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Traditional approaches to development programming with fixed targets and outcomes do not fit complex problems where the pathway to achieve results differs in each context and evolves constantly. Adaptive programming improves responses to complex problems by identifying which solutions bring change. This paper reviews the theory behind adaptive programming approaches and introduces the 'Pathways of Change' tool for achieving sustainability results, developed for the multi-country Women's Integrated Sexual Health programme. Qualitative data, using semi-structured interviews and group discussions from teams in over 17 countries in Africa and South Asia, are presented which examine the application of the Pathways of Change (PoC) tool focusing on successes and challenges across different intervention areas. The PoC responds to the need for a more practical adaptive programming tool that can be tailored to support flexibility in global health programme implementation while meeting donor requirements. Findings suggest that the PoC tool provides a flexible yet robust alternative to traditional monitoring frameworks and is able to facilitate adaptive, contextualised planning and monitoring for multi-country programmes. The PoC tool offers a solution to realise the ambitions of implementing adaptive programming within global health programmes and potentially beyond.

The Global Strategy for Women’s Children’s and Adolescents’ Health emphasizes accountability as essential to ensure that decision-makers have the information required to meet the health needs of their populations and stresses the importance of tracking resources, results, and rights to see ‘what works, what needs improvement and what requires increased attention’. However, results from accountability initiatives are mixed and there is a lack of broadly applicable, validated tools for planning, monitoring and evaluating accountability interventions. This article documents an effort to transform accountability markers—including political will, leadership and the monitor–review–act cycle—into a measurement tool that can be used prospectively or retrospectively to plan, monitor and evaluate accountability initiatives. It describes the development process behind the tool including the literature review, framework development and subsequent building of the measurement tool itself. It also examines feedback on the tool from a panel of global experts and the results of a pilot test conducted in Bauchi and Gombe states in Nigeria. The results demonstrate that the tool is an effective aid for accountability initiatives to reflect on their own progress and provides a useful structure for future planning, monitoring and evaluation. The tool can be applied and adapted to other accountability mechanisms working in global health.

Accountability mechanisms help governments and development partners fulfill the promises and commitments they make to global initiatives such as the Millennium Development Goals and the Global Strategy on Women’s and Children’s health, and regional or national strategies such as the Campaign for the Accelerated Reduction in Maternal Mortality in Africa (CARMMA). But without directed pressure, comparative data and tools to provide insight into successes, failures, and overall results, accountability fails. The analysis of accountability mechanisms in five countries supported by the Evidence for Action program shows that accountability is most effective when it is connected across global and national levels; civil society has a central and independent role; proactive, immediate and targeted implementation mechanisms are funded from the start; advocacy for accountability is combined with local outreach activities such as blood drives; local and national champions (Presidents, First Ladies, Ministers) help draw public attention to government performance; scorecards are developed to provide insight into performance and highlight necessary improvements; and politicians at subnational level are supported by national leaders to effect change. Under the Sustainable Development Goals, accountability and advocacy supported by global and regional intergovernmental organizations, constantly monitored and with commensurate retribution for nonperformance will remain essential.

Good progress has been made in reducing maternal deaths from 1990–2015 but accelerated progress is needed to achieve the Sustainable Development Goals (SDGs) in ending preventable maternal deaths through a renewed focus on accountability and actions. This paper looks at how Maternal Death Surveillance and Response (MDSR) systems are strengthening response and accountability for better health outcomes by analyzing key findings from the WHO and UNFPA Global MDSR Implementation Survey across 62 countries. It examines two concrete examples from Nigeria and Ethiopia to demonstrate how findings can influence systematic changes in policy and practice. We found that a majority of countries have policies in place for maternal death notification and review, yet a gap remains when examining the steps beyond this, including reviewing and reporting at an aggregate level, disseminating findings and recommendations, and involving civil society and communities. As more countries move toward MDSR systems, it is important to continue monitoring the opportunities and barriers to full implementation, through quantitative means such as the Global MDSR Implementation Survey to assess country progress, but also through more qualitative approaches, such as case studies, to understand how countries respond to MDSR findings.

Objective: To describe the types of maternal and newborn health program accountability mechanisms implemented and evaluated in recent years in Sub-Saharan Africa, how these have been implemented, their effectiveness, and future prospects to improve governance and MNH outcomes. \ud \ud Method: A structured review selected 38 peer-reviewed papers between 2006 and 2016 in Sub-Saharan Africa to include in the analysis.\ud \ud Results: Performance accountability in MNH through maternal and perinatal death surveillance was the most common accountability mechanism used. Political and democratic accountability through advocacy, human rights, and global tracking of progress on indicators achieved greatest results when multiple stakeholders were involved. Financial accountability can be effective but depend on external support. Overall, this review shows that accountability is more effective when clear expectations are backed by social and political advocacy and multistakeholder engagement, and supported by incentives for positive action.\ud \ud Conclusion: There are few accountability mechanisms in MNH in Sub-Saharan Africa between decision-makers and those affected by those decisions with both the power and the will to enforce answerability. Increasing accountability depends not only on how mechanisms are enforced but also, on how providers and managers understand accountability.

Since minimal information exists on how individuals work within existing social norms to reduce HIV risk, this study explored the specific factors influencing men and women to reduce their HIV risk in the face of prevailing gender norms in rural villages of Cabo Delgado, Mozambique. Qualitative data were gathered from 160 participants through 29 in-depth interviews to explore gender norms, HIV risk determinants, and risk reduction responses. Results were analyzed using adaptations of grounded theory and constant comparative analysis. Men and women who actively take measures to decrease their risk of HIV infection associate a partner’s acceptance of condom use and an HIV test as confirmation of emotional intimacy in the relationship. Other factors influencing risk reduction efforts include various levels of influence from family or peers, prior experience, relationship dynamics, and a reflection of broader personal outcomes.

A qualitative analysis was carried out of data from 16 group discussions and 29 in-depth interviews conducted in rural and matrilineal areas of Cabo Delgado, Mozambique, to examine how the exchange of sex for resources--primarily money but also food, transportation, housing and gifts--is enacted and perceived in relation to HIV-related risk, and how prevalent gender norms are reflected in this practice. Findings reveal how gender norms shape access to resources differently for men and women as well as how variations in access to opportunities and income earning potential contribute to the emergence of sexual exchange for purposes of survival, but also as a means to ensure sexual and economic agency. Within this practice, individuals are confronting gender norms and re-defining their HIV-related risk. Some men refuse to spend scarce resources on other women by protecting their family from both financial insecurity and HIV acquisition. Among some women who engage in sexual transactions to obtain resources quickly, the resulting agency and decision making power gained are a trade-off to potential HIV risk. Nuanced understandings of gender dynamics and its influence on sexual risk taking and risk-reduction efforts in different local contexts are required.

Despite increasing HIV/AIDS rates among married individuals, minimal research has been conducted on how men and women respond to risk in a marriage. This paper examines strategies used by married individuals to combat HIV/AIDS risk against prevailing gender norms. Qualitative data were gathered in four villages of Cabo Delgado province, Mozambique. Group discussions were held with 160 men and women to explore gender norms, HIV/AIDS knowledge and risk determinants. From the group discussions, 29 individuals were selected for further in-depth interviews to explore relationships between gender norms and risk reduction efforts within marriages. Findings illustrate how infidelity and social limitations placed on condom use not only increase HIV/AIDS risk but also entrench gender disparities. Although power differences between genders can make it difficult to negotiate safe sex, men and women are taking measures to reduce perceived HIV/AIDS risk in their marriage. Married men are reconstructing norms and taking responsibility to protect their family from HIV/AIDS by remaining faithful. For women, responses to HIV/AIDS risk in a marriage are more closely related to their ability to generate an income. Financially dependent women tend to leave a risky marriage altogether in contrast to financially autonomous women who will negotiate condom use with their husband. Factors such as experience with a risky partner, the desire to maintain a good social standing, fear of HIV/AIDS acquisition and parental guidance and support influence men and women to reduce perceived HIV/AIDS risk, despite constraining gender norms and power imbalances in a marriage. Nuanced understandings of the ways in which men and women are already taking measures to decrease noted HIV/AIDS risk, despite gender norms that make this a challenge, should be incorporated into localised responses.

Quality of care is essential to maternal and newborn survival. The multidimensional nature of quality of care means that frameworks are useful for capturing it. The present paper proposes an adaptation to a widely used quality of care framework for maternity services. The framework subdivides quality into two inter-related dimensions—provision and experience of care—but suggests adaptations to reflect changes in the concept of quality over the past 15 years. The application of the updated framework is presented in a case study, which uses it to measure and inform quality improvements in northern Nigeria across the reproductive, maternal, newborn, and child health continuum of care. Data from 231 sampled basic and comprehensive emergency obstetric and newborn care (BEmONC and CEmONC) facilities in six northern Nigerian states showed that only 35%–47% of facilities met minimum quality standards in infrastructure. Standards for human resources performed better with 49%–73% reaching minimum standards. A framework like this could form the basis for a certification scheme. Certification offers a practical and concrete opportunity to drive quality standards up and reward good performance. It also offers a mechanism to strengthen accountability. Postprint

Since the 2010 launch of the UN Secretary-General's Global Strategy for Women's and Children's Health, worldwide political energy coalesced around improving the health of women and children. Nigeria acted on a key recommendation emerging from the Global Strategy and became one of the first countries to establish an independent group known as the Nigeria Independent Accountability Mechanism (NIAM). NIAM aims to track efforts on progress related to Nigeria's roadmap for the health of women and children. It includes eminent people from outside government to ensure independence, and is recognized within government to analyze and report on progress. The concept of NIAM received approval at various national and international forums, as well as from the Nigeria Federal Ministry of Health. This experience provides an example of connecting expertise and groups with the government to influence and accelerate progress in maternal, newborn, and child health. Engagement between government and civil society should become the norm rather than the exception to achieve national goals.