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Background: There is a gap in knowledge about how citizen participation impacts governance of free healthcare policies for universal health coverage in low- and middle-income countries. Objective: This study provides evidence about how social accountability initiatives influenced revenue generation, pooling and fund management, purchasing and capacity of health facilities implementing the free maternal and child healthcare programme (FMCHP) in Enugu State, Nigeria. Methods: The study adopted a descriptive, qualitative case-study design to explore how social accountability influenced implementation of the FMCHP at the state level and in two health districts (Isi-Uzo and Enugu Metropolis) in Enugu State. Data were collected from policymakers (n = 16), providers (n = 16) and health facility committee leaders (n = 12) through in-depth interviews. We also conducted focus-group discussions (n = 4) with 42 service users and document review. Data were analysed using thematic analysis. Results: It was found that health facility committees (HFCs) have not been involved in the generation of funds, fund management and tracking of spending in FMCHP. The HFCs did not also seem to have increased transparency of benefits and payment of providers. The HFCs emerged as the dominant social accountability initiative in FMCHP but lacked power in the governance of free health services. The HFCs were constrained by weak legal framework, ineffectual FMCHP committees at the state and district levels, restricted financial information disclosure, distrustful relationships with policymakers and providers, weak patient complaint system and low use of service charter. Conclusion: The HFCs have not played a significant role in health financing and service provision in FMCHP. The gaps in HFCs’ participation in health financing functions and service delivery need to be considered in the design and implementation of free maternal and child healthcare policies that aim to achieve universal health coverage.
The study adopted the Bossert and Brinkerhoff health governance framework [38,39]. The framework focuses on diverse health systems actors, distribution of roles and responsibility among them, and their ability and willingness to fulfil these roles and responsibilities. The framework uses the principal-agent theory to explain accountability relationships involving three categories of health system actors: decision makers, providers and users/citizens [39]. Decision makers are policymakers in the public service. Service providers include health facilities and health workers. Users/citizens include service users and HFCs. These actors are in three accountability relationships: users/citizens-policymakers; users/citizens-providers; and policymakers-providers (Figure 1). We focused on the agency relationships involving users/citizens because they explain accountability relationships of the HFCs with policymakers and providers. Social accountability is analysed in relation to HFCs because FMCHP design adopted HFCs as the main social accountability initiative. Additionally, HFCs use complaint boxes and service charters. Thus, the agency relationships of HFCs with policymakers and providers were analysed using the five modes of functioning of HFCs – village square, community connector, bothering government, back-up government and general overseer – which had been identified in two previous studies in Nigeria [40,41]. Village square implies that the HFCs use meetings as a vehicle for addressing issues and resolving challenges facing health facilities. As community connectors, the HFCs reach out within their communities and serve as a platform for citizens to share their views about the functioning of health facilities. The HFCs functioning as ‘bothering government’ bother policymakers to address problems in their facilities or programmes. The HFCs mobilise resources and fill service delivery gaps when they function as ‘back-up government’. General overseer means that the HFCs oversee day-to-day running of health facilities, participate in decision-making and monitor implementation of FMCHP. Conceptual framework of the study. The study was undertaken at the State Ministry of Health and in two selected districts (A = Isi-Uzo and B = Enugu Metropolis) in Enugu State, southeast Nigeria. Enugu State operates a district health system in which the 17 LGAs were delineated into seven districts and primary and secondary healthcare integrated within districts, to serve populations ranging from 160,000 to 600,000 persons [42]. The Ministry of Health is restructured into two arms: (1) the Policy Development and Planning Directorate, which houses the FMCHP Steering Committee, is responsible for leadership and governance; and (2) the State Health Board, which houses the State Implementation Committee, coordinates service delivery across the districts (Figure 2). Each district is governed by a district health board and has several local health authorities and network of health facilities providers including primary health centres and cottage and district hospitals. The contraceptive prevalence rate is 31.4%, total fertility rate is 4.8, access to skilled birth attendance is 38%, vaccination coverage is 47%, maternal mortality is 576 per 100,000 livebirths, and under-5 child mortality is 131 per 1000 livebirths in Enugu State [43]. Enugu State District Health System. We adopted a qualitative, case-study design using document review, in-depth interviews (IDIs) and focus-group discussions (FGDs). Case-study design was used because the inquiry focused on ‘what, how and why questions’ [44,45]. The seven health districts in Enugu State were categorised into well-performing and less-performing districts based on provider payment data. We calculated the cumulative provider payment across the seven districts from financial records between 2009 and 2014 and found a range of 2% to 26% with a median of 14%. Using a cut-off point of 14%, three districts were adjudged to be well performing and four less performing. Provider payment was used to judge the success of FMCHP in districts, since state health information system does not disaggregate data by user-fee exemption. From each category, one district was selected by simple random sampling. The respondents from the state level were selected purposively from a list of members of the Steering Committee and State Implementation Committee. District-level policymakers, providers and HFC members were purposively selected based on their location, post and experience in FMCHP, and interviewed until data saturation was reached [46]. Participants, who had less than one-year involvement in FMCHP implementation at state level or selected districts were excluded from interview. Maximum variation sampling was used to recruit 42 women who participated in four focus groups [46]. The participants were women of child bearing age who were 15–49 years, had at least one under-5-year child and were willing to participate in the study. In District A, two communities were selected randomly from a sampling frame of 20 autonomous communities. Working with community women leaders (gatekeepers), the study was advertised during the ‘August’ meeting (women gathering) and participants conveniently selected. In District B, it was more practical to reach urban women in health facilities on immunisation days than through a community approach adopted in district A. One primary health centre and one hospital each were selected randomly from sampling frames of primary health centres and hospitals. The participants were conveniently selected by advertising the research during immunisation day at the health facilities using service providers as gatekeepers. Data were collected using document review, IDIs and FGDs between February and September 2015 during an assessment of governance of FMCHP in Enugu State, Nigeria. Information about social accountability initiatives was extracted from 14 policy documents. Interviews with 44 participants (16 policymakers, 16 providers and 12 HFC leaders) were conducted using a semi-structured in-depth interview guide. The guide explored the role played (or not played) by HFCs in revenue generation, pooling, purchasing and capacity of health facilities during implementation of FMCHP (see Appendix I). Interviews, lasting 60–90 minutes, were conducted in English and tape-recorded. Member checks were used to ensure that participants reviewed their statements for accuracy [47]. Four FGDs were held with a total of 42 women of childbearing age using a discussion guide (see Appendix II). Two focus groups were held in District A with 11 and 12 participants, while two focus groups in District B had eight and 11 participants respectively. The FGDs, which were audiotaped with the consent of participants, were held at venues chosen in consultation with participants and gatekeepers, moderated by one of the authors, and a research assistant served as note taker. Data were analysed using thematic analysis. Audiotapes of the interviews were transcribed verbatim, anonymised and imported into NVivo 11 software [48]. Codes were generated by deductive and inductive process, and defined in a codebook to minimise inter-coder differences [49]. Deductive codes were guided by the conceptual framework and included accountability relationships and modes of functioning of HFCs. Inductive codes, based on a close reading of the transcripts, highlighted the roles (not) played by HFCs in holding policymakers and providers accountable, and the context of these accountability relationships. Two persons coded the transcripts with much agreement. To ensure trustworthiness of findings, the research team was trained in qualitative research approaches, data-collection tools were pre-tested in a different district, findings were triangulated by methods, and inter-coder differences were resolved by unanimity. Member checks and stakeholder validation meetings were also used to verify the accuracy and completeness of findings [50]. Ethical approval was obtained from the Health Research Ethics Committee of University of Nigeria Teaching Hospital Enugu, Nigeria. The participants gave written informed consent for participation and digital recording of interviews.
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