Understanding the micro-practices of accountability and governance in health systems

How can the decision-making practices of frontline leaders and managers, and accountability mechanisms, be strengthened to support health systems' responsiveness


Front-line health managers play a critical role in health systems governance, policy implementation and in accountability processes. However, their decision-making practices are dynamic and complex, and it is difficult to observe and to disentangle the effects of governance issues from other health system dimensions.

As a consequence, conducting research on governance faces significant challenges. One way of overcoming these challenges is for researchers to work directly with health managers to define research questions, identify appropriate methodologies and generate shared knowledge.

This is known as action learning research, and is the approach being used by RESYST at learning sites in Kenya and South Africa to better understand district-level governance issues.


In Kenya, learning sites have been established among District Health Management Teams in rural Malindi and Kaloleni districts in Kilifi County. Researchers have been conducting interviews and observations at national, county, sub-county and facility level to understand the implications for health delivery and management of ongoing devolution to 47 semi- autonomous counties. The Kilifi learning site was established in 2013.

Kenya summary

South Africa

Since 2014 there are two additional RESYST learning sites in South Africa (Sedibeng District in Gauteng Province and Mitchells Plain sub-district in Western Cape). Work in the Mitchells Plain learning site builds on the collaborative research activities of the DIAHLS project which have focussed on strengthening leadership and governance to support improvements in primary health care.


In addition to the learning sites, a related study in Nigeria will develop guidelines for accountability in the implementation of the Nigerian Primary Health Care (PHC) Fund. An initial review of relevant documentation was undertaken in 2013 and empirical work began in 2014.

Nigeria summary