Social accountability for maternal health services in Muanda and Bolenge Health Zones, Democratic Republic of Congo: a situation analysis

The results’ section commences with a description of the respondents; thereafter research
results are presented on expectations, voice, oversight and perceived responsiveness.

Participants

In total, 48 interviews were conducted in the two selected areas, viz., 27 in Bolenge
HZ, and 21 in Muanda HZ. Table 2 shows an overview of the participants who were interviewed. Since the focus is on
maternal health, women in their reproductive period presented the largest group of
respondents (n?=?21). Their ages ranged from 17–39 years (median: 27 years). The median number of
children per woman was three offspring with ages ranging from two weeks to six years;
most of them were from Bantu tribes except in Bolenge where some Pygmies reside. Women
were mostly farmers, with a primary school education and lived with a partner. Four
women had experienced complications during their pregnancy, and one had miscarried
(Tables 3 and 4).

Table 2. Respondents’ categories

Table 3. Women characteristics (Muanda)

Table 4. Women’s characteristics (Bolenge)

Women’s concerns and complaints regarding health services

The term ‘voice’ comprises of five aspects in English: speaking up with respect to needs, expectations and concerns regarding healthcare facilities. It also comprises of complaints about healthcare services. In Lingala these different aspects of the word ‘voice’
are translated by the word posa, which literally means ‘concerns.’ In the text, the word ‘concern’ is used, and therefore,
also refers to expectations and needs. However, to what extent these are actually
voiced, in the sense of speaking out, will be reported in the section entitled ‘women’s
voice.’

As a matter of fact, the researchers dealt with women’s concerns and complaints regarding
maternal health services. At both sites, most women sounded positive about the health
care provided, they did not complain about it and were unsure on what to ask. Most
women perceived healthcare providers (HPs) as professionals who have the required
skills to cure/help them. They believed that they had less knowledge than HPs because
they considered themselves laypersons unable to judge how healthcare should be provided.
They were unsure on how to converse and make their concerns known to HPs, as portrayed
in the following quotation:

“When I have a problem related to my health or my pregnancy, I go to the HP and tell
him all I noticed and felt. He will provide me with healthcare. I don’t see another
way to proceed. I follow only what the nurse tells me to do. What he says is good
for my health. It is up to him to direct my healthcare process.”

(Woman, Bolenge)

Few women have raised concerns, and this holds true at both sites. Women expected
that the local health centre would be extended in the future, with additional rooms
for maternal healthcare even an operating theatre, that equipment such as laboratories
and ultrasound devices would be added, that medicines would be made more readily available
preferably free of charge, as well as an ambulance to transfer women to the referral
hospital. They wanted to have a physician as chief of staff at the health centre.
The above mentioned expectations were raised mainly by women who had attended health
facilities other than the local health centre, or who had heard about other facilities
from other persons’ experiences, or who had a history of recent pregnancy complications.

During the interviews, few women in both communities mentioned maternal health services
or HPs. Only one woman, belonging to???19 years group, mentioned poor treatment during
delivery. This is in contradiction with key informants who claimed to have heard about
many experiences involving inappropriate behaviour and poor treatment in health services
but acknowledged that women often did not report these.

Women’s voice

Regarding concerns or complaints about health services, women need to find ways to
communicate these to HPs. In this study, it appeared that women did not express their
concerns/complaints to HPs. None of the women interviewed reported having heard about
a woman bringing forward her concerns/complaints on her own.

However, it became obvious that when they had concerns/complaints about health services,
women often looked for support from their immediate family members especially their
husbands, their mothers, and their mothers-in-law. The majority of key informants
confirmed that hardly any woman would express concerns and complaints.

Reported reasons for women not to express concerns and complaints

The researchers explored the reason(s) why this occurred. Apart from the fact that
women believed that they were laypersons and therefore unable to judge how health
care should be provided, respondents mentioned fear of reprisals as the main reason.
Nine respondents from Bolenge and three from Muanda indicated that women also feared
that if they expressed their concerns to HPs, the attitude of the latter would change
and therefore they may risk poor treatment as illustrated by the following quote:

“Health providers are complicated, if you have a problem with them. They can get angry
and abuse you.”

(Woman, Muanda).

The majority of respondents at both sites mentioned that there was no formal system
in place at the local health centres, or a representative of the population who could
present complaints or concerns to HPs. Consequently, women failed to report because
they were uncertain on how to voice their concerns, without a risk of reprisal.

Secondly, several respondents from both sites mentioned that women consider themselves
as being unable to influence healthcare functioning or the behaviour of HPs, as highlighted
by a key informant:

“Often, women do nothing; they are disarmed….especially in front of health providers.”

(KI, Muanda)

Thirdly, some community members at both sites (n?=?3) stated that women feared that complaints or concerns would threaten the work
of HPs, and that they would be responsible for the “others’ loss of employment” as
stated below:

“When I have a complaint about a health care provider, I do not express it because
it is not good to put other people’s work at risk. It is his workplace, I cannot endanger
his job. Reporting an incident against a provider is considered as endangering his
work.”

(Mother-in-law, Muanda)

Other reasons mentioned were related to socio-cultural contexts based on age differences.
For example, one woman from Bolenge and one from Muanda responded that they were ashamed
to report incidents as they were younger than HPs.

Another woman stated that in most Congolese customs, a younger woman is not expected
to complain about an older person as highlighted in this quote:

“I feel deeply ashamed; I do not know how to go and complain to somebody [with laugh].
Health providers are older; I will not feel comfortable to speak to them about my
complaints or concerns.“

(Woman, Bolenge)

Three respondents from Bolenge and three from Muanda mentioned that it is not customary
for the population to complain, people preferring to wait until the decision maker
notices the incident:

“We do not tell her [the head nurse] anything, we don’t speak, we don’t complain,
we are just waiting. We do not know what to do; we are expecting that the authorities
themselves will find out.”

(Woman, Bolenge)

Something specific to Muanda: one woman explained that in Muanda, tribesmen prefer
not to engage a complaint or a concern in order to avoid trouble in the community.

Another explanation mentioned by three respondents in Muanda and in Bolenge is the
preference for the women to rather attend another health facility, using an exit strategy
as reported below:

“In case of inappropriate practices, it is preferable to go and follow the treatment
somewhere else. It can happen that a bad practice occurs once. If for the second time,
you come across the same situation, you can go to another healthcare facility.”

(Man, Muanda)

Possible ways to communicate and complain

Reported possibilities to channel concerns and complaints could be regrouped into
using; (a) intermediaries, (b) informal communication, and (c) formal structures.

(a) Using intermediaries

In our study, women answered that they could communicate individually through another
person other than the concerned HP. This person could be found within or outside the
health centre. For example, five women from Bolenge and eight from Muanda shared that
it was possible for them to communicate with; the nurse in charge of the health centre,
a Health Zone Officer or another health care provider who may report to the relevant
health provider. This depends mainly on the level of confidence the woman has in her
relationship with the person she has contacted:

“When a healthcare provider behaves inappropriately, we prefer to speak to another
health worker so that the latter can speak to his colleague. We avoid speaking ourselves
in order to avoid problem as the concerned HP could bear a grudge against us and that
would become a problem.”

(Woman, Muanda)

Respondents also mentioned that women could use a person outside the health facility;
this was often the community health worker (CHW). Eleven respondents from Bolenge
and seven from Muanda mentioned that women could report their concerns to CHWs. According
to the respondents, CHWs who live in the same community and are involved in health
activities within the community could be easily reached and were accessible to the
population. This is confirmed by a CHW:

“The information regarding women’s concerns often stands out when we as CHWs have
noticed for example that there is a woman who gave birth in another health facility
or at home. We visited her and we asked her why she went elsewhere when there was
a health centre there. It is through these visits that we are aware of health providers’
absence and a lack of expertise or equipment.

We present this to health providers during the Health committee’s meeting”

(KI, Muanda)

Women were said to expect that CHWs could have the courage to talk to HPs, because
they were working together. However, two women from Bolenge and one from Muanda expressed
doubts about the ability of a CHW to influence the behaviour or decisions of HPs.
They did not know what happened after their report to a CHW as reported in this quote:

“The last time, I told them [CHWs] what I had noticed in the centre. I reported to
them because they can have the courage to go to speak to health providers… However,
I do not know if they delivered my message.”

(Woman, Muanda)

Community leaders such as a local authority, a village chief, or an administrative
chief officer could also be approached. According to three respondents from Bolenge
and eight from Muanda, the community leaders could be approached because the women
believed that the former could influence the HPs and that their concerns were more
likely to be accepted by HPs than when brought by women.

Two community members from Bolenge stated that it could be possible for women to report
their concerns or complaints to external persons who could come and ask questions
or make surveys in the community for the purpose of collecting population concerns,
arguing that these persons could be effective in transmitting these concerns to decision
makers. It is interesting to point out that the respondents did not mention national
or regional members of parliament even though they have their roots at local level.

(b) Using informal communication

Although people do not complain individually to staff, culturally there are various
ways to communicate. For example, eight respondents in Bolenge and two in Muanda mentioned
that some women believed that by not approaching anyone to complain, they could express
their discontent loudly, through gossip and rustle or create rumours in the community
about HPs, hoping that it would reach them.

(c) Using formal structures

“Women like other members of this community always have a behaviour that consists
of shouting aloud their complaints about Health Centre on the road. You will see one
or two people speak aloud on the road when they disagree…these complaints are often
the origin of rumours in the community.”

(CHW, Bolenge).

According to HPs and some key informants, women could formally report through community
health workers to health committees. HPs reported that they used CHWs as means of
handling interaction between them and community members and for collecting information
from the community and households during home visits. They added that the collected
information is presented and discussed during monthly health committee’s meeting as
feedback from the community:

“For example, we learnt that a woman delivered at home through CHWs. As health providers,
we know all women who attend antenatal care at the Health Centre, when we realize
that a woman does not come any more, we send CHWs to get information about it. So,
CHWs came and collected the information regarding what happened and gave us the information.”

(Health Provider, Bolenge)

Two key informants confirmed that which is stated above and added that after the health
committee meeting, a report had to be sent to the health zone management team. However,
it is important to highlight that community members themselves did not talk about
a formal system and that they often talked about CHWs rather than health committees
suggesting that most women did not link CHWs to health committees.

Specific to Muanda where Cordaid PBF program was implemented, some key informants
(health zone chief officer, purchasing agent manager) mentioned that women could report
to members of the community-based organizations when the latter carried out household
surveys. According to these key informants, the PBF program included community evaluation
of the health centre by community- based organizations that were contracted to make
visits in randomly selected community households especially those who had attended
the local health centre, for collecting views or experiences about the use of this
health centre. The findings of their survey were sent to the health zone management
team through the purchasing agent. However, none of the women interviewed mentioned
community-based organizations and seemed unaware that there was a local organization
that visited community households to collect views or experiences about the use of
the local health centre. Furthermore, other key informants and most of the CHWs did
not mention having heard about such activities.

It is also worth highlighting that none of the community members interviewed at both
sites mentioned that community associations, organizations or coalitions could be
used by women to express their voice.

Respondents thought that although there were many associations in their community
such as local mutual aid associations, professional associations, nongovernmental
organizations, there were no organizations that monitored health centre activities,
or had healthcare goals or discussed healthcare issues during their meetings. Furthermore,
the women interviewed answered that they did not believe in speaking out in a group
or collectively because groups were often not heard by HPs and rulers or that collective
action was not appreciated.

“I prefer to go alone to express my concerns. I do not like speaking in a group, because
often the group is not well considered….the interlocutor is going to answer you without
taking to heart what he tells you. I prefer to express my concerns by myself to be
well understood.”

(Woman, Muanda)

Moreover, community members did not mention that they could either meet together as
a group to present their concerns about healthcare services to the health centre staff,
or organize collective actions such as demonstrations, public campaigns, or public
hearing meetings.

HPs reported that during health activities such as antenatal care and postnatal care
implemented in the health centre, women were given the opportunity to express their
concerns:

“During health visits, we allow them to ask questions or voice their concerns, just
after the health education session. If a woman has sensitive concerns, she can come
to the office, we can discuss them privately.”

(Nurse, Bolenge)

HPs mentioned something that was specific to Muanda: when home visits were carried
out following up on women who had attended a health centre, the latter were given
the opportunity to ask about concerns or complaints.

“During home visits I carried out, I ask them [women] questions about nurses’ behaviour
during ANC for example. Up to now, they have told us that they are satisfied.”

(Nurse, Muanda)

However, health zones chief officers recognized that there is no formal channel that
collects information related to the concerns/complaints by the population in the current
health information system. They also recognized that most reports from health committees
did not mention complaints by the population as well, making it difficult to assess
of the responsiveness of healthcare providers to the concerns/complaints of the population.
They added that they had never received complaints against healthcare providers via
any health committee reports and that not a single health centre offered opportunities
to discuss as a team any complaints or concerns by clients.

Existing community oversight systems

As mentioned above, community members answered that they were excluded in monitoring
and evaluating health services. However, according to key informants and HPs, the
community exerted oversight on health services through health committees. They reported
that during monthly health committee meetings, the nurse- in-charge should provide
information about health centre performance to the population through their representatives.
During these meetings, community health workers’ representatives should report the
information gathered from the community. However, most respondents mentioned that
within the health committee the health staff did not share information about health
centre performance, but simply shared their expectations from the community in terms
of targets and problems regarding health service activities, such as the underachievement
of targets regarding the number of antenatal care visits or home deliveries. The interviews
by key informants revealed that community health workers’ representatives or committee
members participating in these meetings did not deal with community concerns as they
did not formally collect them, therefore the health staff was not informed about them.
As a consequence, according to the respondents, women were mostly informed about health
centre performance or the behaviour of healthcare providers through interpersonal
communications rather than through formal systems.

“I have no information about the activities of the Health Committee.” (KI, Muanda)

“The last time we met, I told them [CHW] what I had found in the centre…However, I
do not know if they delivered my message.” (Woman, Muanda)

“Women of these villages, most of the time, do not take a particular action, but they
would prefer to go to different health facilities. You will see them taking another
direction…they will tell you that they intend to change because some facilities did
not exist in the former health centre.” (CHW, Muanda)

Another aspect specific to Muanda is the statement made by the manager of the Purchasing
Agency that the use of community- based organizations surveys is the community monitoring
of health centre performance under PBF settings. The findings of these surveys are
reported directly to the Purchasing Agency and not to healthcare providers. It is
the Purchasing Agency which presents a summary of the findings during health zone
monitoring meetings and provides feedback to health providers. The purchasing agent
manager argued that these surveys were aimed at reducing the fear of reprisals and
assured more transparency and confidentiality to the community monitoring process.
Nevertheless, HPs asserted that because CBOs did not report survey findings to them
and that reports were compiled collectively for all health centres belonging to a
health zone, they were unaware of grievances brought against them on the one hand.
On the other hand, they added that because no community representative participated
in health zone monitoring meetings, the community was unaware of either the survey
findings of the CBOs or of any decisions made to address them.

Community enforceability mechanisms

While people do not complain as individuals to staff, culturally there are various
ways to acknowledge and communicate good performance and this is mainly done as individuals
according to the respondents. For instance, to reward good performance, women thanked
health staff, and gave them small gifts or small amounts of money, or even reported
positively about HPs. This is embedded in local customs. Women highlighted that it
was not compulsory but optional. It is a means for the population to acknowledge what
health staff have done for them.

“The encouragement is often offered individually. For example, when you are satisfied
with the service provided, you can willingly reward the health worker with sugar or
milk.”

(Woman, Bolenge)

Three community members from Muanda believed that to encourage HPs, women had to continue
attending the health centre or to motivate their acquaintances through their testimonies
regarding the use of the local health centre instead of going to another health facility.
They expected that it would help HPs improve their skills and their income through
users’ fees.

Some respondents mentioned that they could report to their acquaintances or members
of their social networks, expecting to induce a specific HPs’ behaviour indirectly.
For example, five respondents from Muanda and three from Bolenge thought that to discourage
improper practices, they should give negative comments about the health centre services
to their acquaintances, motivating them to go to another health facility, thus reducing
health service intake and affecting either the reputation, the financial turnover
or the motivation of HPs.

“Women in these villages, most of the time, do not take a particular action, but they
would go to a different health facility. You would meet them on the road taking another
direction…they would tell you that they were going to a different health facility
because of the shortcoming or inadequacies of the health centre.”

(KI, Muanda)

On the other hand, this could also work positively: two respondents, a woman and a
man, from Muanda mentioned that they could mention to their acquaintances the performance
at the health centre, showing the good performance of the health staff. This could
reach HPs indirectly. They argued that it was a way of encouraging health staff and
attracting more users, thereby increasing a health centre’s financial resources and
personnel incentives through users’ fees:

“To encourage them [Healthcare providers], we advertise about their HC. We mentioned
their good deeds and give a good report. Good testimonies incite the health staff
to work better and maintain an acceptable level of service.”

(Woman, Muanda)

Respondents also mentioned that they could discourage malpractices, by thanking or
rewarding HPs who performed well in the presence of those who were not aiming to trigger
change in the latter. Alternatively, they could do the opposite of what they did to
encourage appropriate behaviour or treatment by HPs. However, none of the respondents
claimed to have visited traditional healers or traditional birth attendants for reproductive
health issues as a consequence of the lack of trust or responsiveness in the health
services.

Health providers’ responsiveness according to the community

Interviews showed that most women and key informants believed that health staff members
were responsive to women’s concerns when they talked of their health problems, by
supporting their opinions by the perceived attention they received from HPs during
health centre visits. They also based their views on the perceived change in the service
or HPs’ attitude:

“When you expressed your concerns, you would find that the staff improved in the next
session. For example, a [male] nurse replaced for a time the lady who usually performed
Antenatal care. But he was very nervous. I expressed my concerns to the head nurse.
The latter talked with him; he changed and became less nervous with clients.”

(Woman, Muanda)

Three respondents from Bolenge and two from Muanda thought that even though there
was no change in the provision of health service, the health staff were responsive
because they took the time to explain to users why there had been no change or showed
a receptive disposition:

“Health care providers take into account women’s concerns, because they speak about
it even if we have not seen clear decisions yet.”

(Mother-in-law, Bolenge)

One community member from Bolenge and two from Muanda stated that HPs were not responsive
to patients’ concerns as no change was perceived after receiving those concerns. Moreover,
they were likely to get angry and scold the complainant.