Accountability mechanisms are increasingly being used in health programmes around the world, but to what effect? In this working paper from the Harvard Centre for Population and Development Studies, the author argues that accountability mechanisms may not always respond to the needs of marginalised groups in society and that attention needs to be paid to the social and institutional context in which they are placed.
The paper explores processes and challenges to accountability in health systems, and asserts that problems in service delivery can be resolved through interaction between service providers and service users. Accountability mechanisms can function to improve representation of previously neglected concerns. Representation through consultation alone leaves power in the hands of those who consult. Increased access to decision-making processes can lead to real influence when coupled with power to demand investigation and change rules. Hybrid approaches where outsiders are effectively involved in government mechanisms work best, as opposed to purely external or internal mechanisms. Key findings are as follows:
- Power relations are fluid and negotiated; opportunities exist to contest power relations in a number of direct or indirect ways.
- The policy process can transform marginalised peoples’ efforts at representation in ways that may be both positive and negative.
- Improving representation of marginalised groups in the policy process can change both how service providers perceive such groups, and how marginalised people see themselves.
- It is impossible to mobilise for change without access to information.
- Fostering dialogue can break down misconceptions within the hierarchical world of health services, and lead to alliances to negotiate blocks at higher levels in the system.
- Participatory mechanisms are not automatically inclusive, and can mirror or exacerbate social divisions.
There is a growing consensus among policy makers that better accountability supports more responsive health policies and more effective services. Implications for policy include the following:
- To be successful, accountability mechanisms need to emphasise building broad and democratic constituencies to support social change.
- Research is needed into how answerability and enforceability operate within health systems, with careful attention paid to the social context.
- More information is also needed on how accountability efforts address higher-level blockages in service delivery and support continuity of delivery in disadvantaged areas.
- Few case studies describe social context. Without this information, it is difficult to assess which lessons can be transferred and which are context-specific.
- Better documentation is needed of the processes of implementing accountability, as opposed to outcomes. Understanding how problems arise and how they are faced can lead to a deeper understanding of the dynamics involved.
