Solving many of the challenges in health is a complex process and nobody can claim to have a silver bullet for any one problem. It requires gaining a good contextual understanding of a problem and those it affects, coming up with a possible solution, testing and implementing the solution and scaling up if it works. If it doesn’t work, then it’s time to go back to the drawing board to repeat the process, armed with evidence of what didn’t work the first time and why. This strategy has been adopted in global development efforts to solve some of the world’s toughest problems including maternal and new-born deaths before, during and after pregnancy. One key element of this approach is the opportunity it provides for constant learning and trying out new ways when the existing solutions are not giving desired results.
When it comes to tackling maternal and child health issues, most interventions either externally design and implement, or replicate a programme that has worked elsewhere. But designing or replicating programmes in this way is often not enough. It is becoming increasingly necessary to create solutions with a human-centered design approach as it takes into account the perspective of the end user at the inception of the intervention, also taking into account the local contexts, putting some level of ownership into the hands of the people in need of the intervention. It helps create a system where the community can hold people and institutions accountable and empowers them to demand for action when they aren’t seeing any.
This message emerged clearly at the two-day conference in Kigali organised in 2018 by the Sustainable Development Goals Centre for Africa. The conference identified the need to build and strengthen accountability in African health systems and the importance of focusing accountability mechanisms on the citizens as essential to improving health outcomes in Africa. To achieve this, it is critical to listen to communities demands for quality care and leverage the media to strengthen accountability.
Partnering for Accountability
This approach is reflected in the activities of the Accountability Mechanism on Maternal Newborn and Child Health in Kano State (AMMKaS) which aims to facilitate citizen participation in governance. As a multi-stakeholder partnership, it includes Civil Society Organisations (CSOs), media, government and professional bodies who promote innovative accountability and transparency in Maternal, Newborn and Child Health (MNCH) initiatives in the state.
Apart from using strategic advocacy efforts to engage political actors in order to influence transparent spending and timely release of finances for health in the state, the partnership aims to generate evidence to influence decision making at the policy level. It also organises a quarterly interactive forum called Open Kano State Ministry of Health (#OpenKNSMoH) that brings together key organisations and individuals in the sector for regular performance reviews and action.
But AMMKaS didn’t start off working in partnership with the government, explains Hajiya Hafsat Kolo, its Co-Chair. Previously called the Partnership for Promotion of Maternal and Child Health (PFPMCH), it was established over 18 years ago. Their work gained prominence when they started pushing for a bill to provide free healthcare for women and children under five years in 2011.
“Kano State has always been giving free maternal care to women from conception to six months after delivery and to children under five. We wanted this to become a law in the state,” Hajiya Kolo said. One of their greatest challenges was getting government participation and reliable information. This changed in 2013 when the Commission on Information and Accountability (CoIA) recommended they expand their membership to involve government officials.
Now, Liti Gwarzo Abdullahi, the Director of Planning, Research and Statistics (DPRS) at the Kano State Ministry of Health (KSMoH) serves as the second Co-Chair and this has turned out to be a game changer for their work to improve maternal, newborn and child health in the state. The synergy has rubbed off significantly on other areas especially increasing budgetary allocation for health.
Sitting in his dimly lit office on the third floor of the Ministry’s building located along Post office road, Gwarzo, he highlighted some of the ways the partnership has advanced maternal health in the state. AMMKaS’ inputs into the government’s health agenda is highly valued and since government officials cannot directly be involved with advocacy activities, the CSOs are able to go the extra mile. But most importantly, Gwarzo said the transparency created by their involvement in the efforts of the accountability mechanism has helped keep the government officials in check.
Making Accountability Work
Even though AMMKaS has been successful with its goals, it hasn’t always been easy. While they have worked within the limits of their capacities, Hajiya Rakana Umma said when the Maternal Newborn and Child Health 2 (MNCH2) project came on board, it helped strengthen AMMKaS’ work by synergising all their activities. Umma is the Kano State Accountability Coordinator for the MNCH2 project, a five-year, country-led UK Government funded project to improve maternal health outcomes across six northern states.
Hajiya Kolo excitedly explained how the system works. The MNCH2 project set up State Level Accountability Mechanisms (SLAMs) in all the states where interventions were being carried out. The SLAM is a collaboration between community members, CSOs, professionals, community leaders and the media to improve MNCH and other health issues in the state. This helps to provide independent expertise, document community voices on MNCH issues and needs, and champion linkages with other government agencies to improve coordination and MNCH outcomes.
The SLAM has three sub-committees; The evidence sub-committee, which includes community leaders and gathers evidence, the advocacy sub-committee which includes professionals and CSO representatives, and ensures that action is taken based on evidence already gathered, and the knowledge sub-committee which ensures that information is documented and disseminated.
Where accountability structures already existed in the state, the MNCH2 project focused on strengthening them. The structure is also intentional in the way it works with community members and leaders. Community representatives are identified to directly interface with people in the community to get a sense of their problems. Each health facility has a Friends of the Hospital Committee (FHC) which focuses on service delivery at health centres. Their findings are channelled to the larger accountability sub-committee for further action.
Hajia Kolo adds that the group works closely with the Kano Emirate Council on Health and Nutrition, set up by the Emir of Kano, and this has also contributed significantly to their advocacy efforts.
Reaping the Benefits of AMMKaS
Hajiya Kolo believes that AMMKaS has created a conducive atmosphere for work and collaboration between the CSOs and the state government. She says the benefits of the partnership have grown to include the involvement of AMMKaS on boards of major agencies operating in the state. In 2018, they were instrumental to increasing the amount budgeted for health from 12.1% to 13.1% after a series of advocacy meetings with the State House of Assembly members. The Private Health Institutions Management Agency that helps streamline the activities of private practitioners in the state, the Kano State Ultramodern Specialist Hospital (KUSH) and the Kano State Health Insurance Agency (KSHIA) are some of the institutions where AMMKaS members play strategic roles as either board members or advisory duties. Others are the Kano Health Trust Fund and the newly inaugurated committee for implementing the Basic Health Care Provision Fund.
More than just a Cliché
The term “Nothing about us without us” is often used to show that communities should be involved in programs aimed at benefiting them. Effective accountability systems create benefits for everyone involved, but it begins by involving communities, letting them take ownership, and holding their benefactors and partners accountable. This helps ensure sustainability of any community initiative, but also helps keep everyone in check because while AMMKaS holds the government accountable, its members have to be accountable to the people they represent.
The World Health Organization (WHO) describes accountability as a relationship between a duty holder and a person or organisation to whom a duty is owed. An important element is the capacity to impose a sanction if a duty holder fails to deliver, or if their performance is poor. In the case of AMMKaS there is no system to sanction duty holders, and so this sanction almost never happens, which means the absence of consequences can give room for non-performance.
Kano State has been able to increase budgetary allocation for health and even surpassed the Abuja Declaration (A 2001 commitment by the African Union countries to allocate at least 15% of their annual budget for healthcare) by budgeting 15.24% of the 2019 budget for health. However, release of the budgeted funds has not been as effective. The MNCH2 Kano State Team Lead, Dayyabu Yusuf, described the process of tracking budget releases and spending as “not as straightforward as we think” because there are expenses made for the health sector that are not handled by the Ministry of Health. They have had to rely on the audited accounts of the state to effectively track expenditures for the health sector.
This makes it more important for the CSOs and government to work in partnership with accountability systems because government representatives can provide valuable information for precise and efficient advocacy for funds release after budgeting. “You can pass budget, you can increase it to whatever percent but the advocacy to release is the most important. This is the reason why the two co-chairs representing CSO and government work hand in hand. We provide them with information and point them to where exactly they need to go,” says Abduallahi, the AMMKaS Co-Chair representing the Kano State government in the partnership.
Despite its challenges, it appears that AMMKaS is making progress in its goal of strengthening accountability in maternal and child health in Kano State.
Are you from Kano State? Were you aware of AMMKaS and its work? Do you know of other interesting initiatives to strengthen accountability in health? Do you have any ideas for how we can better hold elected officials, the government, CSOs and donors to account? We would love to hear from you.