Why it matters 

Accountability mechanisms seek to promote answerability between the health system and the public or local communities (external accountability) or between different actors and levels of the health system (internal accountability).

External accountability processes have attracted significant attention in recent years, but internal processes and the complex interactions between external and internal processes, have been relatively neglected. In particular, there is limited understanding of the accountability responsibilities and practices of front-line providers and managers within decentralised systems.

What we did 

We've undertaken several areas of work relating to accountability 

Literature reviews 

Strengthening accountability in Nigeria's health sector 

In 2013, Health Policy Research Group in Nigeria carried out a research project that focused on the implementation of the Basic Health Care Provision Fund (BHCPF) in Nigeria, and how evidence could be used to strengthen accountability in its implementation. The Basic Health Care provision fund was set up as part of the National Health Act as a way of increasing funding to primary health services and providing a basic package of health services to all citizens.

Researchers interviewed key stakeholders who are involved in the implementation of the Fund, and developed an accountability framework, setting out key actions and responsibilities for stakeholders at facility, state and national levels.

Tracking implementation of the Health Sector Services Fund in Kenya

RESYST supported a small scale study in two health centres in each of five selected districts, to track the implementation and perceived impact of the Health Sector Services Fund. This research fed into a wider evaluation of a nation wide Direct Facility Funding intervention through the Health Sector Services Fund in Kenya’s Health Centres and Dispensaries. Financing of these peripheral health facilities, and associated strengths and challenges, has continued to be tracked post devolution.

Long-term, action research to understand accountability practices of frontline health providers

As part of the wider learning site approach in South Africa and Kenya, researchers have drawn on a range of data sources to examine the micro practices involved in the implementation of accountability mechanisms. This study found that:

  • Front-line managers operate in a web of accountability responsibilities and demands.
    They are answerable to a range of different actors in different directions and in ways that conflict with each other. 
  • Accountability processes are often shaped by audit-style bureaucratic mechanisms.
    Such mechanisms are often reduced to tick-box-style, routinised, depersonalised activities, aimed more at maintaining the status quo than building relationships.
  • Relationships matter. 
    Some managers gravitate towards more relational processes of accountability. For the good intentions of bureaucratic accountability mechanisms to be met, relational or interpersonal elements are essential and should be recognised, valued and supported.

What we changed

Nigeria: Research on the BHCPF in Nigeria was used to inform guidelines for implementation of the Fund which were produced in 2016. Since then, researchers from HPRG have been part of working groups involved in implementing the Fund and National Health Act. 

Kenya: The HSSF work in Kenya contributed to national and county level discussions on direct peripheral facility funding, prompted by the findings in the policy brief