Improved accountability is often called for as an element in improving health system performance. At first
glance, the notion of better accountability seems straightforward, but it contains a high degree of complex-
ity. If accountability is to be more than an empty buzzword, conceptual and analytical clarity is required. This
article elaborates a definition of accountability in terms of answerability and sanctions, and distinguishes
three types of accountability: financial, performance and political/democratic. An analytic framework for
mapping accountability is proposed that identifies linkages among health sector actors and assesses capacity
to demand and supply information and exercise oversight and sanctions. The article describes three account-
ability purposes: reducing abuse, assuring compliance with procedures and standards, and improving
performance/learning. Using an accountability lens can: (1) help to generate a system-wide perspective on
The current concern with accountability and health systems Frequently, it is the perception of failed or insufficient
reflects several factors. First is dissatisfaction with health accountability that furnishes the impetus for change. For
system performance in both industrialized and example, among the rationales for health sector decentral-
developing/transitioning countries. Discontent has focused ization reforms is the need to establish stronger account-
on costs, quality assurance, service availability/access, equi- ability linkages among citizens, policymakers and service
table distribution of services, abuses of power, financial providers. Hutchinson et al. (1999, p. 103) note this dynamic
mismanagement and corruption, and lack of responsiveness. in Uganda’s reform; prior to the creation of decentralized
Secondly, accountability has taken on a high degree of health committees, ‘. . . citizens unhappy with the perform-
importance because the size and scope of health care bureau- ance of health workers or priority setting by local politicians
cracies in both the public and private sectors accord health had few mechanisms for redressing their grievances or
system actors significant power to affect people’s lives and improving services’.
well-being. Further, health care constitutes a major
budgetary expenditure in all countries, and proper account- Uganda is just one example of how accountability is front and
ing for the use of these funds is a high priority. centre on the stage of current health system improvements
and policy prescriptions. However, as a guide to the specifics
All health systems contain accountability relationships of of what to do to improve health systems, simply calling for
different types. Health ministries, insurance agencies, public more accountability is less than helpful. On the surface, the
and private providers, legislatures, finance ministries, regu- notions of checks and restraints on power and discretion, of
latory agencies and service facility boards are all connected increased oversight and scrutiny, or of closer connections
to each other in networks of control, oversight, cooperation between service users and providers seem straightforward.
and reporting. However, the accountability interests of these However, for accountability to inform policy and
372 Derick W Brinkerhoff
programmes effectively, further conceptual work needs to be ‘stewardship’ in its contribution to government responsive-
done. Calls for more accountability are often efforts by inter- ness and good governance (see Saltman and Ferroussier-
ested actors to change the focus and purpose of account- Davis 2000; Travis et al. 2002). Further, such dialogue can
ability, rather than simply to do ‘more of the same’ (Romzek build citizen trust by signalling that government actors are
2000, p. 35). Accountability risks becoming another interested in citizens’ views and well-being (see Gilson 2003).
buzzword in a long line of ineffectual quick fixes, or, worse,
a one-size-fits-all bludgeon that encourages excess and over- The availability and application of sanctions for illegal or
regulation. inappropriate actions and behaviour uncovered through
answerability constitute the other defining element of
This article focuses on accountability as it relates to health accountability. The ability of the overseeing actor(s) to
systems and policy in developing/transitioning countries. The impose punishment on the accountable actor(s) for failures
analysis reviews and synthesizes the literature on the topic, and transgressions gives ‘teeth’ to accountability. Answer-
noting areas of convergence and of ongoing debate. The ability without sanctions is generally considered to be weak
article addresses the definition and clarification of account- accountability. Most health policy sanctions are based upon
ability, examining how the term can be more precisely regulatory power, for example in the United States,
defined and made more operationally relevant. It then offers Medicare’s authority to levy fines on hospitals that improp-
an analytic framework for accountability and health service erly code patient discharges. The courts intervene with legal
delivery systems that highlights the following questions. sanctions to enforce accountability between provider and
What are the various purposes and targets for accountability? patient, and patient and payer, but this relates to a different
basis of publicly available information on quality and as well as a variety of other indicators, thus joining answer-
performance, accountability is enforced through the ability ability and sanctions. Armed with this database, the agencies
of clients to switch from low quality/performing clinics to can enforce both financial and performance accountability
high quality/performing ones. The ability of health clinic through the negotiation of contract provisions and fees.
users to hold clinics accountable by exercising their exit
option creates incentives for responsiveness and service
Accountability for what?
quality improvement (see, for example, Paul 1992). Of
course, as discussed further below, information asymmetry Defining accountability more precisely also relates to speci-
poses a classic barrier in that clients may not have sufficient fying accountability for what? Three general categories
information to judge quality and performance, and thus may emerge from answering this question. The first addresses the
not demand the ‘right’ kind of health care (Gauri 2001). This most commonly understood notion of accountability, finan-
can dampen the effectiveness of exit for accountability. cial accountability. The literature in this area deals with
compliance with laws, rules and regulations regarding finan-
A related set of ‘softer’ sanctions concerns public exposure cial control and management. The second type of account-
or negative publicity. This creates incentives to avoid damage ability is for performance. The literature here is arguably the
to the accountable actor’s reputation or status. For example, largest, encompassing public sector management reform,
investigative panels, the media and civil society watchdog performance measurement and evaluation, and service
organizations use these sanctions to hold government delivery improvement.2 The third category focuses on
officials accountable for upholding ethical and human rights political/democratic accountability. Literature here ranges
attributable to local cost factors. They also need the capacity and social decision criteria (Saltman and van Otter 1995;
to detect and sanction malfeasance and corruption, for Bovbjerg and Marsteller 1998). In developing countries,
example, procurement fraud, overbilling, falsified staffing these tensions are exacerbated by a lack of resources and
levels and so on (for example, Di Tella and Savedoff 2001). capacity; even if government provides fiscal subsidies, facili-
At the facility level, for example, hospital managers need to ties and caregivers are frequently maldistributed, poorly
be able to account for the disposition of the funds they equipped, and in rural areas, scarce or nonexistent (see
receive from various sources, and to enforce compliance Bloom 2000).
from their staff.
Political/democratic accountability also relates to building
trust among citizens that government acts in accordance with
Performance accountability
agreed-upon standards of probity, ethics, integrity and
Performance accountability refers to demonstrating and professional responsibility (Gilson 2003). These standards
accounting for performance in light of agreed-upon perform- reflect national values and culture, and bring ethical, moral
ance targets. At the health system level, the focus is on the and on occasion religious issues into the accountability
services, outputs and results of public agencies and equation at both agency and facility levels. For example, in
programmes, not on individual service encounters between some countries, caring for the sick is a religious duty, and in
patients and providers. Health system performance account- response health care providers feel an obligation to deliver
ability is linked to financial accountability in that the finan- services. What this means for political/democratic account-
cial resources to be accounted for are intended to produce ability is that health systems whose providers reflect such
example, determining who receives what care, despite official The inability of health facilities to track and report on
procedures. Health service users, especially the poor, are in budgets, collection of fees, pharmaceutical purchases and
a weak position to confront this power. supply inventories, vehicles and equipment, and so on, limits
possibilities for accountability for control and assurance
Secondly, there are often divergences between public and purposes. It results in waste in the health system and can
private interests and incentives, which can constrain efforts create fertile ground for corruption. Further, weak capacity
to increase accountability (see Bennett et al. 1997). For to exercise oversight of facility and practitioner performance
example, Shaw (1999) notes differences between public and hampers efforts at accountability for the purpose of perform-
private sector providers in terms of the extent to which they ance improvement. This capacity gap is aggravated by the
receive and face incentives to act upon service user feedback. difficulty in isolating the contributions of various health
The difficulties of creating performance incentives for public system actors to achieving performance goals. Many
sector providers insulated from client accountability are well developing/transitioning countries that have moved away
recognized (see, for example, Goetz and Gaventa 2001), as from predominantly public provision of health care toward
are the challenges facing incentives design for the private private sector models have weak regulatory capacity, making
sector (see Bennett et al. 1997; Brugha and Zwi 1998). it difficult to exercise quality assurance (see Standing and
Bloom 2003).
Another divergence of public versus private interests arises
between policymakers focused on assuring some minimum Disparities between the sanctions that exist ‘on paper’ and
level of care available to all and individual service users with capacity to enforce them pose equally serious accountability
supporting improved performance/learning. This creates a governance and institutional structures: for example,
framework for categorizing and taking stock of health system national, district and local health councils; hospital boards;
reforms in terms of accountability. medical review boards and professional certification bodies;
decentralization, and so on (see, for example, Mills 1994;
A focus on accountability can lead to an increased under- Savage et al. 1997; Gershberg 1998; NPPHCN 1998; Salmon
standing of health system operations, clearer identification of et al. 2003). In the health economics and financing literature,
the pressures and incentives facing health system actors, and as noted above, accountability implications can be identified
better reform design and implementation. This systemic in the context of analyses of health care markets, principal-
focus helps to identify factors that influence the success agent issues arising from information asymmetries, public-
potential of interventions intended to achieve one or another private mix, demand-driven services and user fees,
of the three purposes. For example, tackling corruption in the priority-setting, and separation of payment from provision.5
health sector is not likely to be sustainable without some Accountability also figures, sometimes implicitly, sometimes
degree of political/democratic accountability, which creates explicitly, in the quality assurance/quality improvement
and strengthens the incentives for health policymakers to literature.6
respond to citizens’ needs and demands.
Once types and purposes of accountability have been
However, few policy designs and strategies for health sector unpacked, a next step in integrating a focus on accountability
reform and system strengthening use accountability as an into health policy and systems strengthening is to develop a
integral theme. Rather, they focus on one or another aspect clearer picture of accountability relationships and connec-
International donors
Local govt officials
Professional assoc
Funding agencies
Health svc users/
Hospital boards
Health councils
Unions
NGOs
MOH
MOH
Agencies of restraint
Funding agencies
Parliament
Local govt officials
NGOs
Hospital boards
Health councils
Professional associations
Unions
Health care providers
International donors
à ð è
Code:
â ò ê
Capacity to supply information or respond to sanctions: Weak , Medium , Strong
Capacity to demand information or impose sanctions: Weak , Medium , Strong
which actors are in a position to demand information and types of accountability, for example financial versus service
impose sanctions, and which actors are charged with delivery performance.
supplying information and are subject to sanctions. To
adequately capture the complexity of accountability linkages, Building on the matrix/matrices, next steps would include
separate tables for answerability and sanctions would be identification of problems/issues related to answerability and
prepared, which would take into consideration the distinc- sanctions, and of which types of accountability (financial,
tions between these two elements of accountability and the service delivery performance, political/democratic) are
different implications for the design of system improvements. involved. Such analysis would inform appraisal of actors’
For reasons of economy, Figure 1 illustrates both information capacity to fulfil accountability roles, help to pinpoint gaps,
demand/supply and sanctions on a single table. and feed into setting purposes and targets. When undertaken
as a team effort, the mapping exercise could also serve to
The table(s) can indicate situations where there are either support the process dimension of achieving change targets. It
two few or too many accountability linkages. There is no could forge consensus among reform team members, as well
universally ‘correct’ number of accountability linkages. How as point to who else needs to be involved. Strategy implemen-
many linkages are appropriate will, to an important extent, tation will depend upon tapping the shared interests of
be situation-specific, and will depend upon the quality, not various actors to build coalitions, commitment and mutual
simply the number, of connections. Nonetheless, the litera- understanding (see Gilson 1997; Gilson et al. 1999; Brinker-
ture and experience suggest the following: hoff and Crosby 2002). Clarifying actors’ connections, capac-
ities and interests is a key input for developing strategies to
The analytic framework presented here represents an initial Bovbjerg RR, Marsteller JA. 1998. Health care market competition
effort to consider accountability from a systemic perspective, in six states: implications for the poor. Occasional Paper No. 17.
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1 In the governance literature, this debate is reflected in a
Cruess SR, Cruess RL. 2000. Professionalism: a contract between
concern that market mechanisms transform citizens into consumers. medicine and society. Canadian Medical Association Journal
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with limited purchasing power? See Blanchard et al. (1997). Regard- Latin America’s public hospitals. Washington, DC: Inter-
ing the role of markets and the private sector in the health sector, American Development Bank.
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