Improving maternal health services performance
and responsiveness through social accountability
mechanisms in DRC :
implementing participatory action research with a
realist perspective
Therese Mambu, Eric Mafuta (KSPH)
Patrick Kayembe (KSPH)
Tjard de Cock Buning (VU)
Marjolein Dieleman (KIT)
Introduction

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.
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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.
Introduction

Citizen engagement is particularly important in fragile states,
because of weak government systems.
Research 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 objectives
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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 objectives
b) Development relevance
 1. Facilitate the development of evidence-informed policymaking 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
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Research 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;
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2. Share experiences through South-South and North–South
learning among researchers and relevant stakeholders;
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3. Communicate evidence for SAMs in maternal healthcare
to the international research community.
Assumption
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 framework
In-country research program

The research is action-oriented and uses a transdisciplinary
approach, involving different types of actors. It covers a 5years period and is organised as follows:
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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
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2. In-depth study (12 months): Situational analysis of existing
political accountability mechanisms for maternal health
services
In-country research program
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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
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4a. Implementation and assessment of the intervention (24
months): Implementation, monitoring and evaluation of
interventions
Related 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
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Approach
Dialogue with wide group of stakeholders
1.
Partnership with 2 NGOs in Burundi and in DR Congo:
◦ Researchers- baseline
◦ Joint discussion:
 Expectations of current interventions = program theory
 Include learning-action cycles
2.
Implementation and research and document:
What works for who and under which circumstances
 Joint organization of policy dialogues
 Joint article writing
3.
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Implementation ILA
Action-learning cycles:
Base line resultsStart constructive dialogue
And adapt social accountability
Experience, discuss and
Explain results in context
Use results to adapt again
the intervention
Achievement 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.
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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 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
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Achievements 3
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Research partners selection and inceptive workshops
(Bujumbura I)
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Discussion on maternal mortality issues and accountability
concepts;
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Planning of context and baseline studies
Achievement 4
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Context study : Is the context supportive
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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 .
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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 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;
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Methods: In-depth interviews of key informants and
documentary reviews
Achievement 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;
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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 4
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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
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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
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Achievement 4
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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.
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Achievement 5
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Baseline study : local existing social accountability
mechanisms
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Methods : in depth interviews of key informants, community
members (women, men, mother-in law) and health providers
Achievement 5
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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 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
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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 5
Conclusion:
 Relative inexistence of social accountability mechanisms
in local level
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Achievement 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 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
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Next 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 challenges
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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?
Thanks