Social accountability in maternal health services in selected districts of Nepal and Gujarat, India

Mukesh Hamal

Research output: ThesisDoctoral dissertation - Doctoral dissertation


The overall research question of the study was: How does social accountability contribute to maternal health outcomes in selected districts of India and Nepal? The sub-questions that contribute to answering the overall research question were: 1.What are the factors that influence maternal health outcomes, and how are they related to each other and to the accountability of the health sector? 2.Which social accountability mechanisms exist for maternal health in the study sites and how do they function? 3.What influence do the existing social accountability mechanisms in the study sites have on the factors of maternal health and its outcomes? The study took a multidisciplinary and system approach, which means the maternal health inequities are assumed to be the result of the simultaneous and complex interactions of multiple actors in the health sector. The exploration of the detailed interactions led to an emerging research design through an iterative process, which started with understanding accountability and social accountability in maternal health services through literature reviews. This phase guided the successive empirical research Phase 2 in terms of providing a framework for data collection and analysis.
Phase 1. The overall research process started with two literature reviews to construct an integrated, multidisciplinary, conceptual model containing a list of relevant factors leading to maternal health inequities. The first review was a scoping review (Chapter 4). It was conducted to identify the factors influencing maternal health inequities in India and explain their influence. We constructed a “Social Determinants of Maternal Health Framework” by integrating several existing frameworks to explore factors specific to maternal health inequities. This review revealed the relevance of social accountability mechanisms in addressing maternal health inequities in India, and it confirmed that in India power asymmetry between different social groups is a crucial factor producing the inequities in India. The second review was also a scoping review (Chapter 5). This one was conducted to trace empirical data showing contextual causal relations in India, for example how accountability problems in the health sector influenced maternal health inequities. For this review we employed a narrative and interpretative synthesis approach to analyze: i. factors influencing maternal health outcomes in India using the 1994 Thaddeus and Maine’s “three-delay model”. This analysis provided a narrative account of causes of the maternal health service use and maternal deaths in India. It particularly highlighted the influence of health sector performance. ii. how accountability problems in the Indian public health sector influenced maternal health outcomes using the “Framework to Analyze Issues of Accountability” that we developed linking existing frameworks on health sector accountability and maternal health. The two scoping reviews guided the empirical research process.
Phase 2. This step consisted of an empirical component using a case study approach. Through primary data collection in two districts in India and three districts in Nepal, we explored the functioning of social accountability mechanisms for maternal health and their perceived influence on maternal health outcomes. The frameworks in Phase 1, the Social Determinants of Maternal Health and the functional aspects of accountability in particular (i.e. answerability and enforceability), and the elements of social accountability from George (information, dialogue and negotiation) were used for the data analysis.
Case study approach This was used mainly to explore how the complex multi-stakeholder constellation structures the social accountability functions in maternal health services. It enabled exploration of complex phenomena within their contexts. India and Nepal are democratic countries in South Asia, which have constitutionally and in health policies and programs recognized health, including maternal health, as a fundamental human right and the responsibility of the government. Both countries promote community participation in the planning and monitoring of health activities of the public sector as a crucial part of governance of the health sector. Instances from the literature show that India has a relatively strong civil society engagement in making the public sector accountable for health services, including maternal health services, while institutional social accountability activities seem to be limited in Nepal and in the health sector, i.e. only a few activities were in place in the rural areas such as social audits and citizen charters. On the other hand, institutional social accountability activities were strongly promoted by the World Bank from 2010 to 2013. Districts were the unit of analysis within the state/country in both cases, which formed embedded units within the cases. Two districts – Dahod and Panchmahal – were selected in Gujarat and three districts – Doti, Kailali and Baglung – in Nepal. The districts were deliberately selected in consultation with civil society organizations (CSOs) or a public health institution that worked in the districts and facilitated the study. All of the selected districts have a high proportion of a poor, rural and illiterate population. The two districts in Gujarat and two districts in Nepal (Doti and Kailali) were considered a single cluster for analysis in each state/country as they are adjoining districts with similar socioeconomic and maternal health status.
Overall conclusion There were formal social accountability mechanisms for maternal health in the study sites both in the government and civil society in terms of structures and activities, except in Baglung (Nepal) where no CSO-led activities were reported. They basically created awareness about maternal health, services and entitlements among women and community members, generated information about health-sector performance, enabled or facilitated women to have dialogue and negotiation with the health sector, and fostered institutional enforcement mechanisms or created incentives for the health sector to respond, thus creating health-sector responsiveness mainly in terms of changes in healthcare professionals’ attitudes and behavior and provision of care. In Gujarat, the social accountability mechanisms were perceived to potentially influence changes in structural and intermediary factors of maternal health ultimately improving the availability, access and use of maternal health services. However, social accountability mechanisms did not function to their full potential and the government structures were particularly constrained due to the lack of clear mandates, capacity and power to conduct the social accountability functions. CSOs played a crucial role in the social accountability processes by facilitating dialogue and negotiations between women and the health-sector actors and enhancing political capabilities of disadvantaged women. Our study suggests that social accountability mechanisms can potentially address inequities in maternal health by making health sector responsive to the needs, particularly of the disadvantaged groups, and ultimately improving the availability, access and use of maternal health services by these groups. This is achieved through the empowerment of the disadvantaged groups by addressing power asymmetries between them and the health sector and enhancing the groups’ engagement in the accountability of the health sector. We argue that the mechanisms can have the best results when they employ a constructive, systemic or multi-level and multi-pronged approach and enhance the collective political capabilities of disadvantaged groups. Further, when social accountability mechanisms exist, it is crucial that women, especially disadvantaged women, are aware of them, that they are represented or actively participate in platforms to voice their concerns, and that the health sector is able and willing to respond to these concerns appropriately.
Translated title of the contributionSociale verantwoordelijkheid in gezondheidszorg moeders in Nepal en Gujarat
Original languageEnglish
QualificationDoctor of Philosophy
Awarding Institution
  • Faculty of Earth and Life Sciences, VU Amsterdam
  • De Brouwere, Vincent, Supervisor
  • de Cock Buning, Tjard, Supervisor, External person
  • Dieleman, Marjolein, Supervisor, External person
  • Bardají, Azucena, Supervisor, External person
Award date10-Dec-2018
Place of PublicationAmsterdam
Publication statusPublished - 2018


  • B680-public-health


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