality of services, express their dissatisfaction and voice health rights [26, 27]. The CHSB is an adopted form of CSC. It creates an environment for tripartite dialogue among service providers, beneficiaries and decision-makers which facilitates monitoring and performance of maternal neonatal and child health (MNCH) services [28, 29].

CSC is a process-oriented tool, where community people along with service providers and stakeholders monitor and evaluate health service against agreed indicators. With the indicators, quality of services, health facility performance, and health governance are monitored using the defined scale or score. At the end of the process, community along with service providers develop an action plan and prioritize the activities based on the given score for further improvement [27]. In the CHSB intervention, as in CSC, community people, service providers, and decision-makers jointly discuss the MNCH issues and then provide mutually agreed scores on the performance indicators and develop action plans for further improvement. The action plans are reviewed semi-annually following the same process. It creates a space for providing immediate feedback to service providers and decision-makers and accordingly responses toward raised concerns [21, 28].

The CSC is found effective for promoting direct feedback mechanism and efficient use of resources at a health facility in Nepal [26]. No study found impact of CSC on maternal health in Nepal. The same is observed regarding the impact of CHSB in Nepal. The CHSB is adopted in Nepal after a successful trial in Malawi where the intervention is found to increase interaction between the health service providers, members of the health committee and community; this improved accountability of health worker as well as the quality of antenatal and postnatal care services. Women were treated better at health facilities and the service utilization trend increased. However, the tool has no significant impact on the indicators which needed the attention of higher-level government authorities [30].

iv. Citizen Charter: Citizen Charter is an information board displayed at all public service centres. Since 2007, GoN has made it mandatory to have charters installed at clearly visible areas within the public office/facilities [27, 31].

Citizen charter includes the information about the availability of services with cost, essential requirements to access services, name of the contact person, time required and name of the person to redress the grievances if any [21, 27].

A study mapping awareness and factors influencing the implementation of citizen charter in health facility concluded that it promotes the transparency of health facility and accountability of health workers towards service users if well implemented [32]. A similar conclusion was drawn by a study conducted in Kenya [33].

v. Grievance/Complaint handling tool: The grievance/complaint handling intervention refers to the provision that allows citizens to file complaint against services and system that hear and address the complaint/grievances [27]. The compliant boxes are major complaint grievance/Complaint handling tool in health system. In some locations, the government has established the digital tool [21].

In the health facility, suggestion or complaint box is a widely used tool for handling the grievances and complaints [21]. The box is placed in the premises of health facilities to receive the complaints and/or grievances from service users, communities as well as other stakeholders about the health services they receive.

No evidence found on the outcome of the grievance/complaint handling tool in improving the responsiveness of the health system.

i. HFOMC: The HFOMC is a local level oversight mechanism in the health system which is responsible for the overall management of a local health facility. The committee is chaired by an elected representative: ward chairperson. Other members include: headteacher of local school, a representative from the local business association, FCHV, ward secretary and a woman nominated by the chairperson. Health facility in-charge acts as a member secretary of the committee [34]

The HFOMC meet once in a month to discuss the health facility operational and management issues. The issues are prioritized, and action plans are made to address the issues. Besides that, HFOMC also involves in dialogue and negotiation in other social accountability interventions, as they are supposed to conduct a social audit in their respective health facility every year. In the other interventions, they are responsible to answer raised concerns and issues [21, 34].

One study [35] reported improved quality of services of birthing centres marked by the availability of 24-hour services, availability of SBA at health facility, improved infection prevention practices and management of labour and delivery in rural health facilities in the areas where HFOMC was actively engaged [35].

ii. FCHVs: FCHVs are self-motivated women aged between 25-45 years preferably married, literate and from a disadvantaged group willing to serve the community. They are trained health volunteers responsible to provide promotional maternal and child health services in their community. Some of the FCHVs are also members of HFOMC [29, 36, 37]. Currently, 51,470 FCHVs (47,328 in rural and 4,142 in urban areas) are working across the country [2].

The FCHVs liaison the Mothers’ group and HFOMC in the community level [38]. Moreover, they play an important role in the initial reporting system in community-based MPDSR and voice mechanism of the marginalized and disadvantaged women in the social accountability interventions [2, 21]. Being an important stakeholder of the community, they also monitor and evaluate the performance and quality of health services [36].

No study was found analysing the contribution of FCHV in the health system responsiveness for the quality maternal health services. However, their contribution in the reduction of maternal and child mortality through community-based interventions has been greatly recognized in Nepal [39].

iii. Mothers’ group for Health: Mother’s group for health refers to the group of married women belonging to reproductive age (15-49 years) [36].

Every month, the group members meet to discuss various MCH issues and best practices. Similarly, they are responsible to establish and maintain an emergency fund for obstetric services for their fellow group members [36]. They also monitor and evaluate the performances of FCHVs on regular basis and make them accountable towards their roles and responsibilities [21, 36].

A randomized controlled trial (RCT) conducted in a rural Nepal showed that MMR decreased by 80% [adjusted odds ratio (0.22, 95% CI 0.05-0.90)] in the women’s group where community participation project with social accountability interventions was implemented [40]. In the trial groups, the uptake of maternal health services improved and infection prevention practice increased two-fold among the birth attendees [40].

Meanwhile, subgroup analysis of RCTs of the same intervention in four countries, Bangladesh, India, Nepal, and Malawi concluded that at minimum 30% of women participation in the accountability intervention reduced almost half (49%) of the maternal mortality [odd ratio 0.51, 95% CI 0.29-0.89] [41].

iv. Civil Society Organizations: The Civil Society Organizations (CSO) refer to the national, local NGOs, international non-governmental organizations (INGOs) and working in the maternal health sector in Nepal [21, 42].

The national NGOs are acting as an oversight mechanism in the health system. They are responsible to facilitate the social audit, CSC/CHSB and community engagement in social accountability interventions. While the INGOs are responsible to provide policy support to the government in the health system strengthening interventions [2, 21].

The CSOs have been recognised for their contribution in health system strengthening and improving maternal and child health outcome through their advocacy role and policy development support to the government [39]. However, no study found exploring the contribution of CSO in the health responsiveness for the quality maternal health services in Nepal and other LMICs.