How does social accountability contribute to better maternal health outcomes? A qualitative study on perceived changes with government and civil society actors in Gujarat, India

Mukesh Hamal*, Tjard De Cock Buning, Vincent De Brouwere, Azucena Bardají, Marjolein Dieleman

*Corresponding author for this work

Research output: Contribution to JournalArticleAcademicpeer-review


BACKGROUND: Social accountability mechanisms have been highlighted as making a contribution to improving maternal health outcomes and reducing inequities. But there is a lack of evidence on how they contribute to such improvements. This study aims to explore social accountability mechanisms in selected districts of the Indian state of Gujarat in relation to maternal health, the factors they address and how the results of these mechanisms are perceived.

METHODS: We conducted qualitative research through in-depth interviews and focus group discussions with actors of civil society and government health system. Data were analyzed using a framework of social determinants of maternal health in terms of structural and intermediary determinants.

RESULTS: There are social accountability mechanisms in the government and civil society in terms of structure and activities. But those that were perceived to influence maternal health were mainly from civil society, particularly women's groups, community monitoring and a maternal death review. The social accountability mechanisms influenced structural determinants - governance, policy, health beliefs, women's status, and intermediary determinants - social capital, maternal healthcare behavior, and availability, accessibility and the quality of the health service delivery system. These further positively influenced the increased use of maternal health services. The social accountability mechanisms, through the process of information, dialogue and negotiation, particularly empowered women to make collective demands of the health system and brought about changed perceptions of women among actors in the system. It ultimately improved relations between women and the health system in terms of trust and collaboration, and generated appropriate responses from the health system to meeting women's groups' demands.

CONCLUSION: Social accountability mechanisms in Gujarat were perceived to improve interaction between communities and the health system and contribute to improvements in access to and use of maternal health services. The influence of social accountability appeared to be limited to the local/district level and there was lack of capacity and ownership of the government structures.

Original languageEnglish
Article number653
Pages (from-to)1-15
Number of pages15
JournalBMC Health Services Research
Publication statusPublished - 22 Aug 2018


This manuscript is a part of the first author’s Erasmus Mundus Joint Doctorate (EMJD) program under International Doctorate in Transdisciplinary Global Health Solutions funded by European Commission (Erasmus Mundus Joint Doctorate Specific Grant Agreement 2013-1479). The authors would like to acknowledge the European Commission for providing the scholarship for the doctoral program. We would like to thank Sherzel Smith for providing technical assistance during data analysis. We would also like to thank Dr. Renu Khanna for reviewing the manuscript and making suggestions. The authors also extend gratitude to the research assistants, all staff from SAHAJ and ANANDI who supported in collection of the data, and all the participants for their time and sharing their experiences and perspectives.

FundersFunder number
European Commission2013-1479


    • Gujarat
    • Health system
    • India
    • Maternal health
    • Qualitative
    • Social accountability


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