Abstract:
Resource constraints, value for money debates and concerns about provider behaviour
have placed accountability 'front and centre stage' in health system improvement
initiatives and policy prescriptions. There are a myriad of accountability relationships
within health systems, all of which can be transformed by decentralisation of health
system decision-making from national to subnational level. Many potential benefits of
decentralisation depend critically on the accountability processes and practices of frontline health facility providers and managers, who play a central role in policy
implementation at province, county, district and facility levels. However, few studies
have examined these responsibilities and practices in detail, including their implications
for service delivery. In this paper we contribute to filling this gap through presenting data
drawn from broader ongoing research collaborations between researchers and health
managers in Kenya and South Africa. These collaborations are aimed at understanding
and strengthening day-to-day micropractices of health system governance, including
accountability processes. We illuminate the multiple directions and forms of
accountability operating at the subnational level across three sites. Through detailed
illustrative examples we highlight some of the unintended consequences of bureaucratic
forms of accountability, the importance of relational elements in enabling effective
bureaucratic accountability, and the ways in which front-line managers can sometimes
creatively draw upon one set of accountability requirements to challenge another set to
meet their goals. Overall, we argue that interpersonal interactions are key to appropriate
functioning of many accountability mechanisms, and that policies and interventions
supportive of positive relationships should complement target-based and/or audit-style
mechanisms to achieve their intended effects. Where this is done systematically and
across key elements and actors of the health system, this offers potential to build
everyday health system resilience.