Abstract
Background: Social accountability or citizen-led accountability has been promoted in many low- and middle-income
countries to improve the quality, access to and use of maternal health services. Experiences with social accountability
in maternal health services in Nepal have not yet been documented. This study identifies existing social accountability
structures and activities in maternal health services in two districts of Far-Western Nepal and explores their functions,
implementation and gaps/challenges.
Methods: An exploratory study was conducted that included in-depth interviews with purposively selected policy advisors
(8), healthcare officials (11), healthcare providers (12) and non-governmental staff (3); and focus group discussions
(FGDs) with 54 women. Data analysis was conducted using thematic content analysis based on George’s information,
dialogue and negotiation framework.
Results: Social accountability in maternal health existed in terms of structures such as mothers’ groups (MGs), female
community health volunteers (FCHVs) and Health Facility Operation and Management Committees (HFOMCs); and
activities such as social audits and community health score board (CHSB). MGs and FCHVs were perceived as trusted
intermediaries, but their functioning was limited to information. HFOMCs were not fully functional. Social audits and
CHSBs were implemented in limited sites and with poor participation by women. Health-sector responses were mainly
found at the local level. Factors contributing to these challenges were the absence of a mandate and limited capacity,
including resources.
Conclusion: Formal structures and activities existed for social accountability in maternal health services in the Far-Western
Development Region of Nepal, but there were limitations pertaining to their implementation. The main recommendations
are: for clear policy mandates on the social accountability roles of MGs and FCHVs; wider implementation of social audits
and CHSBs, with emphasis on the participation of women from disadvantaged groups; improved capacity of HFOMCs;
and improved engagement of the health sector at all levels to listen and respond to women’s concerns.