202 research outputs found
Social capital and the political economy of recovery from injury
No full textPublished: 2017-10-25Injury has long been recognized as a contributor to disability, but there is little data on how processes related to social capital, may influence the emergence of disability. This article aims to present findings from the qualitative arm of a multi-method Prospective Outcomes of Injury Study (POIS), which was established to examine factors influencing recovery following injury in New Zealand. A maximum diversity sample of nineteen injured people, aged 18-64, was chosen from 2856 participants in the quantitative POIS study (Butler, Derrett & Colhoun, 2009). Participants in the study were all on the New Zealand Accident Compensation Corporation's (ACC's) injury entitlement register. Interviews were carried out at six and twelve months after injury, which offered a unique insight into the unfolding impact of the injury on social networks. The findings describe a political economy of social capital that reflects the inverse care law (Hart, 1971). This can be summarised by the observation that those with higher levels of social capital were able to ask for care in ways that maintained the invisibility of the labour involved and also contributed to the growth of social capital. Those with lesser degrees of social capital used strategies to make their needs less visible in order not to lose face and this contributed to the erosion of social capital. The findings indicate the utility of Bourdieu's (1986) conceptualisation of social capital to elucidate the dynamics implicit in the practice of giving and receiving resources following an injury.Mary Butler, Sarah Derret
Outcomes for Pacific Peoples after Injury and the Lived Experiences of Injured Pacific Women in New Zealand
No full textAims
The overall aim of the thesis is to gain an understanding of Pacific peoples’ outcomes and experiences after injury, using data from a Prospective Outcomes of Injury Study (POIS) currently underway in New Zealand. There are two research components; the Quantitative Component aimed at describing and comparing pre-injury, injury related and key outcomes between Pacific and non-Pacific participants 24 months after injury; and the main Qualitative Component which explores the lived experiences of injured Pacific women participating in POIS.
Methods
The Quantitative Component used data collected 3 and 24 months post-injury for 2,256 POIS participants referred to the Accident Compensation Corporation’s (ACC) entitlement claims register. Participants resided in one of five New Zealand regions and aged 18-64 years at the time of injury. Participants identifying with any Pacific ethnicity were included in the analyses. Univariate statistics compared pre-injury, injury related and key outcomes between Pacific and non-Pacific participants; and multivariable analyses were used to generate the relative risks for key outcomes for the Pacific group (with the non-Pacific group as the reference). The Qualitative Component used in-depth face to face interviews informed by the Talanoa Pacific Research Methodology. Interviews were audio recorded and transcribed verbatim. Data was organised using the Framework matrix with assistance from NVivo. Analysis was informed using the Fonofale Model of Pacific Health.
Results
Quantitative Component: There were 150 participants of Pacific ethnicity. There was a prevalence of poor outcomes such as inadequate household income (57%), pain/discomfort (50%), non-recovery (43%) and disability (15%) 24 months post-injury for Pacific peoples. The adjusted relative risk (aRR) of having no problems with anxiety/depression was less for Pacific participants (aRR 0.88, 95% Confidence Interval 0.79, 0.98); that is, Pacific participants were at increased risk of this adverse outcome. There were no other significant differences in risks for all the other outcomes including return to work status.
Qualitative Component: Seven Pacific women were recruited and interviewed out of 15 who reported non-recovery at 24 months post-injury (and consented be a part of the follow up study undertaken in this thesis). The interviews took place six years post-injury for the seven women. Five out of the seven had not recovered by the time of interview and had on-going pain/discomfort and disability. The women identified barriers in the rehabilitation process: personal barriers associated with remaining strong and independent despite disability; cultural barriers in performing their roles to look after their families; barriers with ACC – late payments, unexplained cease in payments, too much information and too many requirements from ACC, and also a lack of information about their ACC entitlements; ethnicity of home helpers, and barriers with the health services – wrong medical treatment, pressure to return to work and lack of understanding of the health system. Family was the foundation of support for all the women.
Discussion
Both the research components show that anxiety/depression and pain/discomfort are concerns for injured Pacific individuals. It appears that Pacific peoples are returning to work despite being burdened by poor health, disability and socio-economic outcomes. The provision of culturally appropriate care and a greater understanding of both ACC and health services processes, and Government multi-sectoral support can help improve injury outcomes for Pacific peoples
Quality of life after injury: an Individual Patient Data (IPD) meta-analysis
No full textThere is a need for information on the Health Related Quality of Life (HRQoL) of injury populations. HRQoL measures, like the EQ-5D, have seen a dramatic increase in use over the last ten years. Despite this, general information on HRQoL pathways to recovery are missing from the literature, as many injury studies focus on specific injury types within exclusive populations. This study: (1) identified studies using the EQ-5D in injury populations, (2) collected individual level patient data, and (3) produced population level predictions of HRQoL, as defined by the EQ-5D, across injury subtypes.
A systematic search of literature concerning injury outcome, published between January 1990 and November 2008 (inclusive), was completed. Studies were excluded if the EQ-5D was not used, a degenerative disease was required for study inclusion or injury was a secondary outcome not required for the study. Researchers were invited to contribute Individual Patient Data (IPD) to the meta-analysis. Injuries collected were grouped into 39 categories based on the Eurocost injury classifications. Multilevel mixed effects models were used to produce predictions across both the dimensions and the Visual Analogue Score (VAS) of the EQ-5D measure.
From a potential pool of 13,785 persons across 39 study datasets, IPD from 10,496 injured persons was sourced from 18 discrete datasets. Predictions were fitted to 25 of the 39 injury categories, covering a wide spectrum of injury types. Point predictions were produced for the dimensions and VAS at 3, 30, 120 and 360 days after injury. Figures were also produced of recovery pathways within the EQ-5D dimensions, where relationships with the facet of the EQ-5D and time were statistically significant.
Across the majority of injuries pain and discomfort (PD) was the most severely impaired dimension at both 30 and 360 days post injury. Recovery for PD was gradual, with fractures of the femur, lower leg and pelvis showing marked improvements in mobility and usual activities at 360 days but not PD. Regardless of anatomical location of injury a similar pattern was seen between fractures, with high initial impairment and rapid recoveries, and strains, where impairment at 30 days was significantly less but recovery was gradual. VAS scores showed a great variation in subjective assessments of general health states after an injury. The dimensions of cognitive function and anxiety and depression showed a limited relationship with most injury categories.
The HRQoL predictions produced here will aid clinical researchers in comparing their populations to norm values, as well as aiding policy makers in obtaining a greater understanding of the burden of injury types. This will aid in both justifying prevention measures, as well as identifying areas for prioritisation of resources
Quality of life after injury: an Individual Patient Data (IPD) meta-analysis
No full textThere is a need for information on the Health Related Quality of Life (HRQoL) of injury populations. HRQoL measures, like the EQ-5D, have seen a dramatic increase in use over the last ten years. Despite this, general information on HRQoL pathways to recovery are missing from the literature, as many injury studies focus on specific injury types within exclusive populations. This study: (1) identified studies using the EQ-5D in injury populations, (2) collected individual level patient data, and (3) produced population level predictions of HRQoL, as defined by the EQ-5D, across injury subtypes.
A systematic search of literature concerning injury outcome, published between January 1990 and November 2008 (inclusive), was completed. Studies were excluded if the EQ-5D was not used, a degenerative disease was required for study inclusion or injury was a secondary outcome not required for the study. Researchers were invited to contribute Individual Patient Data (IPD) to the meta-analysis. Injuries collected were grouped into 39 categories based on the Eurocost injury classifications. Multilevel mixed effects models were used to produce predictions across both the dimensions and the Visual Analogue Score (VAS) of the EQ-5D measure.
From a potential pool of 13,785 persons across 39 study datasets, IPD from 10,496 injured persons was sourced from 18 discrete datasets. Predictions were fitted to 25 of the 39 injury categories, covering a wide spectrum of injury types. Point predictions were produced for the dimensions and VAS at 3, 30, 120 and 360 days after injury. Figures were also produced of recovery pathways within the EQ-5D dimensions, where relationships with the facet of the EQ-5D and time were statistically significant.
Across the majority of injuries pain and discomfort (PD) was the most severely impaired dimension at both 30 and 360 days post injury. Recovery for PD was gradual, with fractures of the femur, lower leg and pelvis showing marked improvements in mobility and usual activities at 360 days but not PD. Regardless of anatomical location of injury a similar pattern was seen between fractures, with high initial impairment and rapid recoveries, and strains, where impairment at 30 days was significantly less but recovery was gradual. VAS scores showed a great variation in subjective assessments of general health states after an injury. The dimensions of cognitive function and anxiety and depression showed a limited relationship with most injury categories.
The HRQoL predictions produced here will aid clinical researchers in comparing their populations to norm values, as well as aiding policy makers in obtaining a greater understanding of the burden of injury types. This will aid in both justifying prevention measures, as well as identifying areas for prioritisation of resources
Exploring Social Accountability Mechanisms in the Primary Health Care System of Nepal: A Case Study from the Dang District
No full textAccountability problems in Nepal’s Primary Health Care (PHC) system is a long standing, yet neglected, issue. This concern has contributed to the increasing interest in direct engagement of citizens on health service delivery to exact accountability from health service providers. However, little is known about the role of citizens in demanding accountability from the service providers. The purpose of this study, therefore, is to explore the social accountability mechanisms by which citizens voice their concerns about health care services, and to gauge responsiveness to their concerns by health service providers in the PHC setting of Nepal.
Using a case study design, interviewer-administered structured questionnaires were used to collect quantitative data from 400 participants (220 service users, 100 Health Facility Operation and Management Committee (HFMC) members, and 80 service providers) from 22 public health facilities in the Dang District. In addition, 39 qualitative interviews with key informants, six focus groups with community members, and document reviews were conducted. Quantitative data were analysed using IBM SPSS 22. Qualitative data were transcribed, organised, and then analysed using the framework method in QSR NVivo 10.
The questionnaire survey found positive attitudes among participants towards citizen engagement in health service accountability. However, there was little awareness among service users of the existence of the Citizen’s Charter and HFMC. Less than one fifth (15%) of service users had ever heard of the Citizen’s Charter and HFMC. The level of awareness of both mechanisms was varied by sex, caste/ethnicity, and occupation of service users. A great majority of HFMC members (84%) and service providers (90%) had heard of the Charter. Similarly, all of the health service providers had heard of the HFMC.
Overall, this study found that the role of social accountability mechanisms in amplifying citizens’ voice, and in demanding accountability from the service providers in the Dang District PHC system of Nepal, was mixed. The collective accountability mechanisms appeared to be more effective than the individual ones in stimulating citizens’ voice and service providers’ responsiveness. Citizens’ voice, in the form of individual complaints, and depth and breadth of participation, was found to be weak in creating incentives to make the service providers accountable. While it appears that the concerns raised did result in increased responsiveness from the health system in relation to issues such as infrastructure, resource mobilisation, and service planning and development, limited responsiveness was apparent in relation to entrenched issues which are directly related to the performance of the service providers, such as health facility opening hours and staff absenteeism. Hence, the social accountability mechanisms were examples of ‘softer’ forms of accountability.
This study also highlighted the potential for the role of social accountability mechanisms to trigger existing traditional bureaucratic accountability mechanisms of the PHC system to make frontline service providers accountable. This role appeared important in the Dang District context where there was limited authority/sanctioning power and resources with citizens/representatives at the local level to hold service providers accountable.
Different factors related to community, service providers and broader health systems were identified as the factors that influenced the effectiveness of both citizens’ voice and responsiveness from service providers. Firstly, lack of knowledge of service entitlement and information asymmetry, little knowledge of voice mechanisms, citizens’ lack of interest in and attitude towards the health sector, economic, educational and cultural factors, power relationships in the community, lack of authority of the community and ‘exit’ options are community related factors affecting the voice of citizens. Secondly, among the service providers and health facility factors, service providers’ attitudes and support, and the availability of resources affected citizens’ voice and responsiveness. Then, the broader health system factors, such as the lack of health sector decentralisation, political patronage, support for the district health system, and the way voice mechanisms were implemented, were highlighted as factors affecting service provider accountability towards citizens.
This study concludes that the evidence for citizens’ voice in terms of demanding accountability from service providers is weak. The limitations of the social accountability mechanisms in the PHC context do not, however, imply that this option for accountability is not viable and therefore should be abandoned. Instead, the awareness of the different factors influencing citizens’ voice and responsiveness should help in designing improved social accountability mechanisms. Most importantly, this study’s findings highlighted the need for strengthening the voice mechanisms by considering their links to the wider contexts and health systems factors, rather than narrowly concentrating on the tools and mechanisms, to yield positive accountability outcomes. Additionally, the government needs to decide what sort of citizen-state engagement it is seeking. If addressing accountability problems are the aim, then there is a need to address the problem of state-citizen power asymmetry. Although confrontational techniques and imposition of sanctions appear to be solutions for the entrenched accountability problems in the PHC system, joint problem-solving seems a promising mechanism to avoid possible power struggles between citizens and their service providers.
This study contributed new knowledge by providing insight into the comparative effectiveness of collective and individual voice mechanisms in a rural and underdeveloped health care system, and by highlighting the potentials for social accountability mechanisms to trigger existing traditional bureaucratic accountability mechanisms of the PHC system to hold frontline service providers accountable when there was limited authority/sanctioning power with citizens. Furthermore, this study highlighted the possibility of existing community health system networks to strengthen the individual voice (complaint management system) and the need for the effective representation of community voice by community representatives and meaningful participation of marginalised communities to strengthen the collective voice process.
What Nepal has achieved despite the formidable barriers (natural, political and socioeconomic) in the health sector in recent decades is impressive. Existing community health system networks and a successful history of citizen engagement in the health sector are unique strengths of Nepal’s health care system. The recent political changes in the country which have created a more democratic environment supporting the expression of voice can be an important opportunity for strengthening citizen engagement in the health system. The insights obtained from the Dang District study about the actual functioning of voice mechanisms provide a useful knowledge base to plan for greater citizen engagement to achieve the health policy objective of establishing an accountable health care system
FICare in a New Zealand NICU
No full textBackground
Family integrated care (FICare) is a model of care which shifts the role of parents from ‘observers’ of their infant’s care to being their infant’s ‘primary caregiver’ in Neonatal Intensive Care Units (NICU). One NICU in the South Island of New Zealand (SI-NZ) implemented FICare after being involved in an international randomised controlled trial (RCT) comparing FICare with standard NICU care. FICare’s model comprises four pillars previously identified as necessary for implementation: 1) Staff education and support, 2) Parent education, 3) NICU environment and resources, and 4) Psychosocial support. The RCT found FICare improved infant weight gain and breastfeeding rates and decreased hospital acquired infections and parental stress. However, alongside trial findings there is a need for qualitative research to inform the effective implementation of FICare – and specifically in New Zealand (NZ).
Aim
To qualitatively understand the experience of providing and receiving care via the FICare model from the perspectives of NICU staff, parents and whānau.
Methods
Group and individual interviews were used to collect data about staff experiences delivering FICare; serial interviews were used for parents’/whānau experiences. Two interviews were undertaken with parents/whānau: 1) during their NICU admission, and 2) six to twelve weeks post-NICU discharge. Interviews were audio-recorded, transcribed verbatim and analysed thematically.
Results
Thirteen multidisciplinary NICU staff were interviewed; there were six parent/whānau first interviews in NICU, and five post-discharge. Staff identified that differences in staff FICare education affected FICare delivery with some receiving more robust education than others. Although providing culturally responsive care is not specified within the FICare model, many staff reported that FICare’s principles aligned well with those of the Treaty of Waitangi. Parent/whānau interviewees reported inconsistencies in care between participants who were able to stay in NICU with their infants and those who could not. Participants who stayed in NICU described experiences of receiving care closely aligned with FICare, such as actions guided by the pillars of Parent education, NICU environment and resources, and Psychosocial support. Parents unable to stay in NICU (e.g. due to work, other child commitments or availability of parent beds), were less likely to report care aligned with the FICare model. Participants staying in NICU reported culturally responsive care and greater satisfaction with parent-staff relationships, parent-infant engagement and trust with staff, compared to those who did not.
Conclusion
Findings led to development of an adapted FICare model – potentially more appropriate for NZ. Future testing of this adapted model (named ‘FICare-NZ’) by other researchers is welcomed. Key aspects of FICare-NZ include the importance of culturally responsive care. Additionally, for successful FICare implementation it is recommended that all staff receive consistent FICare education. Therefore, FICare-NZ can be depicted with ‘Staff education’ becoming a foundational step supporting the other three pillars; with a second, and equally critical, foundational step being added for ‘Culturally responsive care’. FICare-NZ therefore comprises these two steps leading up to three (original FICare) pillars: 1) ‘Parent education’, 2) ‘NICU environment and resources’, and 3) ‘Psychosocial support’. Finally, FICare-NZ proposes a canopy layer on top of the pillars to represent the importance of ‘Parents’ experiences of NICU admission’
A study of the methods involved in the recruiting and training of high school and college student volunteers in three social welfare agencies in Philadelphia, Pennsylvania, 1950
No full textInjured Migrant Study (IMS): A prospective study of post-injury outcomes in New Zealand
No full textBackground
The burden of injury has been well documented, and migrants are more likely to have both higher risks of injury and experience poorer outcomes following injury compared to non-migrants. In New Zealand, a significant gap exists in the current literature concerning both the predictors of injury for migrants and the outcomes for migrants compared to non-migrants. To date, there is little known about long-term outcomes post-injury among migrants and most studies have focused on particular migrant sub-populations.
Aims
The main aims of the Injured Migrant Study (IMS) are to investigate health and disability outcomes among migrants compared to non-migrants at 3-months and 24-months post-injury, and to identify predictors of poor health and disability outcomes for migrants at each time-point.
Methods
This study used data from 2,850 participants in the Prospective Outcomes of Injury Study (POIS) undertaken in New Zealand. Participants, aged 18-64 years at the time of injury, were recruited via Accident Compensation Corporation (ACC) entitlement claims register between 2007 and 2009. Participants were classified as migrants if they were born overseas and as non-migrants if they were born in New Zealand. Data collected from interviews with participants at 3-months and 24-months post-injury were analysed, along with data collected from the National Minimum Dataset (NMDS) for those who were admitted to hospital or treated at an emergency department, for at least three hours, as a consequence of their injury, and data collected from ACC (about the injury itself). Health and disability outcomes for migrants compared to non-migrants, at each time-point, were quantified using Modified Poisson regression with robust standard errors. For migrants alone, various potential predictors were adjusted in separated models according to years living in New Zealand using the same regression method to identify predictors associated with poor health and disability outcomes.
Results
Both migrants and non-migrants experienced similar proportions of poor outcomes post-injury. For example, at 3-months follow-up, 24% of migrants reported poor heath compared to 22% for non-migrants, and 45% had considerable disability compared to 42% of non-migrants. At 24-months post-injury, the proportion reporting poor health declined to 15% for migrants and 14% for non-migrants, while the proportion experiencing considerable disability was 13% among both groups. However, none of these post-injury proportions declined to the proportions experienced pre-injury.
Migrants had a 20% increased risk of reporting poor health and a 14% increased risk of disability at 3-months post-injury compared to non-migrants. This difference did not remain statistically significant at 24-months post-injury. For migrants, years living in New Zealand was not found to be associated with poor health or disability outcomes at either of the two time-points post-injury. Having poor health and inadequate household income pre-injury were strong predictors for poor health at both 3-months and 24-months post-injury among migrants. Additionally, perceiving the injury as a threat to their life at the time of the injury event was a predictor of poor health at 3-months, and living alone was a predictor of poor health at 24-months. Strong predictors of considerable disability at 3-months post-injury among migrants included: pre-injury disability, obesity, injury severity, and perceiving the injury as a threat of severe long-term disability; experiencing two or more chronic conditions pre-injury was only a predictor for migrants at 24-months post-injury.
Conclusions
Poor health and disability were persistent for both migrants and non-migrants out to as long as two years following the injury event. However, migrants are more likely to experience poorer outcomes at 3-months post-injury compared to non-migrants. Certain predictors were associated with poor outcomes for migrants at each time-point. Future studies should explore why injured migrants, compared to non-migrants, in New Zealand are at higher risks of poor adverse outcomes following injury
Comparison of socio-economic and life satisfaction outcomes following a stroke or an injury in New Zealand
No full textBackground: In New Zealand, people unable to work due to an illness may be eligible for a means-tested government benefit whereas injured people are eligible for a wide range of support including earnings-related compensation through the no-fault Accident Compensation Corporation (ACC). The aim of the study was to compare the effect of this difference on socio-economic and life satisfaction outcomes of individuals who experienced a stroke with those who had an injury, and their main informal carer.
Methods: A comparative cohort study was undertaken of individuals aged 18-64 years, who had a first-stroke (n=109). Participants were matched by age, sex, and functional impairment to injured individuals (n=429) participating in the Prospective Outcomes of Injury Study. Demographic, health, socio-economic, and life satisfaction data were collected by interview 3.5 and 12 months after stroke or injury. Logistic regression adjusting for the matching variables, and functional impairment at 12 months, was undertaken.
A cross-sectional survey using a postal questionnaire was conducted with carers of individuals with a stroke (n=22) or an injury (n=65) who indicated that their independence was affected at 12 months and their main support person lived in the same household. Logistic regression, adjusting for age, sex, and the impairment level of the individual being cared for, was undertaken.
Results: At 12 months after the stroke or injury, the odds of being back at work were 3.1 times greater for the Injury Group compared to the Stroke Group (OR 3.1; 95% CI 1.7-5.6). The Stroke Group exhibited significantly greater decline in their income over 12 months and the mean personal (59,640) income in the Stroke Group was significantly lower than the Injury Group (48,156 & 87,295 respectively). The decline in income was greater for those in both groups who had a higher income initially, and for those who had not returned to work. The odds of reporting low standard of living (OR=0.64; 95% CI 0.39-1.0), and income insufficiency (OR=0.52; 95% CI 0.34-0.81), were less for the Injury Group. Greater out-of-pocket expenses were reported by the Stroke Group.
For both Groups, life satisfaction decreased at 3.5 months and increased again by 12 months, but not to the pre-event level, except for those in the Stroke Group with a ‘Low’ income pre-event whose life satisfaction declined and did not recover.
The informal carers of individuals with a stroke showed consistently poorer work, cost, economic, and well-being outcomes compared to Injury Carers, but the small sample size precluded statistically significant differences from being observed.
Conclusion: This is the first study to empirically measure outcomes that occur as a consequence of the different financial and social support systems for illness and injury in New Zealand. While it is possible that unknown confounders, or residual confounding, partly explain the difference between groups, the extra financial and rehabilitative support available through ACC are likely to be the main factors influencing these outcomes.
This study has implications for government policy to review the financial and rehabilitation support that is provided to people after an illness to protect them against greater decline in their socio-economic status
Exploring Social Accountability Mechanisms in the Primary Health Care System of Nepal: A Case Study from the Dang District
No full textAccountability problems in Nepal’s Primary Health Care (PHC) system is a long standing, yet neglected, issue. This concern has contributed to the increasing interest in direct engagement of citizens on health service delivery to exact accountability from health service providers. However, little is known about the role of citizens in demanding accountability from the service providers. The purpose of this study, therefore, is to explore the social accountability mechanisms by which citizens voice their concerns about health care services, and to gauge responsiveness to their concerns by health service providers in the PHC setting of Nepal.
Using a case study design, interviewer-administered structured questionnaires were used to collect quantitative data from 400 participants (220 service users, 100 Health Facility Operation and Management Committee (HFMC) members, and 80 service providers) from 22 public health facilities in the Dang District. In addition, 39 qualitative interviews with key informants, six focus groups with community members, and document reviews were conducted. Quantitative data were analysed using IBM SPSS 22. Qualitative data were transcribed, organised, and then analysed using the framework method in QSR NVivo 10.
The questionnaire survey found positive attitudes among participants towards citizen engagement in health service accountability. However, there was little awareness among service users of the existence of the Citizen’s Charter and HFMC. Less than one fifth (15%) of service users had ever heard of the Citizen’s Charter and HFMC. The level of awareness of both mechanisms was varied by sex, caste/ethnicity, and occupation of service users. A great majority of HFMC members (84%) and service providers (90%) had heard of the Charter. Similarly, all of the health service providers had heard of the HFMC.
Overall, this study found that the role of social accountability mechanisms in amplifying citizens’ voice, and in demanding accountability from the service providers in the Dang District PHC system of Nepal, was mixed. The collective accountability mechanisms appeared to be more effective than the individual ones in stimulating citizens’ voice and service providers’ responsiveness. Citizens’ voice, in the form of individual complaints, and depth and breadth of participation, was found to be weak in creating incentives to make the service providers accountable. While it appears that the concerns raised did result in increased responsiveness from the health system in relation to issues such as infrastructure, resource mobilisation, and service planning and development, limited responsiveness was apparent in relation to entrenched issues which are directly related to the performance of the service providers, such as health facility opening hours and staff absenteeism. Hence, the social accountability mechanisms were examples of ‘softer’ forms of accountability.
This study also highlighted the potential for the role of social accountability mechanisms to trigger existing traditional bureaucratic accountability mechanisms of the PHC system to make frontline service providers accountable. This role appeared important in the Dang District context where there was limited authority/sanctioning power and resources with citizens/representatives at the local level to hold service providers accountable.
Different factors related to community, service providers and broader health systems were identified as the factors that influenced the effectiveness of both citizens’ voice and responsiveness from service providers. Firstly, lack of knowledge of service entitlement and information asymmetry, little knowledge of voice mechanisms, citizens’ lack of interest in and attitude towards the health sector, economic, educational and cultural factors, power relationships in the community, lack of authority of the community and ‘exit’ options are community related factors affecting the voice of citizens. Secondly, among the service providers and health facility factors, service providers’ attitudes and support, and the availability of resources affected citizens’ voice and responsiveness. Then, the broader health system factors, such as the lack of health sector decentralisation, political patronage, support for the district health system, and the way voice mechanisms were implemented, were highlighted as factors affecting service provider accountability towards citizens.
This study concludes that the evidence for citizens’ voice in terms of demanding accountability from service providers is weak. The limitations of the social accountability mechanisms in the PHC context do not, however, imply that this option for accountability is not viable and therefore should be abandoned. Instead, the awareness of the different factors influencing citizens’ voice and responsiveness should help in designing improved social accountability mechanisms. Most importantly, this study’s findings highlighted the need for strengthening the voice mechanisms by considering their links to the wider contexts and health systems factors, rather than narrowly concentrating on the tools and mechanisms, to yield positive accountability outcomes. Additionally, the government needs to decide what sort of citizen-state engagement it is seeking. If addressing accountability problems are the aim, then there is a need to address the problem of state-citizen power asymmetry. Although confrontational techniques and imposition of sanctions appear to be solutions for the entrenched accountability problems in the PHC system, joint problem-solving seems a promising mechanism to avoid possible power struggles between citizens and their service providers.
This study contributed new knowledge by providing insight into the comparative effectiveness of collective and individual voice mechanisms in a rural and underdeveloped health care system, and by highlighting the potentials for social accountability mechanisms to trigger existing traditional bureaucratic accountability mechanisms of the PHC system to hold frontline service providers accountable when there was limited authority/sanctioning power with citizens. Furthermore, this study highlighted the possibility of existing community health system networks to strengthen the individual voice (complaint management system) and the need for the effective representation of community voice by community representatives and meaningful participation of marginalised communities to strengthen the collective voice process.
What Nepal has achieved despite the formidable barriers (natural, political and socioeconomic) in the health sector in recent decades is impressive. Existing community health system networks and a successful history of citizen engagement in the health sector are unique strengths of Nepal’s health care system. The recent political changes in the country which have created a more democratic environment supporting the expression of voice can be an important opportunity for strengthening citizen engagement in the health system. The insights obtained from the Dang District study about the actual functioning of voice mechanisms provide a useful knowledge base to plan for greater citizen engagement to achieve the health policy objective of establishing an accountable health care system
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