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How Is Accountability Measured in Healthcare?

Accountability is a challenging word to unpack. It has many dimensions and applies to all healthcare workers and patients, including psychologists. If you're a behavioral health professional and want to improve accountability in your practice, we hope to help you in this post. We'll explore the meaning of accountability, how it relates to your relationship with clients, how it's measured and what challenges you might encounter.

Table of Contents

What is accountability in health systems, why is accountability important in healthcare, how is accountability measured, accountability best practices, how to encourage accountability, challenges in accountability, improve accountability with icanotes.

Accountability is the idea that individuals are responsible for their actions and obligated to explain their choices. Generally, being able to justify your actions leads to a reward. Not being able to explain an error or wrongdoing brings consequences.

An example of healthcare-related accountability is if a supervisor asks a staff member to explain a documentation mistake. Other examples of accountability include answering to an insurance company or addressing residents' health concerns in a public meeting. Accountability has many meanings in governance, law and ethics, but it is not reserved solely for policymakers. Accountability plays an important role in your relationships at work and at home.

For instance, accountability is a critical component of the client-therapist relationship. As a behavioral health professional, accountability means putting the client's best interests first and always being able to justify your actions. It also means complying with privacy laws and ethical codes of conduct to protect your clients' confidentiality and safety. For clients, accountability may mean explaining why they decided not to follow their treatment plan or take their medication.

Accountability can encourage patients to participate in their treatment and recognize their influence on their mental and physical health. When clinicians and patients work as a team and accept responsibility for their individual actions, clients are better positioned to reach their health goals.

Accountability is critical in all aspects of the healthcare system, from government health policies to employee training programs. Without accountability, healthcare facilities and counseling practices risk decreased morale and productivity, ultimately reducing patients' quality of care. With accountability, you and your staff members are prepared to rectify mistakes, find solutions and commit to responsibilities rather than make excuses. Accountability allows you to learn from errors so you can improve your practice's reputation, reach business goals, decrease the risk of lawsuits and improve client satisfaction.

Healthcare workers are not the only ones who should embrace accountability. Patient accountability in healthcare is equally important and can lead to positive treatment outcomes. When patients accept their role in their health and acknowledge the obstacles that keep them from reaching goals, they can change negative behaviors.

Accountability is more likely to increase if it can be measured. If there's no way to prove someone is accountable for a mistake or failure, there's less incentive to put effort into a task. In general, healthcare facilities measure financial and performance accountability. Financial accountability involves tracking and reporting the use of monetary resources. Performance accountability may refer to measuring how well clinicians and staff members meet goals or score on patient satisfaction surveys.

Regarding the client-therapist relationship, measuring accountability can help clients who struggle to progress or change harmful behaviors. You might set a time to discuss accountability with clients and evaluate their development every so often. During this meeting, talk with the client about how far they've progressed, where they currently stand and where they're heading. If the client isn't accomplishing any goals, ask them questions and determine what needs to change.

Make sure they understand you're trying to find solutions and are not interested in punishing them. You might ask questions such as:

• Why are some tasks not completed?
• Are some activities not important to you?
• Are some activities too difficult to complete?
• Did you set time aside to complete the task?
• Did something unexpected happen to prevent you from finishing an assignment?

Regularly checking in with your clients may motivate them to accept accountability rather than make excuses for not following their treatment plan. Encourage clients to discuss what works for them and what doesn't seem to help, including if they need to focus on something different. Traditionally, therapists use treatment plans to discuss goals and objectives, but you may also use rating scales or checklists to track progress and treatment effectiveness.

Since accountability is a two-way street, consider your own performance when patients take assessments, or ask clients to complete a brief and anonymous patient satisfaction survey. By measuring your performance, you can grow professionally and improve client outcomes.

There is a right way and wrong way to approach accountability. Employees and clients should understand that accountability is not about blaming, getting angry or making others feel guilty. It's about finding solutions and working together to accomplish goals. Here are a few best practices to keep in mind:

• Know the reasons: Make sure you and your clients understand your actions and the purpose of their treatment goals.
• Consider your qualifications: Always ensure you're qualified and trained to provide a service your client requests before taking action.
• Agree on treatment: Any steps you take to help your client should be part of an agreed-upon plan.
• Set clear boundaries: You may need to ensure your client understands your role by establishing clearly defined boundaries.
• Monitor and evaluate: Keep track of your client's progress, so you can identify issues early and make recommendations. Spend time periodically assessing the effectiveness of a client's current treatment plan.
• Help employees change: Make sure employees understand the importance of accountability in your practice and how it impacts patient care and your facility's success. Encourage employees to share their thoughts and feelings.
• Make it easy: The concept of accountability can feel overwhelming to both clients and staff. Focus on changing one behavior at a time.
• Be honest: Part of accountability is being honest. Set an example by being honest if you make a mistake and encourage employees to do the same.

If you wish to understand the psychology behind not taking responsibility, consider this study published in the  Personality and Social Psychology Bulletin . According to the study, people might avoid accountability because it feels threatening to accept blame. However, people are more likely to take responsibility if they view wrongdoings as a chance to grow as a person. Keeping this in mind along with the following tips, you can create a culture of accountability in your practice.

Begin With Collaboration

Ensure clients understand that change happens internally and that you must work as a team to help them overcome difficulties and improve their behavior. Let them know you're there to help them make sense of their priorities and transform these into real goals, but they still have to do their part to make things happen. Lastly, remind them that it's better to be honest if they can't reach a goal rather than make an excuse.

Set Clear Expectations

Setting clear expectations is an essential part of accountability. Clients or staff are not likely to put their best effort into reaching goals if they don't know what's expected of them or why they are working toward a specific goal. Be sure to express what you're hoping to achieve and how clients or employees should complete tasks.

Go over the rewards of reaching goals and how clients and staff can know they were successful. Invite others to share their ideas and concerns. Find out what they want, what expectations they have and what issues they might be experiencing. You'll want to get everyone on the same page for easier collaboration and increased willingness to share thoughts.

Discuss Capabilities

Clients can't reach goals if they do not have the skills or resources needed to complete certain activities. To avoid accountability issues in the first place, set clients and staff up for success by making sure they are capable of doing what's asked of them. Consider what specific tools they might need to achieve certain objectives. Can they obtain these things if they don't currently have them? What can you do to make that process easier?

Determine How You'll Measure Progress

You and your clients should set clear, measurable treatment goals and objectives together and agree on how you'll measure their progress. Find out how much time your client is comfortable spending on assessments or other tools to gauge treatment effectiveness.

Give Feedback

Continually check in with clients and discuss their thoughts and feelings about their therapy sessions. Consider what each client says or use a rating scale to get feedback. A rating scale can show you if clients are satisfied with your services, which clears up ambiguities.

You'll also want to provide feedback and share your thoughts about a client's progress. Encourage open communication and remind the client that you want them to have a more satisfying experience. If you find that something isn't working, brainstorm a solution with your client to help them stay on track.

Build a Strong Connection

If clients resist adopting accountability and working on treatment goals, you may need to give them more time to develop a greater sense of trust. Also, make sure you set agreed-upon goals. Clients must feel ready to change. Otherwise, they may resist moving forward.

Your relationship with your client is critical to improving accountability for both of you. If a client feels a strong connection with you, they are more likely to share their true feelings, thoughts, needs and anything else required to help them change and accomplish goals. They are also more likely to admit mistakes. Ensure they know you're there to help them find a solution if they're having trouble reaching goals.

Acknowledge Success

Whether you're working on building accountability in your practice or helping clients get motivated, make sure to acknowledge accomplishments. For example, you might ask clients to identify activities they enjoy, whether that be watching a favorite TV show or eating a piece of candy. Encourage them to reward themselves after they complete therapy-related homework assignments.

Provide Tools

You can help your clients be more accountable and complete tasks by offering technological tools that make it easier for them to manage their health. For example, you can use an electronic health record (EHR) system that provides a patient portal . Clients can use the patient portal to access their medical history, manage appointments and request refills. Other features, like automatic appointment reminders, help clients prepare for therapy sessions and get to appointments on time.

Overall, you can use technology to give clients greater control of their care and help them be more accountable.

Creating a culture of accountability is not always easy for various reasons. If you find that clients or employees struggle with accountability, try to identify and address the root cause. Some possible reasons clients may have trouble with this concept include:

• Problems at home: Clients may face issues such as financial instability or lack of support at home. Some obstacles may prevent them from focusing on achieving treatment goals and improving their mental and physical health. If you find clients struggling to reach goals due to challenges at home, you may need to adjust their treatment plan to suit their situation better. Remind them that they can still change their behavior to improve their health, even if they need to take baby steps.
• Fear of consequences: If employees or clients worry about the repercussions of making mistakes or failing to reach goals, they're less likely to embrace accountability. Remind staff members that everyone makes mistakes sometimes, and help employees or clients feel safe reporting errors or expressing their concerns.
• Aversion to therapy:  Some clients may be pushed by a loved one to meet with a counselor. Others may be mandated by the court to receive treatment. If clients feel they don't need therapy, they might challenge accountability. Resistant clients require patience, empathy and creativity. You may need to find new ways to interact with them. Allow time for them to trust you. Once you build a connection, they'll be more likely to work to change their behaviors. If you feel stuck along the way, consider turning to peers for support.

Using a secure, timesaving EHR system like ICANotes can help you increase efficiency and support accountability in your practice. With ICANotes, you and your employees can enjoy features such as convenient note-taking templates, a telehealth platform, a patient portal and billing solutions.

You and your staff can decrease errors and spend less time on documentation, allowing you to improve your accountability and reach goals as a team. If you would like to experience ICANotes firsthand, sign up for a free trial . For more helpful healthcare tips, please browse our blog .

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• Published: 29 March 2019

Studying social accountability in the context of health system strengthening: innovations and considerations for future work

• Victoria Boydell   ORCID: orcid.org/0000-0001-5051-9167 1 ,
• Heather McMullen 2 ,
• Joanna Cordero 3 ,
• Petrus Steyn 3 &
• James Kiare 3  

Health Research Policy and Systems volume  17 , Article number:  34 ( 2019 ) Cite this article

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There is a growing body of research on the role of social accountability in bringing about more accessible and better-quality healthcare. Here, we refer to social accountability as “ citizens’ efforts at ongoing meaningful collective engagement with public institutions for accountability in the provision of public goods ” (Joshi, World Dev 99:160–172, 2017). These processes have multiple interrelated components and sub-processes and engage a range of actors in community-driven, often unpredictable and context-dependent actions, which pose many methodological challenges for researchers. In June 2017, scientists and implementers working in this area came together to share experiences, discuss approaches, identify research gaps and consider directions for future studies. This paper shares learnings from this discussion.

In particular, participants considered (1) how best to define and measure the complex processual nature of social accountability; (2) the study of social accountability as an inherently political process; and (3) the challenges of generalising unpredictable, community-driven and context-dependent processes. Key among a range of consensus areas was the need for researchers to capture a broader range of outcomes and better understand the nuances of implementation processes in order to effectively test theories and assumptions. Furthermore, power relationships are inherent in social accountability and the research process itself. In presenting details on these deliberations, we hope to prompt a wider discussion on the study of social accountability in health programming.

Peer Review reports

Introduction

Social accountability is gaining rapid acceptance as a way to address health systems inefficiencies and improve basic public health performance, including planning and service delivery, and to contribute to the attainment of the highest possible standards of health. Here, we refer to social accountability as “ citizens’ efforts at ongoing meaningful collective engagement with public institutions for accountability in the provision of public goods ([ 1 ], p. 161).” Footnote 1 For example, the use of community scorecard processes to improve maternal health services, whereby health providers and community members assess their existing entitlements in service delivery and then prioritise the issues they face in accessing and delivering services [ 2 , 3 ]. These priorities are then jointly shared in multi-stakeholder meetings with health officials, health facilities and the community to identify local solutions and actions for service improvement and to promote mutual responsibility and accountability. Other social accountability processes use a range of tools to trigger such changes, including social audits, public expenditure tracking systems, information campaigns, public hearings, participatory budgeting, and social movement to name a few. Interest in accountability has spurred a proliferation of studies on social accountability and other participatory processes in the context of health programmes. Yet, there has been less discussion on how to go about studying these dynamic and complex change processes.

The evidence on social accountability and health is growing fast. Early reviews found mixed evidence for the approach, partly due to the varied definitions of accountability used and the range of studies undertaken [ 4 , 5 ]. Another set of reviews summarised the quantifiable benefits of social accountability for service improvement, service utilisation and health outcomes using more linear cause–effect measures [ 4 , 6 , 7 , 8 , 9 ].

The definition of success encompasses more than directly measurable health-related outcomes and includes a wider range of governance outcomes such as empowerment, participation, and the responsiveness of duty-bearers [ 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 ]. Joshi notes the expanding number of outcomes related to social accountability “ are expected to unfold, and range from immediate short-term improvements in public services, to more durable long-term changes in states and societies ” ([ 1 ], p. 162). Evaluating a broader range of interrelated outcomes poses several methodological challenges.

In response to these methodological challenges, recent studies on social accountability in health service delivery have attempted to document and assess the complexity of activities and outcomes. Among the methodologies or mixes of methods used are randomised control trials to measure the impact on health and service delivery outcomes [ 2 , 3 ], realist evaluations of social accountability programming [ 18 , 19 ], process evaluations of the implementation processes [ 20 ], psychometric measures of governance outcomes [ 17 ], and Most Significant Change approaches to trace change [ 21 , 22 ], all of which are applied retrospectively and prospectively. These approaches have been developed independently and present a wealth of innovation and experience in their conceptualisation, design and execution. There is, therefore, much to be learned from existing research practice.

In June 2017, researchers and implementers had the opportunity to share experiences, methodologies and findings to help guide future endeavours. WHO’s Department of Reproductive Health and Research, which includes the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, convened an event on studying social accountability in Geneva, Switzerland. In this forum, researchers and implementers of social accountability in the context of health, and specifically in reproductive, maternal, newborn and child health, shared experiences, challenges and successes (see Acknowledgements section for list of participants). This paper shares learnings from this discussion.

In particular, participants considered (1) how best to define and measure the complex processual nature of social accountability; (2) the study of social accountability as an inherently political process; and (3) the challenges of generalising unpredictable, community-driven and context-dependent processes.

Defining and measuring the complex processual nature of social accountability

Social accountability processes aim to support service users voice their needs and make claims to their entitlements and hold those responsible for the provision of quality services to account. Accountability processes feature multiple and interrelated components, steps and actors, with several simultaneous processes of change, triggering collective changes. This process adheres to the definition of a complex intervention [ 23 , 24 ]. Therefore, the object of study is a highly unpredictable process with a range of outcomes, and it accordingly requires some methodological innovation. Difficulties in defining the boundaries of the intervention and outcomes of interest can prove challenging in the conceptualisation of research and the development of appropriate study designs. Given this complexity, the study of social accountability interventions can risk either being reduced to mechanistic formulas or dismissed as too context-specific and lacking a generalisable value that would allow replication.

One challenge is that social accountability is relational and focuses on the relationship between rights-holders and duty-bearers; therefore, interventions change and adapt as they are rolled out in specific localities and relationships [ 25 ]. This unpredictability may lead to activities and strategies falling out of line with pre-set interventions. To address this, many researchers described ways they documented and examined implementation to better accommodate adaptive interventions. Process evaluations are increasingly being used to effectively explore fidelity, dose, reach and cost, and realist evaluation methodologies have also been used to assess fidelity, context, mechanisms, and provide lessons for replication and scale-up [ 18 ].

Descriptive and analytic work on implementation is further complicated by the broad and interrelated set of outcomes that together facilitate change. Outcomes may include both routine health and service delivery outcomes, alongside changes in self-efficacy, social cohesion, trust and responsiveness. Less conventional outcomes in public health, such as increased responsiveness of service providers and policy-makers or the emergence of new norms around empowerment of community members and community capabilities [ 18 , 26 ], pose their own challenges because the metrics used to capture them are not standardised or widely accepted. Relatively new outcomes of interest need formative work to distil the mechanisms of effect and the most appropriate way to measure them. There have been efforts to capture the newer constructs (e.g. empowering service providers, mutual responsibility, increased confidence of service users) using psychometric measures and structured observations, which have been tested and are now moving into multi-country validation [ 2 , 14 , 20 ]. Others have been using approaches such as the Bellwether approach, outcome mapping and process tracing to assess changes in duty-bearers’ actions as a consequence of such interventions [ 3 , 27 , 28 ]. These innovations can be learnt from and built upon.

The composite nature of complex interventions presents yet more methodological challenges. Even when the outcomes are delineated, it may be difficult to attribute them to a specific part of a multi-component intervention [ 24 ]. By their very nature, social accountability processes are not easily standardised in their design and delivery as they are highly influenced by local context. Fox’s reinterpretation of the evaluation of evidence moves beyond treating social accountability as a bounded, tactical intervention built for field experiments, toward social accountability as multi-pronged process that utilises multiple strategies to encourage collective action and voice [ 11 ]. This means that the pathways between intervention and outcome are not linear or easy to attribute, and that a mix of methodologies and a range of data sources may be required to sufficiently describe an intervention’s effects [ 24 , 29 ]. Part of the challenge is determining whether the intervention was delivered as intended [ 30 ].

Evaluation strategies need to respond to this complexity and researchers are developing creative solutions. A recommended approach to studying complex interventions is to develop a theoretical understanding of the change process based on existing evidence and theory, and then model the complex intervention to inform the intervention and evaluation design [ 24 , 29 , 31 ]. Mixed methods approaches enable the collection of data which not only describes outcomes but also the processes, shedding light on factors affecting implementation, while still measuring key effects.

A range of tools and tactics are used to support social accountability processes, from community scorecards, audio-visual documentation of rights violations, village health committees and citizen charters. They may vary in focus, looking either broadly at health systems or focusing on specific service delivery points, and they vary in engagement type from collaborative problem solving to more adversarial approaches. These diverse social accountability processes share three broad components as a part of their theory of change, namely information, collective action and official response [ 5 ]. To date, elements of this theory of change have been evidenced, while others remain theoretical and need further work. Ideally, theories of change should be adaptive to the perceptions of participants and to changing conditions on the ground so that they are participatory and responsive.

Not only are social accountability processes unpredictable and the outcomes varied, but a host of activities, outcomes and ‘unintended outcomes’ (negative and positive) may not be recognised in many forms of data capture. Methodologies are needed to intentionally account for these; for example, the Most-Significant Change approach uses personal accounts of change to determine what is considered most significant, or diffusion of innovation research that studies the adoption of a practice among a group of stakeholders [ 21 , 32 ]. Local social hierarchies and power dynamics influence the implementation of social accountability efforts. These are often unspoken, easily elude the most ‘robust’ study design and scuppering the tidiest field experiment design intervention, and speak to the value of qualitative research [ 33 ]. Ethnographic methods, such as long-term observation, can be helpful in capturing the implicit and taken-for-granted hierarchies of daily life [ 34 ].

The study of social accountability as an inherently political process

The study of social accountability is never neutral as it is explicitly concerned with changing the power relationship between ‘citizens’ and the local duty-bearers, and are inherently political even if they do not intend to be. Many quantitative or clinical study designs attempt to control for and reduce complexity, which often means that the political dimensions of an intervention’s implementation are masked. These dimensions not only need to be recognised as germane to the trajectory and success of social accountability efforts, but also need to account for how the research process itself reflects or perpetuates power dynamics. Involving local political scientists in the evaluation processes can bring expertise and understanding of how power penetrates the capillaries of communities.

It is critical to acknowledge that those who actively challenge the authorities, even in research conditions, risk reprisals and social harm. The social, political and economic repercussions are substantial and, for many, disrespectful treatments may be pervasive and expected [ 11 , 35 ]. Ethical research conduct should extend to these very real-life negative consequences for ‘research participants’ and requires the provision of safeguards and protections. For example, community-based organisations often set up a telephone hotline for supporters/participants when working on accountability. Fields such as anthropology and psychology commonly employ codes of practice (see the American Anthropologist Association’s Principles of Professional Responsibility and the American Psychological Association’s Ethical Principles of Psychologists and Code of Conduct). Given the political character and ethical considerations of studying social accountability, a similar code of conduct could be relevant.

Moreover, researchers could move beyond just accounting for power to examining their role in power relationships. This could entail supporting the communities that they work with, and addressing community members’ concerns and issues, even if this is by simply raising the issue with the relevant authorities, and even if those issues are beyond the study’s objective. There are always dynamics around who sets the research agenda – who decides what questions to ask, how to define impact and who is implicitly entitled to do this. There needs to be openness to the different roles that researchers, implementors and communities can play. More concrete examples of how and where this has been done in a way that considers interests of ‘researchers’, ‘implementers’ and communities affected by the issue/intervention/research, would be beneficial.

The challenge of generalising unpredictable, community-driven and context-dependent interventions

The final area of consideration at the convening was on how best to discern generalisable findings from differently situated social accountability processes that adapt to local context. This area is relevant for replication, scale-up and sustaining successes after the intervention. There was consensus that, to assess an intervention’s potential for generalisability and replication, there needs to be consensus on which elements make for success. This involves unpacking the mechanisms of effect and determining what the ‘active ingredients’ are and how they relate to each other [ 23 , 36 ].

Firstly, identifying scalable ‘active ingredients’ requires moving away from cause–effect models and towards mixed methods, which can relate thick qualitative descriptions with impact measures. As such, across the board, recent well-resourced projects have successfully built intervention monitoring and/or process evaluations into studies of impact. This has varied from better documenting the exact inputs for an intervention, to more detailed process evaluations, including extensive in-depth interviews and observations. Moreover, these processes do not happen in a vacuum but rather in real world settings, where other programmes and interventions may be operating in the same area along with uncontrollable factors external to the programme. Accordingly, many studies map out existing programming as well as other contextual factors (e.g. elections) at play using political economy analysis and process mapping [ 18 , 37 , 38 , 39 ]. Contexts change and context analysis should capture context over time rather than a one-off activity that provides a snapshot.

Yet, even when we better understand ‘what works’, other factors may hinder these processes being replicated, scaled-up and sustained after the intervention. There are no guarantees that the stakeholders key in supporting any scale-up would be interested in doing so or have the appetite for scaling-up processes that challenge the status quo or authorities.

To bring about accessible and better-quality healthcare, it is important to recognise both the value and complexity of social accountability interventions and operate accordingly. In doing so, we should test our theories and assumptions by building on what we know, capturing a broader range of outcomes, and accommodating unpredictable implementation processes. This work happens in the real world, with influential power relationships and high stakes for participants. By moving towards co-design and horizontal approaches, anticipating exclusion and ensuring that safeguards are in place to prevent and mitigate exclusion, the power inherent in the research process itself can change. Finally, we must acknowledge – and advocate – that this work takes time and requires context-specific adaptations.

We recognise the limits of the word ‘citizen’, which excludes non-citizens who also have the right to make claims. We use the term ‘citizen’ as shorthand to refer to all rights-claiming people.

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Acknowledgements

The authors are writing this paper on behalf of the Community of Practice of Studying social accountability in the context of health programming and would like to acknowledge the members of the Community of Practice for their significant contributions, specifically Anayda Portela, Department of Maternal, Newborn, Child and Adolescent Health, WHO; Angela Bailey, Accountability Research Centre, American University; Anne-Marie Turcotte-Tremblay, Institut de recherche en santé publique de l’Université de Montréal; Asiya Odugleh-Kolev Health Systems and Innovation, WHO; Carolyn Blake, Sexual and Reproductive Health Unit, University of Basel; Elizabeth Allen, GOAL Uganda; Eveline Geubbels, Ifakara Health Institute; Fletcher Tembo, Independent; Heather McMullen, International Planned Parenthood Federation; James Kiarie, Department of Reproductive Health and Research, WHO; Joanna Cordero, Department of Reproductive Health and Research, WHO; Kamil Fuseini, Population Council Ghana; Marta Schaaf, Averting Maternal Death and Disability Program, Colombia University; Mary Awelana Addah, Ghana Integrity Initiative; Nanono Nulu, Reproductive Health Uganda; Niranjan Saggurti, Population Council, India; Patrick Kinemo, Sikika; Petrus Steyn, Department of Reproductive Health and Research, WHO RHR; Rajat Khosla, Department of Reproductive Health and Research, WHO; Sara Gullo, CARE USA; Suzanne Cant, World Vision; Victoria Boydell, International Planned Parenthood Federation; and Walter Flores, Centro de estudios para la equidad y gobernanza en los sistemas de salud.

The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated.

This work was produced with the support of the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, a cosponsored programme executed by WHO. The content is solely the responsibility of the authors and does not necessarily represent the official views of the authors’ employers or funders. Any opinion, finding, and conclusion or recommendation expressed in this material is that of the authors.

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Conception and design: VB. Drafting the manuscript or revising: VB, HM, JC, JK. Final approval of the version: VB, PS, JK. All authors read and approved the final manuscript.

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Boydell, V., McMullen, H., Cordero, J. et al. Studying social accountability in the context of health system strengthening: innovations and considerations for future work. Health Res Policy Sys 17 , 34 (2019). https://doi.org/10.1186/s12961-019-0438-x

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DOI : https://doi.org/10.1186/s12961-019-0438-x

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Accountability in Health and Social Care

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Accountability is an of import construct in wellness and societal attention scenes. When the NHS was set up the answerability of professionals was to service users and in medical specialty to a professional codification. Managed attention that was introduced in the 1980s and the rise of the service user motion that led to grounds based pattern resulted in alterations in the wellness attention industry. Clinicians were expected to run into a higher professional criterion at bend of the new millenary. The alterations that health care sector has undergone over the old ages highlight the demand for answerability. The populace that has become more knowing and usage sophisticated agencies of jointing their positions and outlooks, as service users every bit good as taxpayers and consumers demands to be safe when cared for within health care and societal attention scenes. The weaknesss at Winterbourne View infirmary and Mid-Staffordshire NHS Trust highlight the demand for health care practicians to be accountable. Accountability is a cardinal facet of wellness and societal attention pattern. This paper will critically discourse answerability in footings of the legal, ethical and professional rules that underpin health care. This paper will further research answerability in wellness and societal attention, the different countries of answerability in wellness and societal attention scenes and the importance of record maintaining. Persons undergoing intervention are owed a responsibility of attention by all health care professionals taking duty for their intervention ( Fullbrook, 2007 ; NMC 2008 ) .

Care within wellness and societal attention scenes is delivered by a scope of professions. Consequently answerability within the wellness and societal attention system in the United Kingdom is complex because of the legion administrations and subjects involved in the attention of people. Each profession has different duties and agreements, for prosecuting patients and the populace in the planning and determination devising for wellness and societal attention services, and for keeping themselves and each other to account. A figure of policies, protocols and criterions have been developed across the different subjects involved in the proviso of attention. These policies help clinicians dispatch a responsibility of auto and aid in the accomplishment of effectual pattern. These vary between professions and between services, and have been developed by national professional organic structures for single professions, by the Department of Health or other national NHS organic structures Thirty different wellness professions are presently regulated in jurisprudence on a UK-wide footing by nine regulative organic structures ( CHRE 2011 ) .

The NMC ( 2004 ) defined answerability as the agencies that persons are responsible for their actions and possibly asked to warrant them. Duty means being answerable for one’s ain actions. Mulryan ( 2009 ) agrees that this definition is concise but suggests that unluckily associates answerability with incrimination. The intent of answerability is to advance patient safety, trust and professionalism instead than apportion incrimination. Caulfield, ( 2005 ) states that: ‘Accountability is an built-in assurance as a professional that allows a nurse [ or HCA/AP ] to take pride in being crystalline about the manner he or she has carried out their practice.’ Accountability has three constituents:

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• The individual’s professional answerability for the quality of his or her ain work.
• The answerability of wellness professionals within the administrations in which they work.
• Accountability ( with others ) , as a senior member of staff, for the organisation’s public presentation and more widely for its proviso of local services.

Jasper ( 2007 ) postulates that there are four different types of answerability for nurses viz. ; professional answerability, answerability to the employer under a contract of employment, answerability to the patient under bing jurisprudence proviso and answerability to the profession under the Nurses, Midwives and Health Visitors Act 1979. Similar agreements are besides in topographic point for the different professional organic structures. Professional answerability means that the practician is a member of the profession, accepting the position, rights and duties that this brings and therefore utilizing one’s professional opinion and being answerable for it ( Jacobs, 2004 ) . A cardinal feature of a profession is that in the dealing for alone powers and privileges, the public assumes that the profession will modulate itself. The Codes of Conduct for the assorted professions within the wellness and societal attention sectors provide guidelines on how practicians should move. This means that practicians are lawfully accountable for their work and can be removed from the registry for unprofessional behavior that breaks the codification of behavior. There lies the outlook that all professionals will, if asked, be able to warrant the footing of their intercessions.

Healthcare professionals may meet the civil tribunals in relation to negligence claims or trespass against the individual or other civil wrongs the service user might endure as a consequence of clinical carelessness. When a patient suffers harm as a consequence of carelessness they or their household can convey action for carelessness and compensation. Judges use the Bolam Test when finding whether a wellness professional has been negligent ( Tingle and Cribb, 2003 ) . Where carelessness has occurred and injury caused because the professional failed to follow sensible instructions or protocols the employer has a right to take disciplinary action against the employee. Should the practician fail to pattern safely the employer may necessitate a period of supervised pattern, action programs, preparation, guidance, disciplinary processs, suspension or dismissal.

The practician is answerable to the condemnable tribunal when there is an allegation that a offense has been committed e.g. when gross carelessness by the practician consequences in a patient’s decease. In such a instance the practician can be charged with manslaughter and face imprisonment. It is this type of state of affairs that could ensue in a practician being answerable to all countries of answerability ( Ogston-Tuck, 2007 ) . Health service suppliers are accountable to both the felon and civil tribunals to guarantee that their activities conform to legal demands. In add-on, employees are accountable to their employer to follow their contract of responsibility. Registered practicians are besides accountable to regulative organic structures in footings of criterions of pattern and patient attention ( RCN et al, 2006 ) . The jurisprudence imposes a responsibility of attention on practicians, whether they are HCAs, APs, pupils, registered nurses, physicians or others, when it is “reasonably foreseeable” that they might do injury to patients through their actions or their failure to move ( Cox, 2010 ) .

Proper certification is a cardinal facet of entering what health care professionals do and how they decide a peculiar class of action. It is cardinal to the proviso of safe and effectual attention. Proper certification is declarative that there has been some grade of idea, planning, administration in the bringing of attention. It is declarative of a health care practician working in a skilled and safe manner. Prideaux ( 2011 ) posits that there is a strong association between proper certification and betterments in the quality of attention. This besides enables the answerability of professionals to be safeguarded. The different statutory regulators across health care province in their codifications of pattern the importance of keeping clear and accurate records ( General Medical Council ( GMC ) 2006, Health and Care Professions Council ( HCPC ) 2008 ) . The Nursing and Midwifery Council ( NMC ) flatly states that “Good record maintaining is an built-in portion of nursing and obstetrics pattern, and is indispensable to the proviso of safe and effectual attention. It is non an optional supernumerary to be fitted in if fortunes allow” ( NMC, 2009 ) . Indeed, this construct is applicable across to all those who deliver attention in whatever field they pattern. Healthcare records can be used in a assortment of scenes, including professional behavior hearings and tribunals. What is documented and how attention is documented is highly of import. Full and accurate records can protect the practician if allegations of hapless or negligent attention are made. In footings of attention records should be: factual, consistent, accurate, in a logical sequence, ssing accepted nomenclature and contemporary ( NIPEC 2010, NMC 2009, GMC 2006, HCPC 2008 )

Documentation that lacks lucidity or significance is unsafe and fails to accomplish what it is intended to make ( NMC, 2005 ) . Dimond ( 2005 ) has identified a figure of jobs with. These are: deficiency of lucidity e.g. entries like ‘had a good twenty-four hours ‘ deficiency lucidity ; failure to enter action taken when a job is identified, e.g. ‘is enduring increasing hurting ‘ so no record of action taken ; losing information, e.g. disposal of a drug non documented ; spelling errors, e.g. mistake in name ensuing in incorrect diagnosing ; inaccurate records ; failure to papers attention given ; failures in communicating between health care professionals. Following any clinical accident whether it is a drug mistake, verbal maltreatment or force, accident or hurt to a patient, staff or visitant or member of the populace, it is indispensable that this is reported and documented. Near girls should besides be reported and documented. Harmonizing to Hulse ( 2007 ) , the degree of professionalism or carelessness experienced by the client can be demonstrated to the tribunal of jurisprudence by the manner the client records are written. The NMC ( 2010 ) states that proper records provide documental grounds of service delivered to the client and they help to turn to ailments or legal procedures. Furthermore, harmonizing to the Midwives Information Resources Services ( MIDIRS, 2010 ) hapless record maintaining is one of the most common grounds for wellness attention professionals to be struck off the registry. Client records need to be communicated to all members of staff as they promote better communicating and sharing of information between members of the multi-professional wellness attention squad ( NMC, 2010 ) . The NMC ( 2010 ) asserts that good record maintaining helps to place hazards and enables the early sensing of complications.

All health care professionals have a responsibility of attention to guarantee that people in their attention receive attention that is safe and effectual. It is of import that healthcare professionals are cognizant about professional issues like answerability and record maintaining and see them in twenty-four hours to twenty-four hours pattern.

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21 Accountability in Health Care

Department of Sociology

Professor in the Political Science and Public Health Department and Director of Center for Health Economics and Policy (CHEP), Copenhagen University, Denmark

• Published: 02 June 2016
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The debate on accountability within the public sector has been lively in the past decade. Significant progress has been made in developing conceptual frameworks and typologies for characterizing different features and functions of accountability. However, there is a lack of sector specific adjustment of such frameworks. In this chapter we present a framework for analyzing accountability within health care. The chapter makes use of the concept of “accountability regime” to signify the combination of different accountability forms, directions and functions at any given point in time. We show that reforms can introduce new forms of accountability, change existing accountability relations or change the relative importance of different accountability forms. They may also change the dominant direction and shift the balance between different functions of accountability. The chapter further suggests that developments in accountability regimes are best analyzed with a combination of top-down and bottom up perspectives and that there is a need to develop research strategies to support this aim.

The rhetoric of reform usually poses questions of accountability in terms of whether government employees are more accountable after the reform than they were before. While it is not impossible to discuss accountability in terms of more or less, doing so implies a uni-dimensional, linear concept that does not reflect the complexity of public management. (…) A more useful approach, (…) recognizes the various dimensions of accountability and the complex context of public accountability. ( Romzek, 2000 , 22) Accountability is a word that is loaded with meanings that strike fear in the heart and soul of our health care system ( Harber and Ball, 2003 ).

Introduction

The quotation by Romzek suggests that accountability is a core part of most reforms. Accountability is a multidimensional phenomenon, where health care institutions may be subject to several different types of accountability demands and logics at any given point in time. The concept of “accountability regime” is useful for capturing this. The second quote, by Harber and Ball (2003) , refers to experiences of those working in the health care system or in the public sector. It illustrates that a careful balance must be struck between external, sanction-based accountability, and the intrinsic motivation and trust-based interactions in the highly professionalized system of health care.

Recent academic literature has outlined how the accountability discourse has expanded and how accountability has become a “magic word” ( Pollitt and Hupe, 2013 ) associated with a multitude of reforms and organizational changes in the public as well as private sector. Accordingly there has been an inflation in the use of the term, but there is also “a minimal conceptual consensus” that provides us with a point of departure ( Bovens, Goodin, and Schillemans, 2014 ). At the core of the concept of accountability are specific types of relationships between actors and levels within systems, where actors have obligations to account for their decisions and behavior. Actors in these systems must explain and justify their behavior in forums of different kinds, and such account giving may actually have consequences ( Bovens, 2007 ). However, such relationships play out in different, interrelated spheres of modern societies and take a variety of forms. It is therefore important to consider the specific contexts for accountability structures ( Romzek, 2014 ; Mansbridge, 2014 ). National, sector specific, organizational, and micro-level context determine how the balance can be struck between formal and informal accountability mechanisms ( Romzek, 2014 ), and to which extent the systems can rely on a core of trust and selection-based social accountability ( Mansbridge, 2014 ). The distinction between informal and formal is a classical one in organization theory and refers to the distinction between formalized structures and regulations on the one hand and shared norms and expectations on the other ( Romzek, 2014 ). Selection and trust-based accountability refers to the traditional model of health care where formal education and subsequent licensing of medical professionals is the central mechanism for governance and knowledge development ( Mansbridge, 2014 ).

We suggest that a comprehensive framework distinguishing between form, direction, and function of accountability is helpful for understanding the complex accountability structures within health care, in the context of NPM and post-NPM reforms introduced since the 1990s ( Lægreid, 2014 ). We use the two Nordic countries of Denmark and Norway to illustrate selected aspects of this comprehensive framework, and we address the issue of whether the traditional trust-based ( Mansbridge, 2014 ) and somewhat informal ( Romzek, 2014 ) accountability logics within the public decentralized health systems in Denmark and Norway have changed in terms of form, direction, and function. We discuss whether recent reforms have implied a change towards more formalized ( Romzek, 2014 ) and sanctions-based ( Mansbridge, 2014 ) accountability forms and we discuss the possible consequences of such changes.

Accountability Concepts for Health Care

Accountability in health care remains a sparsely analyzed field although it is possible to find examples of literature at least back to the 1970s that refers to the concept ( Etzioni, 1975 ; Day and Klein, 1987 ; Emanuel and Emanuel, 1996 ; Relman, 1988 ; Tuohy, 2003 ; Brinkerhoff, 2004 ; Rosen, Israeli, and Shortell, 2012 ; Denis, 2014 ). A starting point in this literature is the distinction between responsibility and accountability, and it is indicated that there has been a movement from the first to the latter. The physician profession has been the core of health care, but as the patient perspective has become more important there has also been a change from trusting to checking. Since the end of the 1980s it has been argued that health care had moved from the era of responsibility to accountability ( Relman, 1988 ). Most states had relied on professional self-regulation in health care, where the state delegated decision-making authority to the professional bodies of medicine. This worked as long as the quality of the relationship between doctor and patient was in focus, but new ways of governance had to be developed as the states faced the challenges of expansion in funding needs and demands for cost and quality control ( Tuohy, 2003 ). The role of indirect instruments and third parties for maintaining accountability was now brought into the limelight as many governments developed a policy for information gathering and performance management. One way of framing the issue was to see the new regime as part of an “audit society” where control was pushed further into organizational structures, inscribing in it systems that could be audited ( Power, 1997 , 42).

Although the narratives are similar and most seem to worry about the consequences for established trust relations ( Rosen, Israeli, and Shortell, 2012 ), there were also differences among scholars in the way they framed the accountability problematic. Some were more preoccupied with context and how accountability was related to national and organizational cultures ( Saltman, 2012 ) and politics ( Mattei, 2009 ), whereas others were seeking to develop the ideal model of accountability across national systems, focusing more on the variations among the various domains of the health care systems in any country ( Emanuel and Emanuel, 1996 ). It is clear from these contributions that accountability illustrates central dilemmas in the current governance of health care systems ( Thomas, 2003 ). In the following we will depart from a framework for studying accountability developed by Mark Bovens, which may be used to identify and analyze such dilemmas.

Bovens’ (2007) often-cited definition of accountability is based on the distinction between an actor and a forum, and includes the precondition that some form of instrumental authority is involved: The actor may face consequences on the basis of being held accountable by the forum, and the forum actually has the necessary authority to both demand accountability and impose sanctions.

The social expectations of when and how to give account, the content of account giving and the types of potential sanctions associated with account giving vary over time and across different social spheres. Formal rules for accountability relationships represent conscious attempt to establish such expectations and obligations. But accountability also has a more informal and dynamic side, since the formal rules are constantly interpreted and applied in practice. Indeed some types of accountability primarily rest on informal and normative basis ( Romzek, 2014 ), where social sanctions are the main mechanism for ensuring trust-based relationships ( Mansbridge, 2014 ). Such informal, trust and selection-based accountability ( Mansbridge, 2014 ) has been particularly important within the field of health care, due to the high degree of information asymmetry between managerial/public principals and professional agents. This information asymmetry makes it difficult to monitor behavior and makes the cost of monitoring and sanctioning relatively high. At the same time a high degree of flexibility is necessary for health professionals in making decisions on treatment. Selection and trust-based accountability in health care rests on the formal education and subsequent licensing of medical professionals. Once you have been selected into the profession, you are formally entrusted with treating patients and being part of the medical community. Within the medical community a number of informal norms exist to reinforce a constant focus on applying the most up-to-date evidence in treatment practices. This informal, normative pressure operates through medical societies and peer group discussions at the general level, and within the specific organizational settings for delivering health care. Ideally this ensures a high level of professional ethics and best practice. However, one might argue that the degree of actual scrutiny of practices in peer-based systems can be relatively weak, and that there are few formal opportunities for sanctioning if things go wrong. Sanctions are often relatively subtle and relate to lack of promotion and gradual exclusion of the social community. The efficiency of this type of accountability scheme is thus based on the premise that there are a significant number of agents with trustworthy internal motivations for delivering high quality services within this field, and that these internal motivations are backed by widely accepted social norms within the profession to ensure a high level of quality. This premise has been questioned particularly in the past three decades for a number of reasons. First, the availability of information about performance is much greater today than in previous decades. This means that poor performance is much more likely to be discovered by the public. Several highly publicized scandals, for example in England, bear witness to this ( Peckham, 2014 ), but discussions about comparative performance have also been important drivers of health policy in the Nordic countries. Second, although the medical profession may consist of many idealistic and intrinsically motivated individuals, their normative orientation tends to be focused on clinical issues for the individual patient and not the broader and sometimes conflicting societal goals within health systems. Health care professionals may thus work hard to optimize within their clinical performance, but at the same time the system may fail to live up to broader objectives of cost containment, equity, responsiveness, and promoting public health ( Papanicolas and Smith, 2013 ). To ensure such broader objectives and to reinforce the internal normative structures within health professions there has been a pressure to introduce additional accountability structures over the past three decades.

In the words of Mansbridge (2014) the combined result of such changes is that the core of trust and selection based accountability in regards to the professional staff, has increasingly become circumscribed by political, administrative/managerial or market based mechanisms to scrutinize performance and issue sanctions, if particular health professionals or organizational units fail to live up to standards. Some of these new accountability structures are generated by developments within the health care sector itself, while others are a product of general trends in public administration, which has meant that many parts of modern societies have become characterized by a multitude of accountability forms. Such general reforms have introduced new governance forms, which have added to the complexity and ambiguity of the overall accountability structure ( Lægreid, 2014 ). To disentangle the complexity of the new accountability structure we find it useful to introduce an analytical distinction between six different accountability forms ( Mulgan, 2000 ; Willems and Van Dooren, 2012 ).

Political accountability denotes the relationship between political leadership and citizens, in the sense that politics and policies are displayed and performed in a variety of areas where citizens may act as a forum towards political leaders. We emphasize the formal “democratic chain of command” from voters to parliament and from parliament to executive powers (see column 2 in Table 21.1 ). Important accountability mechanisms in these relations are elections, where voters hold politicians to account, parliamentary scrutiny and questions and budgets and budget controls, transparency rules and administrative policy regulations for steering the bureaucracy (column 3 in Table 21.1 ).

By administrative accountability we emphasize accountability relationships inside the administration or by external audit institutions. Important relations are thus between higher- and lower-level administrators in hierarchical relations, and between internal and external auditors and public organizations. There has been a development where traditional “weberian” bureaucratic accountability has been supplemented or in some cases substituted by new public management (NPM)-style “managerial accountability” based on performance measurements, contracting, benchmarking, and so on. External audit is another administrative accountability form. Some types of external auditing have existed for a long periods of time (e.g., general accounting offices and ombudsmen), while others are more recent (e.g., accreditation of hospitals).

Professional accountability refers to accountability relationships that are oriented towards operational quality performance and professional standards. Much of this takes place internally within professional ranks, but there are also external and formal channels for professional scrutiny of conduct, for example through the complaint system, whistleblower arrangements, and audit agencies. Accountability relations are thus between peers and within medical hierarchies. Primary accountability mechanisms are peer reviews, whistleblowers and external examiners and health professionals, and increasingly also between administrators and professionals.

Public accountability refers to the external scrutiny of health care administration and organizations by more or less organized civic society groups and mass media. Both play an important role in health although in a rather ad hoc fashion and with clear bias in terms of which civic society groups (patients, industry, etc.) that have most resources to exercise this type of accountability.

Market accountability has traditionally played the most important role in market- and contract-based health care systems. However, in recent decades there has been an increase in the number of private actors and contractual relationships in most public health systems also. At the same time there has been an increased emphasis on patient choice as a policy tool in health care. A number of performance measurement systems have been developed to support choice including measurements of patient experiences, waiting times, and quality.

Judicial accountability concerns the use of formal legal interventions through civil and administrative courts. This type of accountability has traditionally played a less prominent role in the Nordic, universalistic health systems than in insurance-based systems, as the legislation typically specifies general obligations for public health systems rather than specific rights. However, there has been a tendency to inscribe more rights into the health legislation in recent years (waiting time guarantees, choice of provider, information and informed consent, etc.).

Public or private insurers and public or private bodies responsible for organizing and delivering health services

Function and Direction of Accountability

Classical accounts of accountability distinguish between a constitutional, democratic, and performance function of accountability ( Willems and Van Dooren, 2012 ). Public authorities are held accountable for a variety of well-established rules and procedures to prevent unfairness and abuse of power. Procedural rules regarding due process, equal treatment, openness, and impartiality belong to this category. “Constitutional” rules are meant to provide boundaries for the exercise of public power and to safeguard rights for the individual. Such concerns are also important within health care. The principle of equal rights is safeguarded in universalistic health systems, and all European health systems have a set of minimum requirements for health care insurers and providers. But the issue of “policing the boundaries” of professional conduct and safeguarding rights has a deeper meaning within health care. This is based on the high degree of information asymmetry between professionals and patients, and by the potentially severe consequences for the individual if professionals fail to live up to general standards. This accountability relationship deals with protection of personal integrity, dignity, and safety in all relationships between professionals, pharmaceutical and medical device producers, and patients.

The “democratic” function refers to the interest of citizens (or elected representatives) to be able to control the legislative and executive powers of the state. Citizens should be able to hold representatives accountable for decisions and to select other representatives if necessary. Within health care this means having the means to control and select the formal democratic decision-makers that set the regulatory boundaries for health care and determine principles for allocation of public resources in the sector. In public integrated health systems such as the Nordic systems and the UK this also extends to controlling the public health care delivery organizations and their employees.

The “performance” function deals with the output dimension of public activities (Scharpf, 1999). Citizens and patients should ideally be able to hold health care providers accountable for the results they achieve. Collectively we should be able to judge whether we get optimal societal value for the resources allocated to health care. The types of measurements to support performance accountability range from quality data reported into clinical databases to process data (e.g., waiting times and adherence to standards) and service quality data (e.g., measured as patient-perceived quality). Performance data is often made publicly available to allow comparisons and questioning (public accountability) and to support efforts to develop incentive schemes and sanctions by political, administrative, or private principals (political, administrative, and market accountability).

The performance function has become more important in recent decades for the public sector in general ( Hood, 1991 ; Van Dooren, Bouckaert, and Halligan, 2010 ). This is expressed in a significant growth in monitoring and auditing mechanisms focusing on the three e’s of efficiency, economy, and effectiveness. Within health care we have seen an explosion in performance measuring systems focusing on quality, service, and efficiency.

An additional theoretical distinction should be made about the “direction” of accountability relations.

Schillemans (2011) distinguishes between horizontal and vertical accountability relationships. Vertical accountability refers to situations where a superior demands an account from a subordinate. As with classical hierarchical accountability, a defining characteristic is that authority and distribution of roles are formalized or of a strong character; as is the case between a minister and a ministry. In horizontal accountability mechanisms, the situation is rather an absence of hierarchical relations. Instead there is an accountability relationship to a third party, a peer, or a non-hierarchical forum. The relationship may or may not be formalized; there is no subordination of one actor towards the other, as in the relationship between a semi-autonomous audit agency and an administrative institution or the relationship between interest groups and service producers. Bovens (2007) also suggests this distinction, but includes the possibility of a diagonal arrangement: In diagonal accountability relationships the forum is not hierarchically superior to the actor, but still has sanctioning powers and acts on behalf of another authority. Ombudsmen or independent complaint boards could be examples of such accountability arrangements; they are not superior to the actors they hold accountable, but act on behalf of “the system” or “the public interest.” Sometimes horizontal accountability is reinforced by vertical accountability as political, administrative, or private superiors hold subordinate units jointly accountable.

We now have several dimensions to describe accountability within health systems. First, we can distinguish between different accountability forms , each with several different forums and account-givers and associated accountability mechanisms. Second, we distinguish between different functions of accountability. While democratic and constitutional functions have traditionally been closely linked to political, judicial, and administrative accountability forms, and performance more closely to market and professional accountability forms, it is important to realize that different forms may include concerns for several different functions. For example, professional accountability typically is concerned with a due process and equity as well as performance. Similarly it can be argued that the performance function of accountability has gained importance in public health systems over the past three decades with the introduction of NPM perspectives and tools and that this is combined with different forms of administrative accountability. Third, we distinguish between different directions of accountability. We suggest that horizontal accountability forms have gained importance over time, as more services are delivered in networked structures and as traditional forms of government are giving way to new types of “governance” relations.

In this sense there tends to be a dynamic interaction between the different dimensions as pointed out by Willems and Van Dooren (2012) and accountability regimes should be seen as snapshots of forms, functions, and direction of accountability in a particular context at a given point in time ( Goodin, 2003 ; Tuohy, 2003 ; Mattei, 2009 ). Reforms can shift the relative importance of different forms, functions, and directions over time. This may happen through formal rules, or more implicitly by introducing new institutional structures and relationships. The result can be new configurations of the trust-based accountability core and the formal, sanction-based periphery ( Mansbridge, 2014 ). Understanding the gradual development of accountability regimes provides important insights into the governance of modern health care systems.

Examples of Developments in Accountability for Health Care

The Nordic countries as well as United Kingdom belong to the group of public integrated health systems with a strong public role in stewardship, financing, and delivery of services. Whereas the Nordic countries traditionally emphasize democratic governance at both the central and decentralized levels, the National Health Service (NHS) in the United Kingdom historically represented a more centralized system.

The dominant accountability forms in the Nordic countries have traditionally (until the early 1980s) been professional accountability at the clinical level nested within democratic/political and administrative accountability at national and decentralized levels for managing the system. Judicial accountability has been less prominent than in market-based systems, and market accountability has been of limited relevance due to the dominance of public financing and public provision. This is in stark contrast to, for example the US health care system. Prior to the 1980s the public had limited insight and limited options for comparing health services, and thus played a relatively indirect role in accountability terms, primarily as voters at local, regional, and national level.

However, a number of changes have been introduced from the 1980s and onwards in the Nordic countries, the UK, and most other European health care systems ( Vrangbæk, 1999 ; Magnussen, Vrangbæk, and Hagen, 2009 ; Byrkjeflot, 2011 ; Olejaz et al., 2012 ; Ringard et al., 2013 ; Lægreid, 2014 ). The reforms and dominant change trends can be labeled under the following headlines: (a) NPM style reforms from the 1980s and onwards introducing choice, economic incentives, performance measurements, and transparency (activity, service, and clinical quality); (b) structural reforms changing the balance between central and decentralized governance; (c) changes in the public/private mix of health care by introducing more private providers and encouraging voluntary private insurance; (d) various reforms and changes to promote integration of care; and (e) digitalization and e-based solutions for communication, monitoring, and delivering services.

In terms of accountability this has resulted in the following changes:

Accountability relations have become more complex and layered over time ( Bovens and Schillemans, 2011 ), with new combinations of form, function, and direction.

Administrative accountability has changed to increasingly incorporate “management” and “market” accountability dimensions. In some cases these NPM-related accountability types have replaced more traditional forms, but more often they have been added on top of existing forms sometimes creating tensions and lack of clarity for the involved account-givers ( Lægreid, 2014 ; Byrkjeflot, 2011 ; Vrangbæk, 1999 ).

Professional accountability is increasingly challenged by attempts to superimpose external administrative or market based accountability forms. Professional accountability has become more formalized, standardized, and transparent ( Timmermans, 2005 ).

Although judicial accountability in general is still expected to play a minor role, particularly in the NHS type of systems, there is a tendency to develop more specific rights within health care. This leads to more opportunities for taking judicial action ( Hogg, 1999 )

Market accountability has become more important due to increased use of choice, contracting and privatization within health care.

Social accountability plays a strong role, but various types of ad hoc e-based virtual interest groups and campaigns have supplemented mass media and locality-based movements.

Horizontal accountability has gained importance in post-NPM efforts to create less fragmented health care services and provide seamless service delivery across different health and social care levels. Intergovernmental relationships have become tighter with more formalized mandatory collaboration between regions (hospitals) and municipalities. Regions, municipalities, and delivery organizations engage in “dynamic accountability” relationships based on networks, recursivity, deliberation, innovation, inclusion, and publicity ( Sabel and Zeitlin, 2008 ; Mansbridge, 2014 ). However, stronger accountability pressures from the state level in terms of monitoring and sanctioning mechanisms reinforce this type of horizontal dynamic accountability in case regions and municipalities fail to reach acceptable progress.

Based on these observations we can conclude that there are indications of circumscribing the traditional core of selection and trust-based accountability with a thicker, more complex and more penetrating layer of monitoring and sanctioning accountability ( Mansbridge, 2014 ). This can be seen at the clinical level, where traditional reliance on selection and trust-based accountability forms is challenged by IT-based systems for monitoring performance, and by the widespread use of clinical guidelines, standards, and operation procedures. In terms of the criteria developed by Mansbridge this can partly be explained by a reduction in the price of monitoring due to the introduction of IT solutions and collection of “big data.” Alternatively one can argue that some of the cost has been shifted to those being monitored, as they are responsible for taking the time to enter data and thus supply the basis for (self-) monitoring. A similar development has taken place in the accountability relations for hospitals and public authorities (regions and municipalities). Hospital managers are increasingly held to account for process and outcome quality in addition to traditional economic management. Rising expectations among patients and in the general population contribute to this development. The authority of health care professionals has been weakened and people are less inclined to accept quality differences or failures. A third impetus for the development is a growing need among state-level politicians and administrators for being able to manage increasing costs and medical technology advances. This has necessitated a tighter control regime and better monitoring of performance.

Accountability relations between state and regions are also changing. The state has implemented stronger governance of economic performance and tougher sanctions for budget overruns. Productivity increases are mandatory and failure to deliver such increases result in economic sanctions. In addition the two Nordic states also use softer means in the form of benchmarking and publication of comparative data in order to hold regions and their hospitals accountable and to enable citizens/patients to do the same.

Limitations and Critical Issues for Studying Accountability in Health Care in the Future

In this chapter we have used some of the more recent perspectives in public administration research on accountability to analyze developments in health care. We have also briefly reviewed the literature in on health care accountability, but not in a comprehensive way. Our impression is that the health care literature on accountability has been centered on the relationship between the medical profession and a few of the other dimensions mentioned (e.g., state or market), but that there has been fewer attempts to give an overview of the multiple dimensions of accountability or discuss other dimensions like administrative or social accountability. Our framework can contribute to a more systematic discussion of such issues. The limits of our perspective are that we do not really seek to explain the development or make the systematic cross-national comparisons that may give us a better understanding of the context or the drivers for change. Our perspective is also limited to giving an overall view of the system rather than studying accountability relations from the perspective of the organizations and the actors that are affected by them.

The balancing act between responsibility and accountability will continue to be important in further studies. Responsibility is a more active process—it relates to delegated authority within a hierarchical system. Accountability is more about providing documentation for your competence, trustworthiness, and control ambitions in a system of checks and balances. The inflation of accountability forms is a challenge for most health care systems, but it may perhaps be an even greater challenge for the public systems where health care historically has to a greater extent been integrated into local and central systems for democratic governance. The challenges may be somewhat different in private market dominated systems like the United States, where the focus is on creating accountable care organizations rather than changing the system of health care regulation as such in order to maintain and rationalize a system for public provision of health care ( Fisher and Shortell, 2010 ). There are few comparative studies of accountability regimes in health care (but see Tuohy, 2003 ; Byrkjeflot, Christensen, and Lægreid, 2014 ; Byrkjeflot, Neby, and Vrangbæk, 2012 ). Such studies and also historical case studies of single systems may be useful also in giving input to current reforms, cautioning ambitious reformers against making promises of developing “crystal clear” accountability relations, and so on as they usually tend to do when new reforms are introduced in health care. Unfortunately there is no all-encompassing accountability theory that can help us understand the complex linkages and predict how different regimes are really operating and how they will develop ( Dubnick and Frederickson, 2011 ). It is, however, useful to map the set of accountability relationships in any given system, firstly in order to avoid seeing the trees only and not the forest and secondly to be prepared for surprises relating to accountability relations in health care.

The “top-down” approach to the analysis of accountability structures is valuable in itself but obviously does not make it possible to understand how accountability logics work “on the ground.” We therefore suggest that the “top-down” mapping should be supplemented by a “bottom-up” analysis of accountability regimes as seen from the perspective of different actors within the health system.

The purpose would be to analyze the accountability pressures facing specific actors in health systems and the relative importance of different accountability logics and of how organizations and professionals prioritize and deal with the different types of accountability demands. This type of “bottom-up” analysis would provide a supplementary and perhaps more realistic picture of how the complexity of formal accountability systems appear on the ground. This accountability from below is similar to what for instance Sinclair (1995) has done. The public servants she has interviewed feel the pain of accountability as they speak of a “blowtorch applied to the belly.” “Accountability is multiple and fragmented,” she concludes “being accountable in one form often requires compromises of other sorts of accountability” ( Sinclair, 1995 , 226, 231). Similarly in the studies of accountability in the NAV reforms 1 in Norway ( Fimreite and Lægreid, 2009 ), it was demonstrated how organizations must be accountable upwards to political sovereigns, horizontally to other network partners and agencies, and downwards to citizens and clients. Not surprisingly the study also concluded that it is a very difficult task to balance such multiple accountability relations and logics.

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• Research article
• Open access
• Published: 13 June 2017

Social accountability in primary health care in West and Central Africa: exploring the role of health facility committees

• Elsbet Lodenstein   ORCID: orcid.org/0000-0003-3379-8488 1 ,
• Eric Mafuta 2 ,
• Adolphe C. Kpatchavi 3 ,
• Jean Servais 4 ,
• Marjolein Dieleman 5 ,
• Jacqueline E. W. Broerse 6 ,
• Alpha Amadou Bano Barry 7 ,
• Thérèse M. N. Mambu 2 &
• Jurrien Toonen 5  

BMC Health Services Research volume  17 , Article number:  403 ( 2017 ) Cite this article

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Metrics details

Social accountability has been emphasised as an important strategy to increase the quality, equity, and responsiveness of health services. In many countries, health facility committees (HFCs) provide the accountability interface between health providers and citizens or users of health services. This article explores the social accountability practices facilitated by HFCs in Benin, Guinea and the Democratic Republic of Congo.

The paper is based on a cross-case comparison of 11 HFCs across the three countries. The HFCs were purposefully selected based on the (past) presence of community participation support programs. The cases were derived from qualitative research involving document analysis as well as interviews and focus group discussions with health workers, citizens, committee members, and local authorities.

Most HFCs facilitate social accountability by engaging with health providers in person or through meetings to discuss service failures, leading to changes in the quality of services, such as improved health worker presence, the availability of night shifts, the display of drug prices and replacement of poorly functioning health workers. Social accountability practices are however often individualised and not systematic, and their success depends on HFC leadership and synergy with other community structures. The absence of remuneration for HFC members does not seem to affect HFC engagement in social accountability.

Conclusions

Most HFCs in this study offer a social accountability forum, but the informal and non-systematic character and limited community consultation leave opportunities for the exclusion of voices of marginalised groups. More inclusive, coherent and authoritative social accountability practices can be developed by making explicit the mandate of HFC in the planning, monitoring, and supervision of health services; providing instruments for organising local accountability processes; strengthening opportunities for community input and feedback; and strengthening links to formal administrative accountability mechanisms in the health system.

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Since the 1978 Alma-Ata Declaration on Primary Health Care, participation has been a central theme of health policy and programming. The 2008 World Health Report re-emphasizes the values of community participation to achieve “people-centred” health systems [ 1 ]. Health service users are increasingly seen as citizens who should be allowed to voice their concerns actively, to shape health services and policies in the public interest and hold health providers and policymakers accountable [ 2 , 3 ]. The expectations of this form of accountability referred to as social accountability are high, in particular in countries where health systems face persistent service delivery failures [ 4 ]. In many low-and-middle-income countries, health facility committees (HFC) are one of the well-known vehicles for community participation. They are involved in the co-management of primary public health facilities, in the spirit of the Bamako Initiative that was launched in 1987 (see Table 1 ). While the Alma-Ata Declaration expressed the key principles of Primary Health Care, the Bamako Initiative operationalized the principle of community participation in the organisation of health services. It introduced measures that aimed to give users, through representatives in HFCs, say in determining access to services and the use of funds obtained through the sale of drugs. Some HFCs, especially in health centres with high utilisation rates, developed into structures with significant influence on the management of human, financial and material resources needed to provide quality of care [ 5 , 6 , 7 ].

In many countries, HFCs are attached to health centres and elected by community members to facilitate communication and feedback processes between health providers and citizens or users of health services. They, therefore, have the potential to ensure financial and social accountability of health providers to communities and to strengthen the democratic governance of health systems more generally [ 8 ].

Recent literature reviews on HFCs found that the extent to which HFCs in developing countries can influence service provision is mixed. This is due to the diversity in the composition of HFCs, their roles and responsibilities, the availability of resources, as well as the differences in health systems and policies, community and societal contexts in which HFCs operate [ 4 , 9 , 10 ]. These reviews led to a better conceptualization of contextual elements that influence HFC effectiveness, but they also called for more empirical tests of the frameworks. Based on a synthesis of findings from case studies in West and Central Africa, this paper explores the functioning of HFCs, in particular with regard to their actual and potential role in the facilitation of social accountability. A recent systematic review of the literature on community participation by George et al. revealed that most studies on the topic focus on participation in health promotion interventions and effects on service uptake and less on community involvement and empowerment in the governance of health services [ 11 ]. This paper aims to address this research gap and to provide recommendations as to how the role of HFCs in social accountability can be enhanced.

The social accountability role of HFC

Social accountability is a contested concept used in a variety of disciplines, including in the context of professional health education [ 12 ], New Public Management [ 13 ] and participatory democracy [ 14 ]. In the health sector, social accountability is often viewed as an advanced form of community participation whereby citizens take action to enhance the accountability of politicians, policymakers and service providers. The role of HFCs in social accountability has rarely been assessed. HFCs are defined as “any formally constituted structures with community representation that has an explicit link to a health facility and whose primary purpose is to enable community participation with the aims of improving health service provision and health outcomes” [ 9 ]. HFCs can exist at several levels and take different forms from village level health committees to community health groups and hospital boards for district hospitals [ 4 ]. This study focuses on HFCs at the level of primary healthcare centres offering basic packages of healthcare.

HFCs can perform two sets of activities to improve health service provision, presented in Table 2 as two roles. The first role is to support the functioning of health facilities and the objectives of health providers. HFCs serve as an extension of service providers and engage in community outreach, the co-management of health centre resources and the facilitation of repairs and fundraising. This role is quite prevalent in practices of HFCs in low-and-middle-income countries [ 10 ]. McCoy et al. refer to the activities under this role as facing “inwardly” [ 9 ]. The second role supports users’ and citizens’ voice and the “bottom-up” integration of community preferences in decision-making in service delivery. McCoy et al. call this the “outward” role [ 9 ]. HFCs activities include advocating for access to health care (“social leveller”) or resources (“advocacy”), the monitoring of the quality of care and the use of funds (“control of quality and management”) and the facilitation of feedback mechanisms between health providers and users (“provide accountability interface”). Whether or not, and how HFCs perform these roles varies, as HFCs are complex entities embedded in country-specific political, historical and health system contexts [ 9 , 10 ]. Moreover, in many countries, HFC members work as unpaid volunteers; HFC effectiveness, then, depends on the personal commitment of individual members.

This paper explores the activities HFCs currently perform in providing a social accountability interface only (4th “outward role” in Table 2 ) that are summarised in four steps: information/data collection, dialogue/forum, consequences and counter-feedback to users [ 15 ]. In line with Bovens, HFCs provide a “forum” where they question health providers’ behaviour and actions, and where health providers provide explanations or justifications; when such explanation or justification fails, consequences (sanctions or rewards) can follow [ 15 ]. We added the fourth step “counter feedback to users and citizens” as HFCs are representative of the communities in which they operate and have, themselves too, the obligation to report on their activities and results to the larger community. Apart from assessing the functioning of the accountability cycle in the study countries, we also aimed to explore the effect on health providers’ responsiveness to community issues and demands and the factors that shape HFCs as social accountability interfaces. Figure 1 summarises the conceptual framework for the study. It combines concepts from the work by McCoy et al. and Molyneux et al. on HFCs, and from Bovens’ accountability theory [ 4 , 9 , 15 ]. This framework supported the data collection and analysis.

Conceptual framework

The four steps of the accountability cycle are expected to affect health provider responsiveness, an intermediary effect of social accountability initiatives [ 16 ]. Responsiveness broadly refers to the extent to which a health provider or health policymaker acts upon needs and demands expressed by users, the community or HFCs [ 16 ]. The ability of HFCs to influence provider responsiveness and service provision depends on several interacting factors related to the wider social, cultural, political and health system context and the local context regarding community and HFCs features [ 4 , 9 , 10 , 15 , 17 ]. In this study we were interested in one particular community feature: the presence of other interface structures such as community health workers or local councils. We assumed that other community groups, also those beyond the direct environment of health facilities, demand accountability and advocate for improvements in health services and hence influence the scope and reach of HFCs [ 18 ].

Based on the conceptual framework, the three main research questions of the study are: how is the accountability role of HFCs described in policies? How do HFCs currently facilitate social accountability? What factors shape the role of HFCs as facilitators of social accountability?

This article is based on findings from three country studies that were conducted in 2013 and 2014 in Benin, Guinea and the Democratic Republic of Congo (DRC) [ 19 , 20 , 21 ]. The studies were initiated in the context of the French Muskoka Initiative with UNICEF WCARO that funds operational research in Francophone countries in West and Central Africa to support the emergence of innovative approaches to health systems development. The study adopted a qualitative case-study methodology to understand social accountability practices in selected primary health care settings within their real-life context [ 22 ].

Selection of study sites

The countries were purposively selected; criteria included francophone countries, government commitment to the Bamako Initiative, community participation and HFC development and long-term experience with HFC programmes. In each country, districts ( department in Benin, zones de santé in DRC, prefectures in Guinea) were purposively sampled taking into account the presence of community participation support programmes. In Guinea, two prefectures were selected relatively close to the capital Conakry because of the Ebola epidemic that had not yet reached the capital at the time of the fieldwork.

Within the districts, four health centres were selected based on their health performance. Based on suggestions by McCoy et al., we assumed that well-performing facilities could be associated with well-performing HFCs [ 9 ]. We used health performance indicators as selection criteria (external consultation, assisted deliveries and antenatal care coverage). Not all provinces disposed of performance data, therefore in some cases; the researchers depended on the knowledge of health authorities. The facility closest to the national capital was at 60 km (Guinea) and the most remote facility was at 220 km. from Kinshasa (DRC). Initially, each country team had selected four study HFCs; in Guinea, the dataset of one HFC got lost, totalling the total number of study sites at 11.

Data collection and analysis

In each country, a research team was set up consisting of a senior researcher, a researcher and research assistants. In Benin, the Belgian Technical Cooperation (BTC) participated in the design of the study. The overall study was coordinated by the Royal Tropical Institute (KIT). Senior researchers participated in the protocol and tool development and organised training for the research teams in their respective countries. Data collection took place between January and April 2014. Each country team had a backstopping advisor from KIT, who supported data collection, analysis and feedback on interim reports.

An initial review of the health, decentralisation and community participation policies helped to understand the background of HFCs, the evolution of the Bamako Initiative and the formal arrangements about the role of HFCs in social accountability. Secondly, to investigate the practices of HFCs in facilitating social accountability, we used a mix of methods including semi-structured interviews, focus group discussions and document reviews, each with specific tools. Each of the tools addressed three main topics: (1) characteristics of the HFC and the health facility (local context), (2) examples of social accountability practices, and (3) participants’ perceptions of the effectiveness of social accountability relations and practices. The triangulation of different sources of evidence to answer the same questions was expected to strengthen the validity of the findings [ 22 ].

For the interviews, we targeted participants at each health facility site representing health providers, local authorities, HFC members, community based associations and users (male and female) in order to collect a diversity of views on, and experiences with, the HFCs. A total of 95 individual interviews and 22 focus group discussions were held with different actors (see Table 3 ). The selection and recruitment process differed between the countries, depending on prevalent local procedures. In DRC, the health zone director communicated to the HFC chairman who selected participants based on criteria and numbers set by the researchers. In Guinea, a site visit prior to data collection supported the identification of participants and the issuance of formal invitations through the local authorities. In Benin, the identification and recruitment of participants was done by the HFC chairmen, based on the selection criteria provided by the researchers. Some documents were collected locally including minutes of HFC meetings and health facility reports. Not all HFCs disposed of written material.

All individual interviews were audio-recorded and transcribed in Word. The transcripts of interviews held in local languages, were translated into French. Coding was done based on a coding guide developed jointly by the three research teams based on the conceptual framework and research questions. The coding was done through software Atlas-ti in Benin and the DRC and in Guinea in Microsoft Excel. The country research teams carried out the analysis and triangulation of country-level data. Each HFC was described as an individual case during a workshop in June 2014 where the researchers also jointly identified the first common patterns in the findings. This paper is based on a qualitative cross-case synthesis [ 23 ] that considered the findings of the country studies collectively and aimed to identify, from 11 case studies, common patterns and trends in the way HFCs perform a social accountability interface role. Authors synthesised this data from all three countries on the basis of the country research reports, the initial joint synthesis and their access to the primary data. The activities that are performed by HFCs as accountability interfaces were selected for inclusion in this paper based on a review of their clarity in describing the activity and its effect and on the basis of data (respondent) and data source triangulation. At least two groups out of four participant groups needed to have contributed to the example or the example needed to be confirmed by documentary evidence. Data about contextual factors were derived from the country reports but also by returning to the original data. To identify patterns across the countries and to include the relevant data in this analysis, a regular return to data was needed as well as some re-coding, in particular of contextual factors. Hence, the analysis was an iterative process of explanation building as proposed by Yin [ 22 ]. Investigator triangulation and team discussions contributed to the interpretation of themes and the identification of patterns across the cases, progressively leading to a better understanding and confidence in the synthesis findings [ 24 ]. Information on policy and legal country contexts was derived from previous outputs of the country studies and external literature. Regular validation of findings between the main author and the country research teams was done to ensure the quality of the results.

The first section describes the political and legal context and the evolution of health facility committees in the three countries. The second section discusses the interface role that HFCs currently play, and the last section discusses how contextual factors shape the accountability role of HFCs.

Evolution of HFCs in policies in Benin, Guinea and DRC

In Benin, Guinea and DRC, different types of health committees have been set up from 1979, first as local initiatives and later scaled up to other parts of the country. In all three settings, the health centre level is the lowest level that has an HFC. District or regional hospitals usually have advisory boards or boards of directors but they do not have as main task to enhance community involvement. Table 4 presents the key features of current HFCs attached to primary health care centres.

The table shows that the three countries have HFCs of similar compositions. They all have community as well as health worker representatives, and around nine members who are elected for two to three years. Health worker representatives cannot be elected as board members or chairpersons but can act as secretaries. HFC compositions differ in that guidelines in Benin and Guinea prescribe the need to include representatives from different social groups, while in DRC community health workers form a large proportion of the membership. In the three countries, there is a clear policy commitment to community participation and reference is made to HFCs in many health sector strategies as well as health system strengthening plans.

In Benin, community participation is considered a crosscutting issue and is integrated into different health policies and reform documents. Since the Bamako Initiative, several types of community structures have been installed; it is the health facility management committee (COGECS) that is assessed in this study, further referred to as HFC. After the countrywide installation of HFCs from 1995, the Ministry of Health further defined the mandate and powers of the HFCs in 2004 and 2006. Bylaws stipulate that HFCs are involved in the monitoring of the budget formulation and execution, the management of user fees, and the establishment of drug inventories and orders. The texts specify that HFCs are to promote financial transparency of pricing policies and to prevent extortion of patients and illegal drug sales. They have to report health workers suspected of fund diversion or embezzlement to the authorities to enable disciplinary measures. HFCs are further supposed to contribute to conflict resolution between the community and health providers [ 25 , 26 ]. The Ministry further suggests strengthening the ethical behaviour of health workers through the training of user associations [ 26 ]. For each of the different functions, a training manual exists with concrete suggestions for conflict management and financial control [ 27 ].

In Guinea, the Ministry of Health, in its National Health Development Plan (2004), envisions communities as owners of health facilities instead of clients. The Ministry envisions the development of formative supervision and participatory monitoring with communities to enhance the quality of primary health services [ 28 ]. HFCs are supposed to plan and monitor health services at health facility level. They also engage in supervision, including the checking of health workers’ presence and quality of the reception of patients. The HFC training manual emphasises that supervision is meant to solve problems rather than to control or inspect [ 29 ]. HFCs are expected to “maintain a continuous dialogue” between health providers and the community to reduce conflicts and to transmit perceptions and expectations of the community to providers. Community participation policies in the health sector are increasingly aligned with the overall decentralisation policy that established local governments from 1988. This means that HFCs are now under the authority of local councils and are accountable to local councillors and the mayor. A government-adopted training manual of 2011 reflects this set-up; it describes responsibilities of both HFCs and the health, political and administrative authorities [ 29 ]. After this study, the health system has undergone many changes as a result of the Ebola epidemic, whereby the role and mandate of HFCs are also being revisited.

Community participation in DRC has been revitalised in 2000 as a result of a health sector review that observed continued high mortality and morbidity rates. The Ministry of Health proposed to transform the ineffective or non-existent health management committees into multidisciplinary, multi-sectoral health development committees. The new HFCs are strongly associated with Community Health Workers (CHW) who play an important role in health care in the DRC in the context of a shortage of trained health professionals [ 30 , 31 ]. Each village has a CHW representative in the HFC. The HFC manual lists a range of responsibilities for the HFCs including planning and monitoring of health activities in collaboration with health professionals [ 31 ]. The integration of this governance reform in other health-related policies is yet to be realised. The implementation of the new policy is uneven with some districts benefiting from NGO support and others not.

The data presented here show that the policy framework of HFCs in the three countries has been revised in the last decade, approximately 15 years after the Bamako Initiative. This revision mostly concerned a more precise definition of the mandate and responsibilities of HFCs. In many countries, including in Benin and Guinea, the Bamako Initiative was initially interpreted as a cost recovery mechanism but the revisions in Benin and Guinea re-emphasize the role of communities in controlling the management of health facilities which includes not only financial control but also the monitoring of the quality of care [ 6 ]. The revision in DRC is more driven by a renewed commitment, in particular of external donors, to strengthen the position of community health workers (CHW) in primary health care.

For the three countries, the central role assigned to HFCs in most official documents as well as training manuals is related to the role that we classify as the “inward” role to support the facility and health workers. Despite increased commitment in new bylaws and health policies to strengthen the “outward” role of facilitating social accountability, the researchers did not find specifications of the actual powers and tools for HFCs to take up this role. For example, in both Benin and Guinea, HFCs are expected to monitor health service delivery but ways to address, report or sanction poor service delivery, are not defined. When roles and powers of HFCs to hold health workers to account are only partially defined, it can be expected that many HFCs do not take up this role or develop an approach based on their own experience and practices. In the following, we will focus on these practices to facilitate social accountability according to the four steps of the accountability cycle presented in the framework.

HFC practices in facilitating social accountability

Table 5 provides a summary of the study findings with regard to activities carried out by HFCs within each of the accountability steps. A more detailed account of these steps is provided in the paragraphs that follow.

Information and data collection

HFCs collect information on the performance of the health facility in two ways: through direct observation, monitoring and supervision in health facilities and through users approaching HFC members.

The first method, direct observation and supervision, is strongly related to the traditional role that HFCs have been attributed in the Bamako initiative. Although the three countries followed different paths in implementing the Bamako Initiative, the task of controlling drug management and the financial books at health facility level is key in most of the studied HFCs. An HFC chairman in Guinea illustrates the determination of many HFCs in this domain with regard to supervision of the delivery and management of drugs:

“We control workers’ presence in the health centre and drug prices. We have achieved results such as compliance with drug prices. The health workers were planning to buy and sell the drugs and collecting money without involving us. We demanded our participation in the ordering and reception of the drugs and the deposit of amounts received from drug sales before signing any document” (HFC chairman Guinea, HFCG1).

Besides this core task, in many cases, HFC members are present in the health facility on a daily basis to monitor the quality of care. Through their interaction with patients, they collect and share information about the health services, but they do not document their interactions.

A second way in which HFCs obtain data on health worker performance is through users and citizens approaching individual HFC members directly on the street or in other public spaces or during health information and communication sessions. The latter strategy is particularly prevalent in DRC, where HFC members (including CHW) are conducting home visits for sensitization and public health data collection purposes. Users and companions (who escort patients) use this opportunity to share their concerns about the performance of the health facility without explicitly being invited to. In Guinea, respondents give examples of individual HFC members treating complaints on the spot on a case-by-case basis. Table 6 presents the main issues brought forward by users to HFC members across the 11 cases, in order of importance and triangulated by data from users, health workers as well as HFC members.

In none of the study sites, HFC members pro-actively seek users’ opinions or ask people to share needs, demands, expectations or complaints about health services. Tools such as patient satisfaction forms are not in use or are not managed or accessed by HFCs.

Some HFCs combine methods such as in a case in Guinea where members are present on a daily basis to monitor the quality of care, and to discuss directly with health providers in cases of poor performance. This active supervision is more likely to happen after a user complaint is received.

Dialogue/forum and effect

We identified two ways HFCs use to channel concerns and complaints to health providers. One is the direct pathway whereby health providers are contacted directly, mostly individually; the second is the use of HFC meetings to discuss issues. The responsiveness of health providers to these dialogues is also assessed.

Individual dialogue

Transmission of community concerns directly to providers occurs face-to-face or by telephone. Participants shared a number of examples whereby HFC members confront health providers immediately after having received a complaint (Benin, Guinea). An officer in charge of a health facility and a female participant in Benin stated for example:

“When they observe awkward behaviour, complaints from the village, they call me on the phone…and I go.. . So this is how they behave and … how they do their control…either by phone and I will come and check” (OIC, Benin, HFCB3).

“There are no arguments between health workers and patients here, and if it is the case, the HFC intervenes. HFC members calm everyone, they manage the situation and peace returns” (FGD women, Benin, HFCB3).

Financial accessibility is a major problem for many patients in the three countries, especially in systems where patients have to pay before they are treated or where informal payments are widespread. Complaints about informal consultation fees and high drug prices are very common in the three countries as observed from the FGD with users and HFC members. HFCs seem to deal with these complaints in different ways. They facilitate access by convincing health workers to provide services by guaranteeing the payment, or by negotiating a credit system as the examples illustrate:

“On a Saturday we were working at the health centre, a mother brought a child with anaemia. She did not have much money so that the pharmacy did not want to give her a blood bag for the child. Members of the health committee, who noticed this, vouched for this woman and have promised to pay if the woman did not pay. The pharmacy gave her the blood bag and the child was transfused” (FGD HFC members, DRC, HFCD4).

Dialogue in HFC meetings

Another way of addressing complaints regarding the quality of care that the HFC receives is through HFC meetings. From both interviews, FGD and minutes of HFC meetings, it was observed that HFCs regularly discuss two main issues: health worker behaviour and drug management. Behaviour concerned absenteeism, informal payments, inebriation and unfriendly treatment of patients. Service users in both DRC and Guinea mentioned they had reported absenteeism to the HFC and they were aware of the HFC having addressed the issue in their meetings. According to women in an FGD in DRC, this resulted in nurses being more quickly available in emergency cases and in Guinea the officer in charge has developed a publicly displayed table with staff working hours that is, according to both female users and the officer in charge, being respected. Some respondents in DRC explain that by openly discussing health worker behaviour during a HFC meeting, frustrations from both sides are shared and listened to and that this process helps to address poor behaviour, at least in the short term. There was one case in Benin where the good collaboration between HFC members and health workers even got its own proverb “there is no problem” ( « Toukada mou léo») which refers to a mutual commitment to rectify problems and not let the oil stain .

In Benin and Guinea, HFCs often prioritise drug pricing and related problems such as embezzlement or overcharging in their HFC meetings. Some HFCs meticulously collect health passes, drug prescriptions and patient bills and compare with similar bills and with official prices. When there is visible proof (e.g. written bills), and when verification is possible, HFCs bring a strong case to the table that health managers cannot ignore. In Benin, a facility manager explains the dilemma’s this poses to him:

“When they [HFC] call me to come and check the bills at the dispensary…I must say that I try to save my agent…I cannot undress my agent in front of them like that because it’s a secret between us. Or they [HFC] come directly to surprise us at a meeting with certain bills, I then give the floor and try to calm the HFC while scolding the agent who is at fault…we arrange it together. But last time it almost escalated, and if it were not for our vigilance, they would have locked someone. We were angry with them, we must defend the culprit” (OIC, Benin, HFCB3).

While the systematic collection of evidence to detect fraud is practised by some HFCs, the collection and transmission of evidence on non-financial matters (e.g. health worker absenteeism or behaviour) is less systematic in the study sites and seems to be acted upon on a case-by-case basis.

Consequences and follow-up

As suggested in the previous section, sometimes dialogue and on-site mediation between HFC members and health providers ease frustration. Explanations for behaviour, for example by the facility in charge, may reduce tensions and solve a case. In a number of instances, however, HFCs pursue their quest for change by introducing local enforcement methods or by involving district health authorities.

Local regulation

Strong levels of negotiation and local regulation and enforcement were observed in two sites. In one case in Benin, a HFC introduced regulations and sanctions to enforce health providers’ financial accountability. These included the formal interdiction to sell parallel drugs using the health facility prescription orders or to sell drugs on credit without approval by the HFC. The HFC further decided that health workers who had issued false bills had to repay the debts to the health facility, which some of them have started doing. Finally, the HFC issued a warning that health workers who would fail to apply these rules would be transferred elsewhere. One HFC in DRC had appointed one member as complaint manager who had the task to follow-up the decisions made and actions identified during HFC meetings and to keep them on the agenda when the facility in charge failed to implement them. Although health providers in most sites appreciate the contributions of HFCs in co-management, they were less receptive of HFCs engaging in monitoring consultation payments and fraud detection. In Benin, an HFC member believed that providers “ can threaten to kill HFC members over too much scrutiny ”.

Involvement of district authorities

Community demands or complaints often move up the hierarchy after having been discussed in the HFC meeting. In Guinea this process seems most formalised whereby the transmission of complaints follows a route from the communities to health posts to health facility managers and up to the district authorities, written down in the monthly monitoring reports:

“During some meetings, HFC members get to discuss populations’ complaints. An example is a situation of a health post, which was debated even on the management board. The officer in charge did not get along very well with people because he came to work inebriated. This complaint was sent to the HFC and sent up to the communal council, the health facility and the District Health Team. The worker was eventually replaced” (OIC, Guinea, HFCG2).

Similar examples were reported In DRC, where poor health worker attitude was discussed by HFCs and reported to village chiefs or health authorities, first orally and then written:

“There was a health worker, who had a habit of overcharging services and who did not treat patients well. Several community members reported these complaints to members of the health committee. The committee spoke to the provider, who, instead of changing, continued to act in the same way. Finally, after several complaints, the health committee sent reports to Health Zone Management Office who sacked the health worker in question?” (FGC HFC, DRC, HFCD1).

“Previously, there was a provider here at the health centre. He did not touch the patients, he used a pen to feel and inspect a patient. He did not use his hands like other providers. The people saw it and forwarded a complaint to the central office through the health committee and promised to report this attitude to higher instances or make a court case. This provider was transferred elsewhere”. (FGD men, DRC, HFCD1).

In similar cases, however, the HFC has not been able to trigger sanctions:

“A recent complaint we received was about a vaccination officer who was often inebriated at work… we have repeatedly informed health officials verbally before writing a letter, but so far they have not found a solution…Because it is the State that affects its agents and we often mention in our reports, but in vain. The state must resolve the complaints because it is the state that affects workers in communities”. (HFC Chairman, Guinea, HFCG1)

In the cases mentioned, the main result is a transfer of the health worker to another health facility or the dismissal of a health worker. One HFC in Benin took a different approach to deal with health workers overcharging patients. The HFC required health workers to pledge adherence to the jointly established price list for drugs and to accept the working conditions at the health facility. The pledging was done in front of the district health authority as to enforce the use of this agreement.

Counter feedback to community

The last step in the accountability cycle, counter feedback to the community, does not seem to be practised. When community members report complaints to members of the HFC, most of them indicate they do not know whether their concerns reach the providers. Hence, they do not know whether the HFC members are reactive themselves or whether it is just a lack of counter feedback to the community, even if the concerns have been treated. Some HFC members confirm that they do not report back to the community; instead, they expect users to see the achievements of the HFC when visiting the health facility.

Factors shaping the role of HFCs in facilitating social accountability

With regard to the wider context, the countries share similar policy and legal contexts whereby there is a political commitment to community participation and social accountability by HFCs but limited support and legitimisation through legal tools or practical guidelines. This may explain the observation that none of the HFCs studied applies the accountability cycle in a systematic (regular) or complete (all four steps) way. HFC members and others may not be aware of their role or not have the appropriate instruments and power to perform the role. On the other hand, the findings suggest that despite a disabling legal and political context, the HFCs in the study areas seem to use the limited space or develop the necessary approaches locally to facilitate social accountability. In the following section, we explore the factors that shape the potential of HFCs to provide an accountability interface. It is based on a comparative analysis of the 11 HFC cases presented in the country studies. It addressed three factors: the election and representation of HFCs, remuneration of HFC members and the presence of other interface structures.

Mode of elections, composition, representation, leadership

In all cases, HFCs were installed through an official event, but in none of the cases, HFCs were elected as anticipated in the regulations. Even in cases where elections had taken place in a transparent manner, resulting in an initial representation of different groups in the community, the composition changed soon after installation. Members who were not active or members who are believed to be incompetent or too old were soon replaced. In one HFC in Benin, for example, the Chairman replaced a treasurer deemed “too uneducated”. In two other HFCs, a locally elected councillor took the place reserved for an NGO representative. Sometimes new members are added without a consultation or vote within the HFCs. As a consequence, sometime after the elections, the composition has changed significantly, and in practice, only the executive board (chairman, treasurer) is active. Hence, the mode of election does not seem to be the problem but the recomposition of HFCs that occurred in all cases post-election. In some cases, it led to internal oppositions and unsolvable tensions between members, for example in struggles over the treasurer function. These tensions were also observable during group interviews in the study sites in Benin and Guinea. In others, it led to individualism of members (Benin) and apathy. In two cases, HFC leadership seemed to mitigate these problems; a capable and active chairman or board who insist on actively engaging with the community and providers.

Remuneration

In all three countries, participants mentioned the lack of remuneration for HFC members as an obstacle to the proper functioning of HFCs. In the case of Guinea, however, where HFC members are not paid and where external technical and financial assistance was largely absent, HFCs had similar levels of activity like the ones in Benin that had been receiving support for some years. Participants explained this intrinsic motivation of HFC members as a result of long periods of conflict and health facility destruction in that particular area. They argued that citizens had developed a greater sense of responsibility to manage their affairs. In one site in DRC, HFC members developed their internal operation manual in the absence of government-provided guidelines and, instead of receiving institutionalised support, they received occasional voluntary contributions from communities or individual deputies.

Community features: existence of multiple interfaces

As suggested in the conceptual framework, the presence of other interface structures and in particular their credibility in the eyes of the users and citizens can also influence the use and effectiveness of HFCs as accountability channels. The study aimed to explore this by asking respondents about the presence and performance of other participatory structures.

Although HFCs in the three countries are mentioned as the dominant formal structure providing “the bridge” between users and providers, other interface structures or persons play a similar role.

In Benin, respondents mentioned a large variety of actors such as mutual health insurance associations, women’s and youth associations, NGO’s, and community health workers, but also village leaders and local administrators (“chef d’arrondissement”). In a health facility that had a passive HFC, it was the village council that received and managed complaints. Participants perceived community-based health insurance structures (“mutuelles de santé”), introduced in the 1990’s, as potential strong negotiators but they cover only 5% of the population and hence might not represent the larger community. Participants also mentioned district level platforms in the context of performance-based financing as potential accountability facilitators.

In Guinea, respondents cited the role of elected councillors in local government as well as prefects (government representatives). In Guinea, the HFCs operate synergistically with other local associations, local government and authorities. The democratic decentralisation process in Guinea, introduced since 1990, seems to have led to institutionalised forms of local decision making, as expressed in many examples given by respondents. They are part of larger government efforts to decentralise governance to the local level and act jointly with local governments, education committees, etc. to strengthen the democratic base. Respondents suggested that the strong formal link between HFCs and local government empowered the HFCs and enforced local decision-making.

In DRC, respondents mentioned community health workers and village chiefs and in some areas religious leaders. There seems to be an overlap between HFCs and CHW; CHWs perform health interventions, and they constitute channels through which users share their problems and complaints, as they are members of HFCs. CHWs are generally better known as health workers than as HFCs members. Some respondents appreciated the direct effect that village chiefs could have on providers’ behaviour because of their traditional and perennial authority, but they were less positive about the accountability of village chiefs to the community. Participants mentioned religious leaders as emerging actors in health, primarily used to transfer health messages from providers to the community because of their influence on the community. An HFC member expressed that, regardless of who plays an interface role, there is a need to have a structure like the HFC to bridge the interests of “foreign” health workers and local communities:

“If there are no health committees, providers can deviate, misbehave or destroy infrastructure because providers are foreigners, people from elsewhere who are assigned to the health centre and one day they will leave but the centre will remain. The committee consists of villagers who do not want the centre to be destroyed” (FGD, HFC member, HFCD1).

Although users recognise the need to have an interface structure, they explain that such an interface is only useful to them if they respond to a certain number of criteria. When respondents were asked to identify key characteristics of a “good” interface they mentioned the ability to show leadership and authority vis-a-vis providers; transparency in management and decision making; and the ability to accompany users in the facility. Women in Benin, in particular, emphasised this latter aspect by stating that HFCs main role should be to “alleviate the pain and anger patients live with as a result of unfriendly treatment and poor services at health facilities” . If they fail to do so, they argued, users are even more inclined to avoid the health facility.

Community participation for the purpose of accountability and improved health facility governance has not traditionally been a major component of health programs and evaluation studies. This study aimed to explore the role of Health Facility Committees (HFC) in providing a forum for social accountability in Benin, Guinea and DRC. The findings show that HFCs address access and quality failures in health service delivery through the reception of users’ complaints and regular interaction with health facility managers and workers. The way in which HFCs collect, translate and present concerns and complaints to service providers is sometimes ad-hoc and informal but in some cases more or less institutionalised, for example through HFC meetings. In the absence of (known) formal guidelines or procedures, some HFCs have instituted forms of local regulation to address misbehaviour or fraud by health workers. Through such local dialogues and measures, some improvements are reported such as improved health worker presence, the availability of night shifts, and the display of drug prices. The HFCs in the three countries do not have the power to impose formal sanctions or rewards to health providers in cases of poor responsiveness. Some HFCs, therefore, appeal to the district health authorities enabling the activation of administrative accountability measures of the health system. HFCs then induced the transfer of poorly performing health workers. Although a transfer may not be considered a solution to the problem, it is a formal sanction in many health systems.

From Bovens’ perspective, we can conclude that most HFCs in our study offer a social accountability forum to assess, question and judge health worker actions and behaviour and to enforce change through linkages to authorities [ 15 ]. On the other hand, we saw that the first (data collection) and the last step (counter feedback to service users) of the accountability cycle are less practised and institutionalised. This seems a missed opportunity as service users stress the need to have a structure that represents them at the health centre that acts as a “bridge”, mediator and advocate. Moreover, we saw that reporting to health authorities does not always lead to action; some cases of serious or repeated misbehaviour remain unaddressed by health authorities. Hence, there exists an accountability relation between HFCs and health providers, but its’ functioning is variable and, although effective for some cases of poor performance, not always coherent, authoritative and inclusive [ 15 ].

The observation that many social accountability actions are informal and personal in nature is consistent with findings of other studies on the topic. Molyneux et al., for example, suggest that the use of personal relationships and social networks in social accountability is more common than the use of formally instituted mechanisms [ 4 ]. Also, the confused election and installation processes of HFCs whereby positions are recomposed is a phenomenon that occurs elsewhere and regularly in local management committees in West-Africa, not only in the health sector [ 32 ]. We saw that internal reshuffling of positions might lead to individualistic rather than collective or institutionalised social accountability processes. Many issues are dealt with by an individual HFC member, and even when handled collectively, a small group of HFC members may dominate the HFC agenda. Biased representativeness, combined with limited community consultation (step 1) may translate in HFCs receiving only a fraction of community concerns about the health centre. A similar point is made by Knippenberg et al. who found that in Benin, Guinea and Mali, the voice of marginalised groups is excluded in primary health care management because of elitism in HFCs [ 33 ].

The absence of a systemic and collectively agreed feedback procedure leaves additional opportunities for concerns and issues to be overlooked. Even when HFCs actively collect complaints, there are risks that the complaints get lost because of poor documentation [ 34 , 35 ]. Also, a lack of arbitration and transparency in decision-making can lead to biased or unfair outcomes, in particular when health providers are themselves involved in the issue, when they dominate HFC decision making or when politicians or ‘patrons’ interfere with the judgment or sanctioning of health providers’ performance [ 36 , 37 ]. Some of these risks of biased processes and outcomes of social accountability may also apply to the HFCs in our study. We, however, recognise the tension Loewenson et al. describe between influential individuals having the leverage to engage with health providers and improve the quality of care and the simultaneous absence of the voice of more marginalised groups [ 38 ]. HFCs in this study operate within existing social, cultural and religious structures in their communities. Members often include school directors, teachers, village chiefs, religious leaders and in one case an ex-military officer, who each can draw on a form of authority and legitimacy in their interactions with health providers, even where health providers are HFC members. For example, the two HFCs who instituted forms of local regulation to call health workers to account were headed by school directors. Although power asymmetries may remain between communities or patients and health providers, they may be more balanced and less pronounced between “elite” community members and health providers. Furthermore, HFCs that have an “elite” composition may form alliances with health providers to lobby the health system and local government authorities. In their study on HFCs in Nigeria, Abimbola et al. argue that members with a high social or economic status are particularly important in contexts where HFCs receive little government or external support; they can bear the costs of participation and facilitate all the functions HFCs are expected to play [ 39 ]. The question remains how linkages and accountability relations between HFC representatives and communities, in particular, marginalised groups and women, can be ensured. The tension between representation and influence is likely to be present in other social structures such as women’s groups, local governments or health insurance associations and is not limited to HFCs; it will remain an important point in future debates and research on the nature of collective action and power relations in social accountability.

Practical implications

The conceptual framework of this study provides a useful lens to identify barriers and opportunities for strengthening social accountability through HFCs. Our findings affirm the importance of HFCs for health service and system responsiveness and, therefore, support recent calls on governments to acknowledge HFCs in their policies and on funders and global policymakers to support HFCs’ role in the governance of health systems [ 8 ]. It is clear that, to develop more coherent, authoritative and inclusive social accountability processes and achieve more equitable outcomes, actions at multiple levels and with multiple actors are required.

HFCs need to be empowered through a more explicit mandate in the field of planning, monitoring and supervision of (clearly defined quality issues within) primary health service delivery. They need instruments to propose agreements, allow more systematic data collection and documentation and skills to engage in dialogue and feedback with health providers and other stakeholders. The consequences of a lack of responsiveness of health providers to HFC feedback need to be clearly defined. In a pilot project in Mali, for example, HFCs are empowered through a results-based contracting approach with health providers. Rather than relying on higher-level health authorities for follow-up and enforcement, HFCs have the possibility to attach predetermined rewards and sanctions to health provider performance [ 40 ]. Such contracting approach may increase the formalisation of roles and transparency of social accountability processes that is now often absent. Pilot initiatives with Community Scorecards involving HFCs in DRC have contributed to more inclusive interactions between communities and health providers [ 41 ]. Their validation, upscaling and embedding in the wider health system, however, requires more complex reforms.

Social accountability relations are part of a larger governance landscape. HFCs as accountability forums will not be successful if they cannot leverage formal sources of power such as those within the administrative accountability system. This means that district health management teams need the institutional capacity, power and incentives to supervise health workers and follow up on community concerns and complaints. Decentralisation reforms and devolved budgets enable such capacity [ 41 ]. Also, formulations or revisions of community participation guidelines need to define HFCs position and complementarity vis-à-vis other interface structures, such as health insurance platforms in Benin, [ 42 ], local governments in Guinea and CHWs in DRC. In DRC, CHWs are elected within their communities; as HFC members, they constitute an important channel for service users’ voice. Hence, through the strengthening of HFCs, the organisation of CHWs and community voice can be strengthened and vice-versa [ 43 ]. This may not apply to contexts where CHWs are employed by the Ministry of Health (where they might be perceived more as health workers than as community representatives) or where they are not members of HFCs (having limited influence in formal community structures). Hence, HFCs should be conceptualised as one accountability forum amidst other structures that can perform similar or complementary roles, each according to their competencies, position (facility-based or external) and power.

Furthermore, our findings suggest that HFCs can generate responsiveness and improved community-health centre linkages at the local level. But, as suggested elsewhere, is it not likely that HFCs engagement in local social accountability leads to the kinds of increases in human and financial resources and drugs needed for good quality of care [ 44 ]. Therefore, social accountability initiatives need to distinguish between different levels of responsibility and take into account providers’ capacities and resources to respond to concerns and claims raised by HFCs. Initiatives also need to consider how accountability practices and procedures can be respectful of health providers’ rights to transparent and fair feedback processes and consequences. Finally, a challenge in practice will be how to sustain social accountability practices through HFCs in the face of other pressing health and health system challenges. The Ebola epidemic in Guinea, for example, re-emphasizes the role of HFCs: that of health messengers and surveillance assistants. In DRC, policy discussions revolve around the need to develop more intersectoral committees to address the broader determinants of health. In the context of changing needs for community participation, HFCs will be asked or required to shift priorities and navigate their multiple roles. In such contexts, it will be important to reflect on ways in which feedback loops and accountability forums can be maintained at the local level to ensure that poor health worker practices are addressed and to promote people-centred health services.

Strengths and limitations

This study contributes to a further understanding of the potential of HFCs in strengthening health provider accountability and responsiveness. Although the findings present just a fraction of a whole range of practices and factors characterising the interaction between service users, HFCs and health providers in the study sites, they provide a synopsis of current practices and challenges of social accountability across three countries. In research synthesis, decisions are made on the most relevant aspects to cover. The team took such decisions iteratively with key moments of consultation between the researchers and the authors. The final set of themes covered in the paper, however, is more a subjective choice of the authors and therefore they may have disregarded important themes to the three country contexts. Furthermore, although coordination and quality assurance measures were in place, the country research teams worked in different contexts and with varying qualitative research experience that might have influenced the quality of the interviews, and the type of responses researchers got. Finally, because the initial research questions focused on the potential accountability role of HFCs and in interviews we inquired about examples of ‘good’ practice, there may be a bias in the results; the data provided more positive examples than expressions of dissatisfaction with HFC performance.

This qualitative study explores the ways in which HFCs in West and Central Africa facilitate social accountability in primary health care. The findings confirm that many barriers to the quality of daily service provision can be addressed at the frontline of service provision even if accountability relations are poorly defined in policies or operationalised in guidelines. The study concludes that policymakers and funders should recognise and further support the role of HFCs in promoting responsive health services. For HFCs to facilitate social accountability in an inclusive and sustainable way at the operational level, their mandate and powers in service monitoring need to be made more explicit, and they need instruments to facilitate a full accountability cycle, in particular regarding community consultation and feedback.

Abbreviations

Belgian Technical Cooperation

Community health worker

Comité de Gestion du Centre de Santé (Bénin)

Democratic Republic of Congo

Focus group discussion

• Health facility committee

Royal Tropical Institute

Non-governmental organisation

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Acknowledgements

The study was coordinated by the Royal Tropical Institute (EL, JT, MD) contracted by the Regional Office of UNICEF for West- and Central Africa (JS). Implementing partners were the Sociology and Anthropology Department of the University of Abomey-Calavi, in collaboration with the Observatory for Public Services in Africa (OSPA) in Benin (AK); the Kinshasa School of Public Health in DRC (EM, TM), the University of Sonfonia (BB) and the VU University of Amsterdam (JB, EL). We would like to acknowledge the input of Graziella Ghesquire, technical advisor of the Belgian Technical Cooperation in Benin, the ethical review committees of the Universities and Ministries and colleagues and partners for comments and input on the initial proposal and our preliminary results. We are grateful to Vanessa Wongolo, Pierre Meliho, André Aina, Odette Alihonou (Benin), Goethe Makindu, Alain Mahamba, Ruth Yala (DRC) and Abdoulaye Conté (Guinea) for assistance with data collection and analysis. This project would not have been possible without the support and co-operation from all the interviewees, including the MOH staff at provincial, district and health facilities levels, Health Facility Committee members, users and citizens, local authorities and members of local associations at various facilities.

The design and implementation of the research project “The interface role of health committees in West- and Central Africa” was funded by the French Muskoka Initiative Partnership Programme and UNICEF WCARO (reference: 43,140,117), the Royal Tropical Institute (KIT) in the Netherlands and the Belgian Technical Cooperation in Benin. The analysis and writing process by the main author (EL) was funded by the Netherlands Organization for Scientific Research (NWO) (reference W 07.45.201.00).

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Data is not available for online access. Readers who wish to gain access to the data can write to the corresponding author, E. Lodenstein, with their request. Access to the country reports can be granted upon approval by the funder.

Authors’ contributions

EL, JT, MD, AK, BB, TM and EM jointly designed the research protocol and data collection instruments. They participated in data collection, analysis and writing of the individual country reports. EL coordinated the comparative analysis and synthesis and composed the manuscript; MD and JT contributed to revision of the manuscript and AK, BB, TM, JB and EM provided feedback on the draft version of the manuscript. All authors read and approved the final manuscript.

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Approval for the research was obtained from ethical review boards at the Department of Sociology, Anthropology of the University of Abomey, Benin, and the School of Public Health in Kinshasa and the Ministry of Health in Guinea in 2013. Prior to all interviews, written consent was obtained from study participants. To protect the identity of the facilities and participants, general pseudonyms have been used in the reporting.

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Social accountability and health systems’ change, beyond the shock of Covid-19: drawing on histories of technical and activist approaches to rethink a shared code of practice

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Recognition of the value of “social accountability” to improve health systems performance and to address health inequities, has increased over the last decades, with different schools of thought engaging in robust dialogue. This article explores the tensions between health policy and systems research and practice on the one hand, and health equity-focussed activism on the other, as distinct yet interacting processes that have both been impacted by the shock effects of the Covid-19 pandemic. This extended commentary brings multidisciplinary voices seeking to look back at health systems history and fundamental social-institutional systems’ behaviors in order to contextualize these current debates over how best to push social accountability efforts forward.

There is a documented history of tension between long and short processes of international health cooperation and intervention. Social accountability approaches, as a more recent strategy to improve health systems performance, intersect with this overarching history of negotiation between differently situated actors both global and local on whether to pursue sustained, slow, often community-driven change or to focus on rapid, measurable, often top-down interventions. Covid-19, as a global public health emergency, resulted in calls for urgent action which have unsurprisingly displaced some of the energy and aspiration for systemic transformation processes. A combination of accountability approaches and mechanisms have their own legitimacy in fostering health systems change, demanding collaboration between those that move both fast and slow, top-down and bottom-up.

We argue that social accountability, much like all efforts to strengthen health systems, is “everybody’s business” and that we must understand better the historical processes that have shaped the field of practice over time to move forward. These differences of perspective, knowledge-base and positioning vis-a-vis interventions or longer-term political commitment should not drive a conflict of legitimacy but instead be named, subsequently enabling the development of a shared code of conduct that applies to the breadth of actors involved in social accountability work. If we are concerned about the state of/status of social accountability within the context of “building back better” we must approach collaboration with a willingness to create dialogue across distinct disciplinary, technical and politically-informed ways of working.

Over the last two decades, there has been increasing use of “social accountability” language and practices in global health, particularly in the area of health policy and systems research and interventions. In our use of the term “social accountability” in a contemporary context we refer to the broad range of strategies that are used to bolster community engagement and to hold public and private actors to account within the context of the public health sector, while noting that many health systems are pluralistic in nature and not wholly (or even partially) publicly controlled or owned. Social accountability organizes constituencies and information to generate dialogue or confrontation, and can aim to do different things, such as: address equity issues, quality of care, and unequal power relationships between citizens, care providers, health systems managers, and policy makers. Alternatively it can be mobilized to draw attention to service providers’ blind spots and/or broken public commitments. This extended commentary explores the tensions, actual or perceived, between health policy and systems research interventions and program implementation on the one hand (the world of “technicians”), and health equity-focussed activism on the other (the world of “activists”), as distinct yet interacting fields that have both been impacted by the shock effects of the Covid-19 pandemic. We use “technicians” and “activists” as short-hand for schools of thoughts or patterns of approach, recognizing that these terms are an over-simplification of what is in fact a more complex reality of shifting roles and strategies.

With increased global health attention to social accountability, health program actors have moved closer to the spaces where health equity activists, local, ‘global’ and in-between, articulate their demands for accountability on governments and public duty-bearers. The authors of this commentary are part of the Community of Practice (CoP) on measuring social accountability and health outcomes convened by the Department of Sexual and Reproductive Health and Research based at the World Health Organization. As researchers coming to this topic with different foundational framings – a social historian and participatory ethnographer (EN), a health systems researcher working within a national context where the history of health systems creation marked a political turning point (VS), and health systems researchers and practitioners both internationally and nationally situated (ES, PW)— we have seen these two fields of activity - health systems research and practice, and health equity-focussed activism—develop over time as distinct, yet interacting, processes. More recently, we have witnessed the Covid-19 pandemic as a ‘shock event’ that has disrupted the world and subsequently these fields of activity in which we, the authors, are differently involved. The wide range of public health and health systems responses to Covid-19 have taken center stage, resulting initially in a the dominance of command-and-control responses, while participatory and community-led responses emerged more slowly, or rather, with less international attention [ 1 ]. Within this context, social accountability for health equity efforts are in a state of flux. This paper constitutes a dialogue between our distinct disciplinary backgrounds, institutional positions, fields of practice and orientation to social accountability debates, with the aim of calling attention to the patterns of thought and action that have shaped what now constitutes social accountability work in global health. We start by taking a historical perspective showing that questions about social accountability fit within a larger (and longer) story of competing approaches to international public health and unresolved tensions between them. We then outline our understanding of social accountability as a core feature of social and institutional system. We explore the nature of the difference between at the “technicians” and “activist” schools of thought and practice in current debates, and conclude with a set of principles that may better guide critical reflection on the legitimacy, limitations, and risks inherent to different approaches and the imperative to find common ground in light of the health, economic, societal and political impacts of Covid-19.

Given the already-existing challenges in maintaining focus and momentum across a diverse range of social accountability efforts in global health, we seek to look back, look forward, and discern what this moment offers in terms of strengthening an equity-focussed agenda.

Social accountability, the long and short of it

Historical perspectives can help us better understand the current moment for social accountability in health. Accountability theorists and health systems researchers talk about the importance of historical context, but there is often little effort made to deepen understandings of how the past has shaped the systems, structures and logics of the present. International development and global health actors, naturally engaged in planning and forecasting, can have tremendous blindspots when it comes to the past failures and unmet promises of their own institutions or within their fields of practice [ 2 , 3 , 4 , 5 ]. One outcome of the ahistoricity of these fields is that shared understandings or consensus narratives of the recent past—whether that be a political cycle or just the last timebound project—are decoupled from the more distant past, which leaves unexamined the potential threads of connectivity between them [ 6 ].

This is not the place to elaborate on the breadth of historical research that could reasonably inform current social accountability approaches, but rather a reflection on the value of integrating long- and short-term perspectives in social accountability processes, as well as giving attention to intergenerational commitments to social justice. Short-term versus long-term ways of working have emerged in different areas of global health: service delivery and capacity building, system strengthening, technically-driven health interventions and community-engaged, participatory public health approaches. It is important to recognize that the tensions between these distinct modes of practice are not new phenomena in international health cooperation. Though this commentary is not a bibliographic review, it draws on one authors’ (EN’s) historical research over time related to international public health/global health, as well as an intergration of historical perspectives into a contemporary health research practice. This commentary reflects an emerging and expanding field of literature that has identified some of the origins of, and the repeating nature of, tensions between “activist” and “technical” approaches to health from the interwar period through to the turn of the twenty-first century [ 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 ].

We begin with a brief review of relevant historiography on the emergence of “health systems” and “accountability” as concepts and as fields of practice. Prior to the spread of “health systems” approaches in international public health (circa mid 1960s), transnational networks of public health/sanitarian activists and technicians recognized the interrelationship between local infrastructure, sanitation, education, economic status, agricultural development, nutrition as linked to health outcomes. As early as 1937, at the Bandung “Intergovernmental Conference of Far Eastern Countries on Rural Hygiene” one can identify the emergence of “intersectoral and interagency cooperation” across fields of practice, distinct disciplines, and areas of expertise with the aim of addressing shared public health challenges [ 10 ]. The identification of tensions between “vertical” (disease-oriented, top-down) and “horizontal” (community-led, multidisciplinary) approaches to public health, and articulation of a “system” of health in which all approaches could be conceivably encompassed, was first articulated by Carlos González of Venezuela’s Ministry of Health and Social Welfare in a 1965 background paper written on behalf of the World Health Organization’s (WHO) “Study Group on the Integration of Mass Campaigns Against Specific Diseases into General Health Services” [ 9 , 11 ].

In 1967, the WHO set up the in-house Division of Research in Epidemiology and Communication Sciences (RECS) to develop new planning methods for health “systems” in “developing” countries, led by Kenneth Newell, and drawing on the experience and expertise of innovators in multidisciplinary planning approaches from diverse country contexts [ 9 ]. In 1975, Newell launched Health by the People, an edited compendium of community public health initiatives which highlighted the grassroots work of social medicine activists in Latin America, South East Asia, the Middle East and China [ 12 ]. For the sake of brevity, this is a top-line reading of what was in fact a dynamic transnational movement of interconnected health systems thinkers, practitioners and community public health activists. However, we outline these few key moments in the chronology to give some sense of the expanse of time in which community-based - or what might now be called “people-centred” approaches - to health systems development and change were being first developed. Thus, in 1978 when the Declaration of Alma Ata called for community-led approaches to health systems development, in addition to rearticulating health as a human right, this marked the culmination of fifty-plus years of international health cooperation and learning [ 13 ].

The Alma Ata moment, contrary to how it is portrayed in global health literature, marked the beginning of a shift away from “horizontal” or community-led, multi-sectoral, ‘activist- inclusive approaches to health systems development within international/global health circles. By 1979, within the WHO, UNICEF and amongst Western global health leadership, the tide had turned towards a politically neutral and economically feasible “selective” approach to Primary Health Care [ 3 , 8 , 14 , 15 ]. With a global economic downturn, increased restrictions on development aid, the rise of neoliberalism and conocomitantly new logics of efficiency and efficacy at scale, the period of the mid 1980s to late 1990s saw those who advocated sustained, grassroots processes of change in public health lose ground to those focused on disease or health-issue specific interventions and increasingly siloed areas of expertise [ 8 , 16 ]. Within this overarching context, the World Bank, which by the mid-1990s was a leading actor in global health and development, began to experiment with “pro-participation” approaches to public service planning processes, incorporating the language of Alma Ata, while at the same time promoting metrics-driven, top-down (“vertical”) health interventions [ 17 ]. With the 2004 publication of the World Development Report, pro-participation approaches, renamed “social accountability” went from being a practice emergent in public health activist circles to a set of techniques aimed at addressing short-term health systems change [ 18 ].

The development of systems thinking and the tensions between “activist” and “technician” led approaches to public health are important precedents to understand contemporary accountability ecosystems framings. Over time, conflicts have emerged between health systems strengthening researchers and practitioners on the one hand, and health equity-focussed activists on the other, the former associated with timebound project cycles and the latter with generational societal transformations [ 19 , 20 ]. A “whole systems approach” takes into account a broader set of influencing actors, institutions and their interrelationships on health outcomes, as well as the mechanisms that connect grassroots or community-led efforts to changes at higher levels of public health decision-making and resource allocation [ 18 ]. Within this “whole system” approach the value of differently positioned, and differently skilled actors pursuing accountability for health equity is clear. Thus, we don’t argue here in favor of either “technician” or “activist” approaches to social accountability, but instead unpack the tensions between them and why they might exist, and how to draw on both/all ways of working within different time-scales of change.

Prior to the the Covid-19 pandemic, accountability theorists and practitioners in health systems were concerned with the rise of digital technologies, the increased corporatization of health systems and the concomitant challenges of embedding accountability mechanisms within institutions, regulatory powers, professional associations, and at an international level – a shifting group of global health governance leaders. Within the context of the Covid-19 crisis, as with most emergencies, the first instinct has been to focus on short-term response and “command and control” interventions, at the expense of measures which may have provided more community engagement and involvement in the development of prevention and risk management strategies [ 21 ]. While there is no question that we have needed the rapid scaling of personal protection, social distancing, progress in management of respiratory distress in intensive care, and rapidly developed and scaled vaccine strategies, we are also well aware of the need for adequate resourcing of health systems broadly speaking, and attention to ways in which health systems continue to underperform for the most marginalized and vulnerable populations [ 21 , 22 ].

Without knowing the future development of the Covid-19 pandemic, we know that it will not be the last pandemic or global health emergency [ 23 ]. To date, it has triggered a number of old dysfunctions in ways that are potentially damaging to social accountability efforts—for example when the space for critical engagement between health duty-bearers and service recipients has shrunk and when communities have been left out of critical decision-making processes. At the same time, it has made clear the necessity of social accountability oriented towards the achievement of greater health equity. When the longer historical record of international public health cooperation is taken in account, it is easier to place social accountability efforts – both technician and activist-led – within a context of unresolved tensions between distinct ways of thinking about and addressing health systems challenges. These debates are not merely theoretical or intellectual in nature, but are reflected in contemporary policy processes and development assistance for health financing.

Accountability meanings and practices in contemporary health systems work

Accountability takes many forms (administrative, managerial, legal-political, market-driven) of which social accountability is just one element [ 18 , 24 ]. In the health sector, activists and technicians tend to focus their efforts where managerial, administrative, legal-political forms of accountability are failing. Social accountability approaches commonly aim to give “teeth” to other forms of accountability [ 25 , 26 , 27 ]. Activist approaches look to social accountability as a means to rebalance or shift power dynamics, but in the specifics, they often relinquish the responsibility to managerial and administrative forms of accountability, mobilizing again when new gaps or shortcomings appear. Health systems technicians, especially those operating at the transnational and international level of cooperation, commonly intervene through time-bound projects and investments, attached to measurable outcomes. They do not seek to replace existing forms of administrative accountability, but often try to spur improvements in efficacy and impact. While there can be stark differences in the positioning, perspective and methods of these distinct categories of actors, what we label here as “technicians” and “activists”, they share the belief that accountability is a non-negotiable element of a functioning social and institutional (in this case, health-focussed) system [ 27 , 28 , 29 , 30 ]. For illustrative purposes, Tables  1 and 2 provide a short summary of the experience of VS and PW, respectively in Brazil and Uganda.

We can now examine where perspectives diverge, in spite of this common ground. Social accountability activists, whether local, national or transnational in practice, see problematic hierarchies of power, broken institutional commitments, or at a minimum public service provider blind spots, as a starting point for change. They may focus on health systems changes specifically, but will often look more broadly at societal arrangements and structural inequalities to determine which issues matter most, to whom, and how they should be addressed. By contrast, heath systems technicians, be they working for on behalf of donor governments, philanthropic funders, or working as project implementers, may perceive gaps in performance relative to the investments made by the institutitions or governments for whom they work and be expected to address and resolve problems that have proved intractable to prior health systems professionals. Within the field of what is still considered “global” health, funding for health systems strengthening (through social accountability or other means) has long been, and remains a small slice of the overall funding pie, though by comparison with the resources available to local civil society organizations and activist groups, these funds are relatively substantial [ 36 ].

Table  3 summarizes the distinct perspectives between the two sets of actors, bringing to the surface what might otherwise remain implicit differences of approach with the aim of helping social accountability advocates of all types to find productive common ground and a forward path.

Most dichotomies oversimplify and Table 3 is no exception. That said, what this table captures are the ways that each set of approaches have the potential to pull towards opposing extremes, when what is needed is more work that builds bridges between health systems duty bearers, funding bodies and institutions, and health equity activists [ 37 , 38 , 39 ]. Historically speaking, the confluence or divergence of controlled or organic, fast or slow drivers of change in health systems has been contextually-specific and dynamic (meaning, unpredictable). What has remained true over time, to return to the historiographic review with which we began, is the challenging nature of working with an awareness of both “fast” and “slow” processes of change, historically-rooted yet contemporarily experienced dynamics of power, both locally specific and internationally governed accountability initiatives when seeking health systems change.

Discussion: a pressing need to move forward, again

The Covid-19 pandemic triggered a ‘crisis’ response as global health emergencies often do [ 1 , 21 , 23 , 40 ]. Within the context of international public health cooperation and national-level public health response, those that have been working towards greater social accountability for health equity have experienced Covid-19 from diverse positions, some as front-line health care providers, some as activists and organizers of mutual aid responses, some supporting health systems responses more or less remotely, in greater or lesser personal safety and teleworking opportunities.

Those concerned about the state of social accountability efforts within the context of pandemic response and beyond must learn from our international public health forebearers the value of both ‘technicians’ and ‘activists’ in driving health systems change. In a context of rapid change, including processes already underway prior to Covid-19 such as shifts in global political leadership and the emergence of increasingly mixed health systems, accountability efforts aimed at addressing health inequities are all the more crucial.

In considering the impact of Covid-19 within the much longer time scale of international public health cooperation and health systems development, we suggest that social accountability should be pursued prior to, or in anticipation of, future disruptions and shocks. Those working in the social accountability space may have different methodological tools and experiential knowledge to contribute, but without drawing on the fullest spectrum of human creativity and problem-solving capacity, the effort to address longstanding health systems inadequacies will remain stunted.

Conclusion: toward a code of practice?

Staying with the construct social accountability “technicians” and “activists” can we discern a shared set of values or “code of practice” to help shift towards more effective collaboration? We conclude with some suggestions.

“First do no harm” and “building synergies” remain valid principles, although their operationalization in practice is debated. A step in this direction may be to accept the plurality of our perspectives, and recognize the legitimacy of differently-framed agendas and diverse knowledges. Working across distinct academic disciplines, diverse forms of technical and professional expertise, and institutional cultures, let alone meaningfully incorporating indigenous and non-Western knowledge and practice, requires humility, openness and a willingness to be made uncomfortable when confronted with the limitations of one’s own assumptions. That said, when we cast our eye over the broad sweep of health systems history and the longstanding tensions between those who proffer “vertical” (top-down, disease- or health-issue oriented) versus “horizontal” (systems-wide, socially-oriented, community-engaged) approaches to public health, it is clear that there is no one model way of working. Social accountability efforts oriented towards improving health equity demand dialogic and relational approaches from both “technicians” and “activists” even if at times this dialogue proves oppositional and fraught [ 41 ].

For activists, the attention of “technicians” is an acknowledgement of their own success in demonstrating the value of social accountability to improving meaningful community engagement in health systems improvements. In seeking alliances to achieve time-bound targets with the support and funding of external interventions, social accountability activists can still leverage these opportunities for learning and coalition building, while recognizing that cooptation—institutional or personal--are ever-present challenges. On the other hand, donor agencies, health systems planners and managers of externally-funded health projects intervening in social accountability processes should recognize the disruption that their short-term work brings. Such technicians should be more attentive to the history of past health systems efforts both specific to the contexts where they work, as well as within the broader landscape of international public health cooperation before steaming ahead with “new” innovations in design and approach. Respect for endogenous processes and local perspectives should be an active and ongoing commitment. What this history teaches us is that working towards a collaborative “middle” ground is an ongoing learning process, one that is not devoid of confrontation or dissent. As with all health systems strengthening interventions, further illuminated by the wide-ranging impacts of Covid-19, social accountability is “everybody’s business” [ 42 ]. To do better than our forebearers in international public health cooperation, it is necessary to maintain awareness of how the past has shaped the present, how what what appears ‘short term’ might in fact just be an inadvertent repetition of past patterns, and that meaningful change requires ongoing commitment to open- if challenging – dialogue between distinctly positioned actors.

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This commentary piece is based wholly on publicly available secondary materials (e.g. journal articles, reports and commentaries in the public domain). There were no original data or supplementary materials generated or consulted in the creation of this commentary.

Abbreviations

Community Based Organizations

Community and District Empowerment for Scale-up

Community of Practice

Division of Research in Epidemiology and Communication Sciences

Short Message Service

Sistema Único de Saúde or Universal Health System

United Nations Development Program

United Nations International Children’s Emergency Fund

World Health Organization

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Acknowledgements

The authors have written this paper as part of the Community of Practice on measuring social accountability and health outcomes and would like to acknowledge fellow members, specifically: Elizabeth Allen, UNICEF; Elena Altieri, WHO; Bright Amissah-Nyarko, HERO Network Ghana Coalition of NGOs in Health; Jayathilaka Chandani Anoma, WHO; Tom Aston, Independent Consultant/World Vision; Mary Awelana Addah, Ghana Integrity Initiative; Angela Bailey, American University; Colin Baynes, University of Washington; Anshu Banerjee, WHO; Sandrine Biau Lalane, Unité de Santé Internationale; Julianne Birungi, UNICEF; Victoria Boydell, Global Health Centre, the Geneva Graduate Institute; Vanessa Brizuela, Partnership for Maternal Newborn and Child Health; Carol Anne Bryson, Department for International Development; Suzanne Cant, World Vision International; Venkatraman Chandra-Mouli, WHO; David Clarke, WHO; Mark Connolly, University of Groningen; Sana Contractor, Centre for Health and Social Justice; Joanna Cordero, Independent Consultant/WHO; George Danhoundo; WHO; Elizabeth Ekirapa-Kiracho, Makerere University School of Public Health; Rania Elessawi, UNICEF; Walter Flores, Centro De Estudios Para La Equidad y Gobernanza;Christine Galavotti, Bill and Melinda Gates Foundation; Bela Ganatra, WHO; Nina Gerlach, UNAIDS; Asha George, University of the Western Cape; Florencia Guerzovich, Independent consultant/Global Partnership for Social Accountability; Sara Gullo, Independent Consultant; Kamden Hoffmann, Corus International; Beverly Johnston, USAID; Ilze Kalnina, Partnership for Maternal Newborn and Child Health; James Kiarie, WHO; Eugene Kisonga, Mbeya Council Health Board; Kira Koch, WHO; Joan Kraft, USAID; Etienne Langlois, WHO; Anne Laterra, CARE; Elizabeth Lodenstein, KIT Royal Tropical Institute; Cecily Marston, London School of Hygiene & Tropical Medicine; Adriane Martin Hilber, Swiss Tropical and Public Health Institute; Heather McMullen, Queen Mary University; Vernon Mochache, independent consultant; Besinati Mpepo, World Vision International; Alice Monyo, Sikika; Sigilbert Mrema, Ifakara Health Institute; Dela Nai, Population Council Ghana; Erica Nelson, Institute for Development Studies, University of Sussex; Moses Ngulube, CARE; Jill Oliver, University of Cape Town; Ligia Pania, International Health John Hopkins University; Maria Plesons, Independent Consultant/WHO; Anayda Portela, WHO; Dheepa Rajan, WHO; Valery Ridde, Institut de Recherches pour le Développement; Miriam Sabin, Lancet; Niranjan Saggurti, Population Council; Eric Sarriot, Gavi the Vaccine Alliance; Marta Schaaf, Independent consultant; Vera Schatten Pereira Coelho, CEBRAP; Anne Selbert Kuhlmann, St Louis University; Gita Sen, Public Health Foundation of India; Donat Shamba, Ifakara Health Institute; Shaila Mahmood Shehrin, ICDDRB; Kenneth Sherr, University of Washington; Francis Squires, Independent Consultant; Petrus Steyn, WHO; Fletcher Tembo, Hivos; Courtney Tolmie, R4D; Özge Tuncalp Mingard, WHO; Sara Van Belle, Institute of Tropical Medicine; Peter Waiswa, Makerere University School of Public Health; Etobssie Wako, CARE International; Tom Wein, Independent Researcher; Gill Westhorp, Realist Research Evaluation and Learning Initiative, Northern Institute at Charles Darwin University.

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EN and ES developed the initial concept for the paper, which was further developed in a joint seminar for the 2020 CoP virtual meeting, with contributions by VSC and PW. EN and ES drafted the paper, with input from VSC and PW. All authors contributed to rewrites and revisions. All members of the CoP were given the opportunity to provide additional feedback in the final drafting stage, and we thank in particular those who took the time to suggest edits (Marta Schaff, Joanna Cordero, Petrus Steyn, Moses Ngulube, Kamden Hoffman, and Ilze Kalnina). EN and ES incorporated the edits and finalized the text. The authors alone are responsible for the views expressed in the article and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated. All authors read and approved the final manuscript.

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Nelson, E., Waiswa, P., Coelho, V.S. et al. Social accountability and health systems’ change, beyond the shock of Covid-19: drawing on histories of technical and activist approaches to rethink a shared code of practice. Int J Equity Health 21 (Suppl 1), 41 (2024). https://doi.org/10.1186/s12939-022-01645-0

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Accountability as a virtue in medicine: from theory to practice

• John R. Peteet   ORCID: orcid.org/0000-0001-5362-1765 1 ,
• Charlotte V.O. Witvliet   ORCID: orcid.org/0000-0003-4364-6816 2 ,
• Gerrit Glas   ORCID: orcid.org/0000-0003-2359-9119 3 &
• Benjamin W. Frush   ORCID: orcid.org/0000-0003-1389-427X 4  

Philosophy, Ethics, and Humanities in Medicine volume  18 , Article number:  1 ( 2023 ) Cite this article

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Accountability is a norm basic to several aspects of medical practice. We explore here the benefits of a more explicit focus on the virtue of accountability, which as distinct from the state of being held accountable, entails both welcoming responsibility to others and welcoming input from others. Practicing accountably can limit moral distress caused by institutional pressures on the doctor patient relationship. Fostering a mindset that is welcoming rather than resistant to feedback is critical to enhancing a culture of learning. Analysis of failures of accountable practice offers opportunities for improving the delivery of clinical care.

A conceptual description

Accountability is an important, if implicit, value in medicine. Yet the distinction is not often made between being held accountable and the virtue possessed by one who embraces being accountable . While accountability understood as a characteristic of relationships in medicine is important, we argue that the virtue of accountability, understood as a specific character disposition, is prior to and required for accountable relationships to form and function effectively in the domain of healthcare. We suggest here that, absent a robust commitment to accountability as a virtue, physicians and other healthcare practitioners would be unable to effectively serve the patients under their care, the practitioners with whom they work, and the institutions which employ them.

In order to understand why accountability proves so central to sound medical practice (which we take to be the broader construct of healthcare delivery beyond the practice of allopathic medicine as a single discipline), it is first important to grasp how accountability has traditionally been construed. In a seminal paper on accountability in health care, Linda and Ezekial Emmanuel [ 1 ] described three components of the concept – loci, or the parties involved ( who is accountable, and to whom ), domains ( what they are accountable for), and procedures ( how parties are held accountable). The details of these procedures, they suggested, differ depending upon the operative model at play in health care – whether professional, economic and/or political.

The structures governing professional accountability in healthcare have since been clarified further by Gerrit Glas [ 2 ], who distinguishes among differing functions of norms or values in medicine, and clarifies the relationship between values and virtue. Glas argues that qualifying moral norms/principles/values focus on the nature and purpose of the practice, while foundational principles and insights are those on which the practice is based (usually scientific, technological expertise, insight into therapy, engineering and the like), and conditioning norms are the legal, administrative, institutional and economic conditions that allow practitioners to fulfill their role. While values refer to things in life we deem worthy and valuable, norms are the standards which we are supposed to enact in order to attain the things in life we deem to be valuable. The act of adhering to or exhibiting certain values in our lives is termed ‘norm-responsive’ (or value-oriented/guided) behavior. Norm-responsive behaviors, in turn, become virtues when they are internalized throughout one’s upbringing, education, and training. This process of internalization implies that they become a durable part of who a person is in the role they are supposed to fulfill in the future.

Glas furthermore calls attention to the risk of overemphasizing either the micro (patient care), meso (administration, financial) or macro (regulatory and certification) spheres in which these norms operate, and of allowing foundational or conditioning norms to function as qualifying ones [ 3 ].

Ultimately, a lack of clarity on how, and to whom, healthcare practitioners ought to be accountable has important downstream consequences. For example, the risk of conflating qualifying and conditioning norms which govern accountability is demonstrated by the Emmanuels’ prescient warning that “portraying physicians as caring professionals while forcing them to act as economic producers … will ultimately discredit the entire practice of medicine and sow distrust and cynicism that cannot easily be overcome.” [[ 1 ], p. 238]. Put another way, the authors warn against the tendency of large institutions to structure physicians’ practice such that they are ultimately accountable for financial considerations, rather than the health and well-being of individual patients. The term “burnout” has since been applied to the resulting demoralization and sense of moral injury that occurs when professionals violate their values, which is more likely to occur as economic or institutional norms supersede the moral norms of the healthcare provider relationship.

Clinical medicine, whether practiced well or poorly, ineluctably consists of the actions and experiences of individual patients interfacing with individual healthcare practitioners, and communication among individuals on the healthcare team. Despite the tendency to view issues such as healthcare quality, patient outcomes, or even burnout, as functions of populations, the moral foundation of medicine ultimately consists in the interactions between individuals. Thus any goal of understanding these broader issues in healthcare also must take seriously the roles, practices, and values of individuals in addition to systems. Understanding accountability as a virtue that might be modeled, taught, learned, and practiced highlights what kind of persons clinicians need to be in order to care well for their patients, form effective teams, and ultimately allow for the flourishing of the broader systems in which they operate.

The practice of accountability in medicine

While a sound conceptual understanding of accountability is important, accountability as a virtue holds little weight in medicine unless it is intentionally cultivated and practiced (given that a virtue rather than a duty based approach emphasizes the practical, educational prerequisites of acquiring good habits) in ways that promote flourishing. Accountability, then, warrants not just attention but also action in order to move from theory to practice [ 4 ]. In contrast to the state of being held accountable, the practice of accountability as a virtue undertaken by individual moral agents, as addressed by Witvliet and colleagues [ 5 ], page 2, entails:

(a) welcoming being accountable to others across relationships with others to whom one rightly owes a response–both in receiving capable, sound input of trusted persons and in providing transparent explanations of their own decisions and actions; and (b) being willingly accountable for one’s own attitudes, thoughts, emotions, and actions–working to improve or correct one’s responses for a positive impact. Welcoming accountability to others for fulfilling one’s responsibilities to them requires practical wisdom to neither reflexively conform to nor disregard others’ requests or expectations. As such, accountable practice requires clarity about what is owed to whom, empathy in order to appreciate the expectations of the other, and self-regulation to respond appropriately. A culture of accountability is one that actively seeks to instill this clarity, empathy, and self-regulation and thus fosters accountable practice.

Consider the contrast between a welcoming and a resisting mindset toward supervisory feedback [ 6 ], a practice which is central to both medical training and practice within medical institutions. A welcoming mindset (1) values feedback as beneficial, useful, growth-producing and equipping for one’s future, (2) values the supervisor as a person whose perspective and experience can help one grow in competence, and (3) values oneself as able to learn from, adapt to, and benefit from the feedback. By contrast, a resistant mindset (1) devalues such feedback as a hassle or burden that is potentially pointless, inconvenient, annoying, frustrating, and difficult, (2) devalues the supervisor’s perspective and input as unnecessary, and (3) devalues change in oneself, instead focusing on how one already knows one’s own abilities and how to work, preferring not to change. Whereas a welcoming mindset embraces learning and growth, a resistant mindset neglects this. A welcoming mindset inclines one to regard the supervisor as a worthy person and engage in empathic perspective-taking; by contrast, a resistant mindset works against the perspective-taking so important for empathic connection and learning another important point of view. A welcoming mindset emphasizes one’s capacities for self-regulation which is essential for responsibly modulating one’s attitudes, thoughts, emotions, and actions in light of feedback; in contrast, a resistant mindset undercuts self-regulation and responsible change.

Contemporary healthcare acknowledges, if only implicitly, the importance of accountable practice as outlined by Witvliet and colleagues, through existing methods for reviewing and improving care. Morbidity and Mortality (M and M) conferences, Quality Assurance and Improvement (QA/QI) efforts, and the systematization of supervision in clinical practice all attest to this. An emphasis upon the centrality of accountability is also explicitly built into medical training; the Accreditation Council for Graduate Medical Education (ACGME) names accountability as an element in the core competence of professionalism, by which medical trainees are regularly evaluated. However, whether the term “accountability” refers to the condition of being held accountable or to welcoming accountability is generally left undefined, and no consensus exists on how to work toward cultivating the virtue.

Exploration of failures of accountability

One of the clearest ways to recognize the importance of accountability as a virtue affecting healthcare is to note when its absence adversely affects patient care, practitioner experience, or the functioning of healthcare systems. To explore this, we consider four examples of failures of accountability extending from the micro to the macro level, in order to better understand and then address the factors involved.

Rita Charon’s seven minute video “Intern Progress Note” [ 7 ] features a harried medical intern who is responsible for an increasing number of patients despite the failures of the system to support the intern in performing the tasks involved. The medical intern is clearly attempting to practice accountably to patients, but the patients’ needs exceed the intern’s capacity. Physicians in outpatient primary care also often find themselves frustrated if not overwhelmed by the multiple expectations crowding out time for the role they entered medicine to play [ 8 , 9 ]. One wonders why no one offers to help. What accounts for an apparent lack of mutual accountability to and for one another?

Potential contributing factors include a traditionally hierarchical medical culture, where superiors believe their juniors must negotiate competing loci of accountability without assistance; stress on co-practitioners which constrains their ability to act more generously or collaboratively; and almost certainly, larger competitive economic or political forces which de-prioritize the experience of practitioners and individual patients alike in the name of financial or temporal expediency. Practicing accountably would require clarification of priorities (to whom is the clinician primarily accountable, and for what?), recognition of collective responsibility (to whom and for what?) and, accordingly, a shift from an error-focus toward a systems approach to safety, quality, and self-learning in organizations [ 10 ].

A progressive, young health care organization contracts with payors to care for a population of people who live with disabilities in the community, aiming to minimize costly hospitalizations. The organization’s CEO makes an executive decision to cut the staff of the clinic team because it loses money relative to the team in the field who visits clients in their homes. Clinicians request a meeting with the CEO, objecting that no one had consulted them, or had offered to examine how their patients experienced the quality of their care. One might ask what accounts for this failure to involve clinicians in discussion of their shared accountability to patients and to the financial viability of the organization.

It seems possible that the CEO inappropriately applied an economic and political model in lieu of a professional model, in such a way that what was owed patients and staff, including respect for their dignity and worth, was de-prioritized, perhaps out of a concern to responsibly steward organizational resources. It could be that while these factors were indeed considered, there was a failure of healthy, transparent communication. It could also be that the CEO was insufficiently aware of the importance of the organization’s social responsibility [ 11 , 12 ] and the risk of succumbing to market driven competition. This lack of awareness could relate to the CEO’s own vulnerability to a performance-based identity that implicitly or explicitly measured their (and the enterprise’s) worth comparatively, rather than in relation to the moral context within which they are accountable—to both people within, and outside of, the organization.

Here, accountable practice in the micro-sphere might entail questioning whether the clinic staff was legitimately accountable to the CEO for productivity metrics if these measures conflict with those mandated by their relationships with patients and their obligations to provide professional care. At the meso- and macro-level of organization of care it could (again) be asked whether both the medical staff and the CEO were sufficiently aware of what it means to be socially responsible as an organization.

An academic medical center recruits a division chief based solely on research reputation, without including practice-oriented members of that division as part of the search committee. Within months of arriving, the new chief enacts arbitrary and dictatorial changes to staff roles and requirements that result in multiple complaints, resignations and concerns about deteriorating clinical care. The hospital leadership then confines the new hire to the lab and appoints an interim chief.

In this case, an apparently narcissistic personality with limited capacity for empathy and self-regulation with humility—which are intrinsic to the practice of mutual accountability—was initially selected by leaders of an institution. These leaders were concerned with the organization’s competitive reputation as a comparative measure of its worth, rather than prioritizing the moral context of professional accountability. Here, exercising the virtue of accountability at the institutional level would involve recruiting a chief with different character dispositions—such as empathy, humility, and self-regulation—who was capable of supporting and engaging others with relational responsibility, rather than dominance that sought others’ servile acquiescence.

A patient experiences severe back pain beginning during physical therapy, five days following a lumbar laminectomy. The original neurosurgeon had taken a personal leave due to work stress. After some difficulty in securing an appointment, the patient was readmitted to the hospital where the surgery was performed. On meeting the covering surgeon who had a burgeoning caseload, the patient expresses appreciation for being accepted as a patient. In response, the covering neurosurgeon, who has no time for more than a glance at the imaging, dismissively remarks, “I didn’t accept you, and your imaging is probably fine,” discharging the patient before being able to walk. The patient requires admission to another hospital where a careful review of the MRI shows nerve impingement.

One wonders here not only about character, but also work culture and the stress imposed on the covering neurosurgeon, whose professionalism was undermined by an excessive caseload and the personal leave of a colleague due to work pressures. For the covering neurosurgeon to show accountability as a virtue would have meant providing care the patient was due by carefully reviewing the evidence related to the patient’s symptoms and concern, as well as addressing aspects of the work culture that could be improved to de-escalate stress and promote adequate supports for medical staff, patient appointment times, and transparency.

Toward cultures of accountability in medicine

These scenarios show how factors such as hierarchical cultures, personal narcissism, deficient communication, institutional competition, and work stress can combine to undermine the practice of accountability. They suggest to us a need for the following to work toward accountable practice:

A systematic root cause analysis of failures of accountable practice is important. We suggest beginning with an examination of the responsibilities and obligations of the relevant stakeholders, including how these are being met or missed, and proceeding to consider factors such as work overload or a lack of support that could be making requisite components of the virtue—transparency, empathy or self-regulation—difficult. In their study of accountability in five hospital systems, Aveling et al. [ 13 ] found that various forums of accountability such as Morbidity and Mortality (M and M) conferences could be helpful. However, their effectiveness was also conditioned by the vested interests of senior staff and had the potential to become punitive. Their analysis highlighted the process as a responsibility shared by all individuals involved.

More explicit discussion of the core values of health care organizations (including at the level of their governing boards) are valuable to guard against lapsing into comparative valuing with the pressure that creates. Performance-based identities at the organizational level can inadvertently place productivity and/or reputation ahead of quality patient care, thereby reversing the order between relevant normative principles highlighted in Glas’ work. This reversal occurs when principles that shape the conditions for the practice of healthcare (such as efficiency and maximizing productivity) transform into principles that qualify that practice. The resulting culture of stress and demoralization elevates the risk of moral injury occasioned by decisions driven by misplaced priorities at odds with more foundational values.

Heightened awareness of the need of a shared notion of corporate responsibility goes hand in hand with developing a systems approach to quality, safety, and prioritizing of care. Medical flaws and failures are seldom errors for which only one individual can be held accountable; they also and always deserve to be investigated as expressions of the functioning of the organization as a whole. As the work of Aveling et al. [ 13 ] and the example of Dr.Bawa-Garwa [ 14 ] suggests, rule-based approaches to achieving a just work culture are less effective than a participatory process in which all individuals create, modify and are subject to the social forces that are an inescapable feature of any organizational system. Glas [ 3 ] suggests some possible ways that a physician stressed by intruding forces from meso and macro levels could amplify their reflective space. [Wording is modified for inclusion.] A healthcare professional

“could, for instance, raise [one’s] voice in [one’s] own professional organisation; discuss [one’s] worries with the administrators of the hospital; search for common ground between [oneself], the administrators and patient representatives; take part in the council of hospital employees; participate in advocacy groups; raise public awareness of what is going on in the sector, for instance on social media; or become politically active. Professionalism entails the awareness of and the ability to negotiate about the conditions under which healthcare is delivered.”

These examples underscore the need for the social contract between medical disciplines (e.g., psychiatry) and society to be reviewed and renegotiated on a regular basis [ 15 ].

Discernment is also important at the individual level to navigate what it means to welcome being accountable to other people and also to one’s highest authorities and ideals—especially in the frequent case of competing claims for loyalty. Aveling et al. [ 13 ] found in their study of accountability in five hospital systems that individuals often triumphed in the face of adversity through the exercise of a morally-founded agency, even though it seemed that the conscious choices and actions of individuals were heavily conditioned by strongly reinforced norms and other constraints, some of them deeply institutionally and historically patterned. One’s highest loyalties might be for example to a beloved work community, or to personal and professional ideals, perhaps supported and shaped by reference to one’s faith tradition [ 16 ]. This involves both a naming and a rank-ordering of goods for the individual, to place the parties or institutions to whom one is accountable in their proper context. It also may call for transparency to enable discussion and attempts at consensus in cases where values are not shared, as in the case of conscientious objections to providing care. This does not mean that professionals operating within the healthcare context will avoid such dilemmas of accountability—only that they might approach these dilemmas with more clarity when they have done the work of discerning commitments a priori.

Identifying and cultivating the requisite ingredients of accountability as a virtue will benefit trainees in developing the virtue. While medical training is typically viewed primarily as a time of informational and technical acquisition, it is in fact better understood as a profound period of moral formation [ 17 , 18 ]. In order to select for those who might flourish in this intense space, what questions can leaders ask to better recognize state and trait accountability in job applicants? Sample behavioral questions already being suggested to interviewers for use in residency recruitment interviews include:

“Describe a time when you disagreed with an evaluation or feedback you received about your performance. How did you handle the situation? What impact did it have on you? What did you learn?” “Describe a time when you received negative feedback and turned it into an opportunity to make a correction or improvement, or to grow and learn.”

It is important to know how important empathy and self-regulation are to the virtue of accountability to others, to identify specific ways individuals may benefit from remediation. The human aversion to negative feedback can be particularly strong for seniors in medicine who have generally enjoyed success amidst the rigors of schooling and training. Remediation and feedback by peers are critical for improved future practice. For example, similar to the way that mentalization training has been developed to enhance empathy in the treatment of individuals with borderline personality disorder, exercises are now being studied which can enhance a welcoming mindset to feedback from others by valuing what one can learn from others’ perspectives and seeing oneself as capable of adapting as needed. Such work points to the value of adopting a welcoming mindset to supervisory feedback, which elevates empathy, self-regulation, and accountability [ 6 ].

We started by making a distinction between the state of being accountable and the virtue of accountability. We argued for the importance of the virtue of accountability to responsibly and competently serve patients, collaborate with colleagues, carry out professional formation, and uphold proper standards of care and professionalism. We discussed failures of accountability in cases that reached from the micro to the macro level, i.e., in the provision of patient care, the operation of the clinical team, the realization of a hospital’s teaching mission, and the system of healthcare delivery. We offered a theoretical frame and examples with practical steps toward both remediation and prevention as well as proactive cultivation of the virtue, ultimately with the goal of improving patient care, practitioner experiences, and the well-working of healthcare systems.

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Acknowledgements

This paper was made possible through the support of grant TRT 0171from the Templeton Religion Trust. Authors JP and CW received funding for writing and authors GG and BF participated in a conference funded by the grant. The opinions expressed in this paper are those of the authors, and do not necessarily reflect the views of the Templeton Religion Trust.

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JP contributed the organization and case examples, CV to the definitions used, GG to the philosophical explanations, and BF to the Discussion. All authors read and reviewed the final manuscript.

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JP is a consultation-liaison psychiatrist at Brigham and Women’s Hospital, Boston, and an Associate Professor of Psychiatry, Harvard Medical School. CW is the Lavern '39 and Betty DePree '41 VanKley Professor of Psychology at Hope College; GG is a psychiatrist, and professor of philosophy at the Free University of Amsterdam. BF is a resident in internal medicine at Vanderbilt University Medical Center.

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Peteet, J.R., Witvliet, C.V., Glas, G. et al. Accountability as a virtue in medicine: from theory to practice. Philos Ethics Humanit Med 18 , 1 (2023). https://doi.org/10.1186/s13010-023-00129-5

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Defining and Assigning Accountability for Quality Care and Patient Safety

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• • Describe how accountability relates to patient safety and quality.
• • Identify at least two types of accountability.
• • Define systems theory and systems thinking.
• a. It focuses on individuals.
• b. It is unrelated to systems thinking.
• c. It provides a set of concepts that are specific.
• d. It focuses on relationships and interactions.
• a. patient preferences.
• b. sanctions.
• c. licensure data.
• d. incentives.
• a. Hospital policy
• b. Payer policy
• c. Federal law
• d. Vendor suggestions
• a. The Future of Nursing: Leading Change, Advancing Health
• b. To Err is Human
• c. Centers for Medicare & Medicaid Services Special Report
• d. Social Transformation of American Nursing
• a. Core educational curricula, licensure regulations, and uniform standards of practice emerged in the 1990s.
• b. Core educational curricula, licensure regulations, and uniform standards of practice emerged in the 1910s.
• c. By the 1980s, the growth of diagnostic and treatment options made care and accountability more complex.
• d. By the 1970s, the growth of diagnostic and treatment options made care and accountability more complex.
• a. Nurse practice acts vary from state to state.
• b. Nurse practice acts are consistent from state to state.
• c. Nursing curricula are standardized.
• d. Licensure exams test advanced knowledge.
• a. Accountability should be based solely on licensure.
• b. Scope of nursing and medical practice can overlap.
• c. Accountability is easy to assign when an error occurs.
• d. Regulators should not strive to develop standardized principles for assessing behavior.
• a. Economic accountablity should not supersede licensure requirements.
• b. Economic accountablity should be an integral part of scope of practice.
• c. Economic accountablity means payment should not be linked to performance.
• d. Economic accountablity means that all hospitals should receive the same reimbursement.
• a. Nearly 100,000
• b. Nearly 200,000
• c. Nearly 300,000
• d. Nearly 400,000
• a. a population that is getting younger.
• b. a lack of development in biotherapies.
• c. an explosion of information technology.
• d. insufficient patient-safety performance measures.
• a. State board tests
• c. Individual state boards
• d. State licensure
• a. The lack of development in diagnostic technologies
• b. Basic preparation with clearly defined follow-up education
• c. Baccalaureate programs with a large clinical component
• d. A lack of uniform requirement for continuing nursing education
• a. Well-defined quality metrics
• b. Broad quality standards
• c. Expectations that vary per individual
• d. Penalties for violations that vary per hospital
• a. Systems thinking states that individual competency is the only factor to be examined in an error.
• b. Systems thinking requires that the nurse responsible for an error should shoulder the blame.
• c. Systems thinking views problems from the perspective of interrelationships, factors, and microsystems in an overall system.
• d. Systems thinking views problems from the perspective of silos of information that do not interact.
• a. All nurses must develop leadership competencies.
• b. Only nurses seeking management roles need to develop leadership competencies.
• c. An organization should not offer leadership mentoring programs to staff.
• d. Only baccalaureate nurses need to develop leadership competencies.
• • Describe how accountability relates to patient safety and quality. 1 2 3 4 5 _____________
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Professional Accountability in Social Care and Health Challenging unacceptable practice and its management

• Roger Kline - Association of Professionals in Education and Children's Trusts (ASPECTS)
• Michael Preston-Shoot - University of Bedfordshire, UK
• Description

The book will appeal to those with supervisory and management responsibility and academics planning modules concerning law, ethics and professional practice. It presents scenarios, case studies and information that will help students and practitioners to gain the necessary knowledge, understanding and skills to be able to weigh up difficult dilemmas relating to health and social care practice, before deciding on how to act' Chris O'Grady Senior Lecturer Nursing, School of Health, Medical Science and Society, Glyndwyr University Wrexham

This book is a useful resource and provides an excellent bibliography of cases, procedural guidance and relevant research. Much of this material is very practical and could be easily adapted to develop a training intervention to raise awareness in the local context. It will be of use to those taking on challenging roles as ethical advisors or complaints assessors with the caveat of course that local knowledge is central to good management.

A really useful book that is a great companion to the Transforming Nursing Practice Law and Professional Issues in Nursing. This really digs down to the nub of the issues and allows experienced care workers to discuss and debate using their knowledge of case studies to share good practice and to identify where other teams experience issues.

In the past professional accountability sent shivers down the spines of many working in the increasingly complex world of health and social care. It still does. and primarily due to practitioners not considering the 'what if and what about'. This accessible, readable and lively text opens the issues up, sheds light on complexity and takes the reader into the places they know they need to go but would at time prefer not to. A great addition to the literature.

This book summarises effectively evidence from recent serious case reviews in both children and adult services and the importance of learning from these. It also includes good sections on managing workload and the boundaries of confidentiality. As such, it highlights both work pressures and ethical dilemmas and is therefore insightful for any social work student.

This is a very good book that will help HNC Health and Social care students to understand the professional accountability in health and social care.

This book can be used throughout the course in relation to units 1, 2, 3, 4, 5, 10

The way in which the book has been written enables students gather knowledge and also through the use of carefully selected activities it encourages students to reflect on practice and ask questions?

In my view a helpful text which, stimulates an exploration of accountability and professionalism in social work and social care. Good coverage of law and ethics with helpful case examples to support application of, and reflection on learning. These can also be adapted to make good in class activities.

Nicely presented book which helps students to get into this very important topic.

A book that informs professionals within health care and social work about accountability in the workplace and what practitioners should be aware of. This book is very informative and has case studies throughout which informs the reader of how to deal with difficult situations which challenge accountability.

This book offers a good balance between theory, case studies and case law examples, that provide students with a good overview of the issues arising. Case studies provide excellent links to practice and have been a useful took in stimulating discussions. This book is an essential read for people working in social care.

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Studying social accountability in the context of health system strengthening: innovations and considerations for future work

Victoria boydell.

1 Global Health Centre, Geneva Institute of International and Development Studies, Geneva, Switzerland

Heather McMullen

2 Queen Mary, University of London, London, United Kingdom

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There is a growing body of research on the role of social accountability in bringing about more accessible and better-quality healthcare. Here, we refer to social accountability as “ citizens’ efforts at ongoing meaningful collective engagement with public institutions for accountability in the provision of public goods ” (Joshi, World Dev 99:160–172, 2017). These processes have multiple interrelated components and sub-processes and engage a range of actors in community-driven, often unpredictable and context-dependent actions, which pose many methodological challenges for researchers. In June 2017, scientists and implementers working in this area came together to share experiences, discuss approaches, identify research gaps and consider directions for future studies. This paper shares learnings from this discussion.

In particular, participants considered (1) how best to define and measure the complex processual nature of social accountability; (2) the study of social accountability as an inherently political process; and (3) the challenges of generalising unpredictable, community-driven and context-dependent processes. Key among a range of consensus areas was the need for researchers to capture a broader range of outcomes and better understand the nuances of implementation processes in order to effectively test theories and assumptions. Furthermore, power relationships are inherent in social accountability and the research process itself. In presenting details on these deliberations, we hope to prompt a wider discussion on the study of social accountability in health programming.

Introduction

Social accountability is gaining rapid acceptance as a way to address health systems inefficiencies and improve basic public health performance, including planning and service delivery, and to contribute to the attainment of the highest possible standards of health. Here, we refer to social accountability as “ citizens’ efforts at ongoing meaningful collective engagement with public institutions for accountability in the provision of public goods ([ 1 ], p. 161).” 1 For example, the use of community scorecard processes to improve maternal health services, whereby health providers and community members assess their existing entitlements in service delivery and then prioritise the issues they face in accessing and delivering services [ 2 , 3 ]. These priorities are then jointly shared in multi-stakeholder meetings with health officials, health facilities and the community to identify local solutions and actions for service improvement and to promote mutual responsibility and accountability. Other social accountability processes use a range of tools to trigger such changes, including social audits, public expenditure tracking systems, information campaigns, public hearings, participatory budgeting, and social movement to name a few. Interest in accountability has spurred a proliferation of studies on social accountability and other participatory processes in the context of health programmes. Yet, there has been less discussion on how to go about studying these dynamic and complex change processes.

The evidence on social accountability and health is growing fast. Early reviews found mixed evidence for the approach, partly due to the varied definitions of accountability used and the range of studies undertaken [ 4 , 5 ]. Another set of reviews summarised the quantifiable benefits of social accountability for service improvement, service utilisation and health outcomes using more linear cause–effect measures [ 4 , 6 – 9 ].

The definition of success encompasses more than directly measurable health-related outcomes and includes a wider range of governance outcomes such as empowerment, participation, and the responsiveness of duty-bearers [ 10 – 17 ]. Joshi notes the expanding number of outcomes related to social accountability “ are expected to unfold, and range from immediate short-term improvements in public services, to more durable long-term changes in states and societies ” ([ 1 ], p. 162). Evaluating a broader range of interrelated outcomes poses several methodological challenges.

In response to these methodological challenges, recent studies on social accountability in health service delivery have attempted to document and assess the complexity of activities and outcomes. Among the methodologies or mixes of methods used are randomised control trials to measure the impact on health and service delivery outcomes [ 2 , 3 ], realist evaluations of social accountability programming [ 18 , 19 ], process evaluations of the implementation processes [ 20 ], psychometric measures of governance outcomes [ 17 ], and Most Significant Change approaches to trace change [ 21 , 22 ], all of which are applied retrospectively and prospectively. These approaches have been developed independently and present a wealth of innovation and experience in their conceptualisation, design and execution. There is, therefore, much to be learned from existing research practice.

In June 2017, researchers and implementers had the opportunity to share experiences, methodologies and findings to help guide future endeavours. WHO’s Department of Reproductive Health and Research, which includes the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, convened an event on studying social accountability in Geneva, Switzerland. In this forum, researchers and implementers of social accountability in the context of health, and specifically in reproductive, maternal, newborn and child health, shared experiences, challenges and successes (see Acknowledgements section for list of participants). This paper shares learnings from this discussion.

In particular, participants considered (1) how best to define and measure the complex processual nature of social accountability; (2) the study of social accountability as an inherently political process; and (3) the challenges of generalising unpredictable, community-driven and context-dependent processes.

Defining and measuring the complex processual nature of social accountability

Social accountability processes aim to support service users voice their needs and make claims to their entitlements and hold those responsible for the provision of quality services to account. Accountability processes feature multiple and interrelated components, steps and actors, with several simultaneous processes of change, triggering collective changes. This process adheres to the definition of a complex intervention [ 23 , 24 ]. Therefore, the object of study is a highly unpredictable process with a range of outcomes, and it accordingly requires some methodological innovation. Difficulties in defining the boundaries of the intervention and outcomes of interest can prove challenging in the conceptualisation of research and the development of appropriate study designs. Given this complexity, the study of social accountability interventions can risk either being reduced to mechanistic formulas or dismissed as too context-specific and lacking a generalisable value that would allow replication.

One challenge is that social accountability is relational and focuses on the relationship between rights-holders and duty-bearers; therefore, interventions change and adapt as they are rolled out in specific localities and relationships [ 25 ]. This unpredictability may lead to activities and strategies falling out of line with pre-set interventions. To address this, many researchers described ways they documented and examined implementation to better accommodate adaptive interventions. Process evaluations are increasingly being used to effectively explore fidelity, dose, reach and cost, and realist evaluation methodologies have also been used to assess fidelity, context, mechanisms, and provide lessons for replication and scale-up [ 18 ].

Descriptive and analytic work on implementation is further complicated by the broad and interrelated set of outcomes that together facilitate change. Outcomes may include both routine health and service delivery outcomes, alongside changes in self-efficacy, social cohesion, trust and responsiveness. Less conventional outcomes in public health, such as increased responsiveness of service providers and policy-makers or the emergence of new norms around empowerment of community members and community capabilities [ 18 , 26 ], pose their own challenges because the metrics used to capture them are not standardised or widely accepted. Relatively new outcomes of interest need formative work to distil the mechanisms of effect and the most appropriate way to measure them. There have been efforts to capture the newer constructs (e.g. empowering service providers, mutual responsibility, increased confidence of service users) using psychometric measures and structured observations, which have been tested and are now moving into multi-country validation [ 2 , 14 , 20 ]. Others have been using approaches such as the Bellwether approach, outcome mapping and process tracing to assess changes in duty-bearers’ actions as a consequence of such interventions [ 3 , 27 , 28 ]. These innovations can be learnt from and built upon.

The composite nature of complex interventions presents yet more methodological challenges. Even when the outcomes are delineated, it may be difficult to attribute them to a specific part of a multi-component intervention [ 24 ]. By their very nature, social accountability processes are not easily standardised in their design and delivery as they are highly influenced by local context. Fox’s reinterpretation of the evaluation of evidence moves beyond treating social accountability as a bounded, tactical intervention built for field experiments, toward social accountability as multi-pronged process that utilises multiple strategies to encourage collective action and voice [ 11 ]. This means that the pathways between intervention and outcome are not linear or easy to attribute, and that a mix of methodologies and a range of data sources may be required to sufficiently describe an intervention’s effects [ 24 , 29 ]. Part of the challenge is determining whether the intervention was delivered as intended [ 30 ].

Evaluation strategies need to respond to this complexity and researchers are developing creative solutions. A recommended approach to studying complex interventions is to develop a theoretical understanding of the change process based on existing evidence and theory, and then model the complex intervention to inform the intervention and evaluation design [ 24 , 29 , 31 ]. Mixed methods approaches enable the collection of data which not only describes outcomes but also the processes, shedding light on factors affecting implementation, while still measuring key effects.

A range of tools and tactics are used to support social accountability processes, from community scorecards, audio-visual documentation of rights violations, village health committees and citizen charters. They may vary in focus, looking either broadly at health systems or focusing on specific service delivery points, and they vary in engagement type from collaborative problem solving to more adversarial approaches. These diverse social accountability processes share three broad components as a part of their theory of change, namely information, collective action and official response [ 5 ]. To date, elements of this theory of change have been evidenced, while others remain theoretical and need further work. Ideally, theories of change should be adaptive to the perceptions of participants and to changing conditions on the ground so that they are participatory and responsive.

Not only are social accountability processes unpredictable and the outcomes varied, but a host of activities, outcomes and ‘unintended outcomes’ (negative and positive) may not be recognised in many forms of data capture. Methodologies are needed to intentionally account for these; for example, the Most-Significant Change approach uses personal accounts of change to determine what is considered most significant, or diffusion of innovation research that studies the adoption of a practice among a group of stakeholders [ 21 , 32 ]. Local social hierarchies and power dynamics influence the implementation of social accountability efforts. These are often unspoken, easily elude the most ‘robust’ study design and scuppering the tidiest field experiment design intervention, and speak to the value of qualitative research [ 33 ]. Ethnographic methods, such as long-term observation, can be helpful in capturing the implicit and taken-for-granted hierarchies of daily life [ 34 ].

The study of social accountability as an inherently political process

The study of social accountability is never neutral as it is explicitly concerned with changing the power relationship between ‘citizens’ and the local duty-bearers, and are inherently political even if they do not intend to be. Many quantitative or clinical study designs attempt to control for and reduce complexity, which often means that the political dimensions of an intervention’s implementation are masked. These dimensions not only need to be recognised as germane to the trajectory and success of social accountability efforts, but also need to account for how the research process itself reflects or perpetuates power dynamics. Involving local political scientists in the evaluation processes can bring expertise and understanding of how power penetrates the capillaries of communities.

It is critical to acknowledge that those who actively challenge the authorities, even in research conditions, risk reprisals and social harm. The social, political and economic repercussions are substantial and, for many, disrespectful treatments may be pervasive and expected [ 11 , 35 ]. Ethical research conduct should extend to these very real-life negative consequences for ‘research participants’ and requires the provision of safeguards and protections. For example, community-based organisations often set up a telephone hotline for supporters/participants when working on accountability. Fields such as anthropology and psychology commonly employ codes of practice (see the American Anthropologist Association’s Principles of Professional Responsibility and the American Psychological Association’s Ethical Principles of Psychologists and Code of Conduct). Given the political character and ethical considerations of studying social accountability, a similar code of conduct could be relevant.

Moreover, researchers could move beyond just accounting for power to examining their role in power relationships. This could entail supporting the communities that they work with, and addressing community members’ concerns and issues, even if this is by simply raising the issue with the relevant authorities, and even if those issues are beyond the study’s objective. There are always dynamics around who sets the research agenda – who decides what questions to ask, how to define impact and who is implicitly entitled to do this. There needs to be openness to the different roles that researchers, implementors and communities can play. More concrete examples of how and where this has been done in a way that considers interests of ‘researchers’, ‘implementers’ and communities affected by the issue/intervention/research, would be beneficial.

The challenge of generalising unpredictable, community-driven and context-dependent interventions

The final area of consideration at the convening was on how best to discern generalisable findings from differently situated social accountability processes that adapt to local context. This area is relevant for replication, scale-up and sustaining successes after the intervention. There was consensus that, to assess an intervention’s potential for generalisability and replication, there needs to be consensus on which elements make for success. This involves unpacking the mechanisms of effect and determining what the ‘active ingredients’ are and how they relate to each other [ 23 , 36 ].

Firstly, identifying scalable ‘active ingredients’ requires moving away from cause–effect models and towards mixed methods, which can relate thick qualitative descriptions with impact measures. As such, across the board, recent well-resourced projects have successfully built intervention monitoring and/or process evaluations into studies of impact. This has varied from better documenting the exact inputs for an intervention, to more detailed process evaluations, including extensive in-depth interviews and observations. Moreover, these processes do not happen in a vacuum but rather in real world settings, where other programmes and interventions may be operating in the same area along with uncontrollable factors external to the programme. Accordingly, many studies map out existing programming as well as other contextual factors (e.g. elections) at play using political economy analysis and process mapping [ 18 , 37 – 39 ]. Contexts change and context analysis should capture context over time rather than a one-off activity that provides a snapshot.

Yet, even when we better understand ‘what works’, other factors may hinder these processes being replicated, scaled-up and sustained after the intervention. There are no guarantees that the stakeholders key in supporting any scale-up would be interested in doing so or have the appetite for scaling-up processes that challenge the status quo or authorities.

To bring about accessible and better-quality healthcare, it is important to recognise both the value and complexity of social accountability interventions and operate accordingly. In doing so, we should test our theories and assumptions by building on what we know, capturing a broader range of outcomes, and accommodating unpredictable implementation processes. This work happens in the real world, with influential power relationships and high stakes for participants. By moving towards co-design and horizontal approaches, anticipating exclusion and ensuring that safeguards are in place to prevent and mitigate exclusion, the power inherent in the research process itself can change. Finally, we must acknowledge – and advocate – that this work takes time and requires context-specific adaptations.

Acknowledgements

The authors are writing this paper on behalf of the Community of Practice of Studying social accountability in the context of health programming and would like to acknowledge the members of the Community of Practice for their significant contributions, specifically Anayda Portela, Department of Maternal, Newborn, Child and Adolescent Health, WHO; Angela Bailey, Accountability Research Centre, American University; Anne-Marie Turcotte-Tremblay, Institut de recherche en santé publique de l’Université de Montréal; Asiya Odugleh-Kolev Health Systems and Innovation, WHO; Carolyn Blake, Sexual and Reproductive Health Unit, University of Basel; Elizabeth Allen, GOAL Uganda; Eveline Geubbels, Ifakara Health Institute; Fletcher Tembo, Independent; Heather McMullen, International Planned Parenthood Federation; James Kiarie, Department of Reproductive Health and Research, WHO; Joanna Cordero, Department of Reproductive Health and Research, WHO; Kamil Fuseini, Population Council Ghana; Marta Schaaf, Averting Maternal Death and Disability Program, Colombia University; Mary Awelana Addah, Ghana Integrity Initiative; Nanono Nulu, Reproductive Health Uganda; Niranjan Saggurti, Population Council, India; Patrick Kinemo, Sikika; Petrus Steyn, Department of Reproductive Health and Research, WHO RHR; Rajat Khosla, Department of Reproductive Health and Research, WHO; Sara Gullo, CARE USA; Suzanne Cant, World Vision; Victoria Boydell, International Planned Parenthood Federation; and Walter Flores, Centro de estudios para la equidad y gobernanza en los sistemas de salud.

The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated.

This work was produced with the support of the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, a cosponsored programme executed by WHO. The content is solely the responsibility of the authors and does not necessarily represent the official views of the authors’ employers or funders. Any opinion, finding, and conclusion or recommendation expressed in this material is that of the authors.

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Authors’ contributions.

Conception and design: VB. Drafting the manuscript or revising: VB, HM, JC, JK. Final approval of the version: VB, PS, JK. All authors read and approved the final manuscript.

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1 We recognise the limits of the word ‘citizen’, which excludes non-citizens who also have the right to make claims. We use the term ‘citizen’ as shorthand to refer to all rights-claiming people.

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• Research article
• Open access
• Published: 13 April 2018

Improving social accountability processes in the health sector in sub-Saharan Africa: a systematic review

• Georges Danhoundo   ORCID: orcid.org/0000-0003-3125-2772 1 ,
• Khalidha Nasiri 1 &
• Mary E. Wiktorowicz 2  

BMC Public Health volume  18 , Article number:  497 ( 2018 ) Cite this article

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Social accountability is a participatory process in which citizens are engaged to hold politicians, policy makers and public officials accountable for the services that they provide. In the Fifteenth Ordinary Session of the Assembly of the African Union, African leaders recognized the need for strong, decentralized health programs with linkages to civil society and private sector entities, full community participation in program design and implementation, and adaptive approaches to local political, socio-cultural and administrative environments. Despite the increasing use of social accountability, there is limited evidence on how it has been used in the health sector. The objective of this systematic review was to identify the conditions that facilitate effective social accountability in sub-Saharan Africa.

Electronic databases (MEDLINE, PsycINFO, Sociological Abstracts, Social Sciences Abstracts) were searched for relevant articles published between 2000 and August 2017. Studies were eligible for inclusion if they were peer-reviewed English language publications describing a social accountability intervention in sub-Saharan Africa. Qualitative and quantitative study designs were eligible.

Fourteen relevant studies were included in the review. The findings indicate that effective social accountability interventions involve leveraging partnerships and building coalitions; being context-appropriate; integrating data and information collection and analysis; clearly defined roles, standards, and responsibilities of leaders; and meaningful citizen engagement. Health system barriers, corruption, fear of reprisal, and limited funding appear to be major challenges to effective social accountability interventions.

Although global accountability standards play an important guiding role, the successful implementation of global health initiatives depend on national contexts.

Peer Review reports

In sub-Saharan Africa, concerns have been raised regarding the quality of services delivered and health outcomes [ 1 ]. Existing health system bottlenecks such as drug shortages [ 2 , 3 ], disrespect of patients in public health facilities [ 4 ], health workers’ focus on donor-funded activities that offer access to per diems [ 5 , 6 ], and drug and bed net pilfering [ 7 , 8 ] are among the factors that affect health service functioning in sub-Saharan African countries. The 2008 Accra Agenda for Action and the 2005 Paris Declaration on aid effectiveness emphasized country ownership for development policies through citizen engagement. Social accountability is a process in which citizens are engaged to hold politicians, policy makers public officials accountable for the services that they provide. It can be defined as “an approach towards building accountability that relies on civic engagement, i.e., in which it is ordinary citizens and/or civil society organizations who participate directly or indirectly in exacting accountability” [ 9 ]. In the context of health care, social accountability is a form of participatory citizen engagement in which citizens are recognized as service users who are ultimately impacted by health care decisions and thereby can affect change in health policies, health services and/or health provider behaviour through their collective influence and action [ 10 ]. Scholars consider two key aspects of social accountability: answerability and enforceability [ 11 , 12 ]. Answerability is the obligation of politicians, policy makers, and providers to explain and justify their actions. This includes being answerable for meeting performance objectives, measured against a number of goals or standards in a complex relationship that involves several stakeholders with vested interests and different levels of authority [ 13 ]. Enforceability refers to the capacity to ensure an action is taken and can involve penalties, consequences or remedies for failure to do so . In many sub-Saharan African countries, community participation, especially women’s, in accountability processes is fragmented [ 2 , 14 , 15 ]. Social accountability can play an important role in addressing corruption, increasing trust in public servants and government, which is key to accelerating efforts to achieve the Sustainable Development Goals (SDGs), and increasing the power and influence of citizens on agenda-setting [ 16 , 17 , 18 , 19 ]. Identifying the conditions for implementing successful social accountability initiatives can help community leaders, civil society organizations (CSOs), or non-governmental organizations (NGOs), to increase their leverage. While there have been several studies examining social accountability initiatives on health outcomes in various sub-Saharan African countries, there has been no systematic analysis of these initiatives in aggregate to identify common enabling and limiting factors to success. The objective of this paper is to analyze the conditions that foster effective social accountability initiatives in sub-Saharan African countries.

Search strategy and selection criteria

We systematically reviewed the published literature from 2000 to 2017 to identify studies regarding social accountability interventions in sub-Saharan Africa. Literature searches were carried out in the electronic databases Ovid MEDLINE, Social Sciences Abstracts, Sociological Abstracts, and PsycINFO. Search terms included combinations of: social accountability, accountability, citizen-led accountability, citizen voice, health sector, community participation, community engagement, sub-Saharan Africa, and Africa. The search terms were used in combination with the Boolean operators AND, OR, and * (asterisks).

The PRISMA criteria for reporting systematic reviews was followed [ 20 ]. We initially screened all unique publications for eligibility based on relevance of title and abstract. We included quantitative (e.g., randomized controlled trials) and qualitative studies (e.g., observational and ethnographic studies) published in the English language in which the population of interest was in sub-Saharan Africa. Studies that examined a social accountability intervention exclusively or as part of a larger study were included. Studies in which the accountability intervention did not involve a significant citizen engagement component were excluded. Other exclusion criteria included documents published in a non-English language, grey literature, theses, reports, protocols, proposals, editorials and non-peer-reviewed publications.

Data abstraction

Data were recorded on country and location of intervention, social accountability intervention, participant characteristics, facilitator characteristics, study design, intervention characteristics, study outcome measures, reported results, and enabling and limiting factors identified. Study quality was assessed using a checklist and included assessment of use of a control group and randomization (for intervention studies), objectivity of outcome measures, adequate method of analysis described (for qualitative studies), and description of the population of interest.

The screening and selection process is outlined in Fig.  1 . The initial search identified 1039 potentially relevant papers. Twenty-five additional papers were identified by looking through the references of included studies; 448 papers were removed due to duplication, leaving 616 papers for screening. Based on title and abstract, 406 papers were discounted as not relevant based on the inclusion criteria. Of the remaining 210 papers for which the full-text was reviewed, 196 were removed due to either irrelevant region or participants of focus (e.g., high income countries), irrelevant topic or accountability approach (i.e., looking at other forms of accountability other than social accountability), unavailable full-text, or being a commentary, book or dissertation. The remaining 14 studies met inclusion criteria and were included in the final review: 7 qualitative [ 14 , 21 , 22 , 23 , 24 , 25 , 26 ], 5 mixed methods [ 27 , 28 , 29 , 30 , 31 ] and 2 quantitative articles [ 32 , 33 ].

Search, screening, selection, and inclusion process diagram

Additional file  1 summarizes the characteristics of the included studies. Study locations included Kenya [ 27 , 30 ], Uganda [ 22 , 32 ], Ghana [ 21 , 22 ], Zambia [ 29 ], Tanzania [ 29 ], Benin [ 23 ], Guinea [ 23 ], the Democratic Republic of Congo (DRC; [ 23 , 24 , 25 , 26 ]), Malawi [ 33 ], Sierra Leone [ 14 ], and Nigeria [ 14 , 31 ].

Quality assessment of included studies

The methodological quality of the studies is summarized in Additional file  2 . Study methodological quality ranged from moderate to very good. Three (21.4%) of studies used a controlled intervention design [ 30 , 32 , 33 ], and one (7.1%) used an uncontrolled intervention design [ 28 ]. Four (28.6%) studies did not include a baseline assessment [ 14 , 21 , 23 , 27 ]. Two (50.0%) of four intervention studies did not include a control group [ 28 , 32 ], and two (14.2%) studies did not clearly specify their outcome measures [ 14 , 21 ].

Approaches to social accountability

A variety of social accountability approaches were used. Eight studies (57.1%) used health facility committees as their primary social accountability mechanism [ 21 , 23 , 24 , 25 , 26 , 29 , 30 , 31 ], one (7.1%) used a health facility charter [ 27 ], two (14.2%) used citizen report cards [ 22 , 32 ], and three (21.4%) used scorecards [ 14 , 28 , 33 ]. Two (14.2%) studies explored perspectives on a variety of social accountability mechanisms [ 24 , 25 ].

Enabling and limiting factors to social accountability initiatives

Study outcomes are reported in Additional file  1 . Two (14.2%) studies used household surveys [ 27 , 32 ], three (21.4%) used questionnaires to assess their health facility and care experiences [ 28 , 31 , 33 ], and one (7.1%) used a questionnaire to assess health indicators [ 30 ]. The remainder used qualitative analytic approaches such as content or thematic analysis to interpret focus group or interview discussions [ 22 , 24 , 25 , 26 , 27 , 28 , 29 , 31 ].

Successful interventions

Eleven (78.6%) of articles reported overall positive results from their social accountability approach.

Health committees

Of the eight articles using health committees as the social accountability approach, six reported overall success.

In Kenya, dialogue and engagement between the service delivery system and communities served via health facility committees in six districts proved to be a significant factor for improving certain health indicators [ 30 ]. After two years, intervention sites had significantly higher immunization coverage (91%) compared to control sites (66%). Several other health indicators improved more at intervention sites compared to control sites (i.e., health facility deliveries, insecticide-treated bed net use, latrine presence, food availability, and water treatment; see Additional file  1 for specific results). Breaking down the results by district, however, reveals that in four out of six districts, the intervention was unable to change the low rate of health facility birth deliveries at any of the sites. Further, there was no difference in family planning rates for both conditions, although this was not a statistically significant finding. Clear roles and functions of health committees, representativeness and inclusiveness of community in health committees, sustainability of improvements, and valid data sources were identified as facilitating factors. Poor capacity for data management and lack of community-targeted initiatives were identified as limiting factors.

In Nigeria, Uzochukwu et al. [ 31 ] found overall positive effects of both village-level and district-level health committees. For example, 89.3% and 100% of village- and district- level committee members, respectively, reporting observing changes in provision of drugs and 100% felt they should participate in community mobilization. Between 7.1 and 35.7% of community members reported not participating in health activities, such as community mobilization of health programs and identifying health needs in the community, because of religious differences, political issues, fear of government stopping funding, and opposition to committee leadership. The authors stressed the importance of involving citizens in the decision-making process early and also found that district and village health committees were dysfunctional in part due to a lack of understanding and recognition of their roles. Lodenstein et al. [ 23 ] compared 11 health facility committees across Guinea, Benin and DRC and noted various ways that they could facilitate social accountability: they initiate information and data collection, provide a forum for dialogue, ensure consequences and follow-up of complaints, and provide feedback to the community.

In the DRC, through interviews with 35 community members and health officials, Mafuta and colleagues [ 25 ] identified the following factors as facilitators of social accountability initiatives: community associations and groups, experiences in social mobilization and networking, cultural diversity and marginalized population, women’s status and participation in community groups’ activities, existing media and access to information, supportive regulatory environment, resources, and negotiation ability. They also identified certain contextual factors that limit social accountability initiatives: lack of networks, insufficient capacity for community mobilization, poor socioeconomic conditions (e.g. poor wages, lack of safe water and electricity), lack of radio and media coverage in rural levels, and poor negotiation ability. Mafuta et al. [ 26 ] made similar identifications, in addition to emphasizing the support of health zone management teams in community participation activities and improving the attitude of health providers towards voice at the health facility level. Mafuta et al. [ 24 ] showed the importance of considering contextual factors. For example, six out of 20 women from two health zones in the DRC cited it being customary for people not to complain as a cultural factor that prevented them from raising their concerns.

In Ghana, one year after the development of scorecards to improve maternal and newborn health services at 37 health facilities, a 41% increase in essential drugs rating, 22% increase in infrastructure rating, 47% increase in accessibility and access to information rating, 14% increase in water, sanitation, and hygiene rating, and an 18% increase in essential equipment rating were reported by citizens, community leaders, and health and non-health stakeholders [ 28 ]. The authors assessed whether engaging multiple health and non-health stakeholders resulted in improvements. They documented that engaging a broad range of stakeholders, including citizens, in social accountability initiatives targeting local health facilities can lead to improvements in maternal and newborn health services due to a heightened sense of shared ownership. They also identified higher levels of community engagement in districts where the chiefs of maternal and newborn health councils were engaged. The authors noted that successful implementation could be limited by lack of external financial and technical inputs, weak community leadership, and lack of sustainability of this intervention without continued commitment from community members to remain engaged and widen its reach.

In Nigeria, scorecards highlighting maternal, newborn, and child health indicators that were developed by state officials in collaboration with CSOs, media, community advocates, and health professionals were successfully used to increase the health budget from 8% in 2014 to 15% in 2016 [ 14 ]. The scorecards were promoted through social media campaigns and pressured electoral candidates. This case demonstrates the utility of strategic partnerships between multiple stakeholders at the national level. In Sierra Leone, the use of scorecards gave voters and politicians access to health financing evidence (including mismanagement). As a result, 5 out of 6 political parties signed a “Health Manifesto” and 68 parliamentarians signed pledge cards [ 14 ]. Leveraging social accountability tools such as the media has proved to facilitate social accountability by relaying information on the roles and responsibilities of various officials. These specific commitments by candidates were broadcast on television and radio to ensure citizens were aware of the specific responsibilities they agreed to take on once elected. The study authors note that significant time and data were required in order to successfully implement the mechanism.

In Malawi, in a two-year cluster-randomized control trial, Gullo et al. [ 33 ] found several improvements on scorecard indicators. In the intervention group, CHW visits to pregnant women increased by 20% and by 6% in the postnatal period, compared to the control group. There were also significant increases in ratings on the relationship between health provider and community (37%), availability and accessibility of reproductive and maternal health information (22%), commitment of service providers (26%), level of youth and male involvement (23 and 33%, respectively), availability of referral transportation (21%), and women’s satisfaction with health services. The authors document that facilitating factors for success included instilling communication, trust, responsiveness and quality of patient-provider interactions, as well as emphasizing locally-relevant solutions to improving access.

Citizen report cards

In addition to scorecards, citizen report cards (CRCs) have also been successfully used as a social accountability tool. Björkman and Svensson [ 32 ] conducted a randomized field experiment in nine Ugandan districts using citizen report cards as a social accountability intervention to elicit health provider and staff behaviour change. Report cards were developed that summarized the community’s perception of various issues. Results demonstrated significantly improved uptake of health services and health outcomes. For example, after one year, 36% of treatment facilities had suggestion boxes while no control facilities had them. Seventy percent of treatment facilities also posted information on free services and patients’ rights, while only 4 out of 25 control clinics did so. Furthermore, waiting times to see a health provider were 119 min in the treatment facilities compared to 131 min in control facilities. The absentee rate was 13 percentage points lower in the treatment facility. With regards to health service uptake, the authors reported significantly higher child immunization rates in the treatment group as compared to the control group and a 33% reduction in the under-five mortality rate in the treatment group. Their study demonstrated that leveraging partnerships and involving citizens, particularly disadvantaged groups (seniors, women, disabled individuals), in the accountability process is a strong facilitating factor of social accountability.

Patient charters

A mixed methods study conducted in one Kenyan district found that citizens perceived patients’ rights charters as useful to providing information regarding their local health facility and assisting them with budgeting [ 27 ]. The authors studied four facilities: two high ranking and two low ranking. Sixty-six percent of service users reported being aware of the local facility service charter, while the proportion of those who had seen the facility service charter was lowest among one of the two high ranking facilities (50%) and highest among one of the two low ranking facilities (72%). The authors hypothesized that this may be because people reported paying attention to the charter only if they experienced a problem with their service, as is the case with low ranking facilities. Documented barriers to the effectiveness of the charter were that there was a lack of standardization across facilities and that the information included in the charter was fragmented and at times, selective. Health workers also raised fears of reprisal for speaking out after being empowered by the charter. Additionally, in the qualitative component of the study, service users noted that their local culture did not encourage openness and that community issues were often dealt with by community leaders such as tribal chiefs and village elders, thereby weakening the utility of the charter.

Unsuccessful interventions

Three (21.4%) of articles reported unsuccessful results from their social accountability approach.

Citizen report cards (CRCs)

From a qualitative perspective, Katahoire et al. [ 22 ] revealed that although community members, including mothers and caretakers across several Ugandan districts, felt CRCs promoted community dialogue and involvement in monitoring health providers, the type of data included on the CRCs were disputed. For example, responses to the question why do children sometimes fail to get the medical care they need were grouped into categories such as “abusive health workers” and “mother sharing doses among children or not giving full doses to children”. These were criticized as not being reflective of all communities. In addition, members with low education levels reported that the CRCs were difficult to understand, and requested more illustrations to complement the statistics. The authors recommended further research and reflection on the type and method of presentation of data on CRCs.

In an ethnographic study of the Mukono District of Uganda, Golooba-Mutebi et al. [ 21 ] reported numerous barriers to effective social accountability based on interviews with health administrative officers and service users. The authors reported that health committees rarely met and were not responsive to citizen complaints about service issues, thereby weakening monitoring of service provision. Participants also expressed that involving powerful third power parties such as established CSOs, NGOs, or local leaders would aid in increasing health provider responsiveness to concerns. Even when citizen concerns reached supervisors and managers, corruption was highlighted as an obstacle to successful reform as ill-behaving health workers were often found to be protected by powerful politicians, thereby undermining the enforceability aspect of social accountability. Similarly, Few et al. [ 29 ] reported that in Lusaka, Zambia and Dar es Salaam, Tanzania, there was a low level of awareness of health committees in communities. They also recorded a tendency for community members and committee members to view health committees as bodies designed to service health centres as opposed to the community.

The findings of this systematic review suggest that well-designed and well-implemented social accountability interventions are effective in improving health service quality and outcomes. However, the variability of outcome measures and reporting standards make it difficult to comment on overall effects. In addition, many of the studies, including some of the intervention studies, did not include matched control groups, making it difficult to parse whether reported outcomes are due to the social accountability intervention or due to simply participating in the study. The use of self-reported outcome measures in many studies is also a limitation.

The United Nations’ Sustainable Development Goal 16 (SDG 16) explicitly identifies “effective, accountable, and inclusive institutions at all levels” as essential elements of sustainable development [ 34 ]. Our review indicates that successful social accountability interventions involve engaging different sectors and stakeholders, namely community members and health facility staff; ensuring social accountability tools are locally- and contextually- based; integrating data and information collection and tools; fostering trust between citizens and leaders; having clear roles, standards, and responsibilities of those involved in the accountability process; having financial and technical support from experienced groups; and involving citizens and community meaningfully in the process. Limiting factors included lack of motivation from citizens to participate in the implementation of social accountability; fear of reprisal for speaking out; lack of funding and strategic expertise; the amount of time it takes to develop, plan, implement, and evaluate social accountability projects; and lack of government involvement. Only 6 of the 14 social accountability interventions we reviewed were facilitated or supported by a government structure, such as a Ministry of Health or district health management team [ 14 , 22 , 24 , 25 , 26 , 29 ]. Furthermore, we observed a lack of timely engagement of citizens in the social accountability process. For example, in the mixed-methods study by Blake et al. [ 28 ] using scorecards, citizens were primarily engaged during the scorecard development and assessment phases as opposed to being engaged early on during the process of deciding: what measures should be included in scorecards? How should the scorecard results be presented? The process seemed to be dominated by the researchers, as opposed to making citizen engagement and empowerment central to the process. The approaches used in the cluster-randomized controlled trial by Gullo et al. [ 33 ] and the comparative intervention study by Kaseje et al. [ 30 ] were consultative and included community and service users to develop the study’s framework and methodology.

Lack of sustainability has been highlighted as an issue of concern for social accountability interventions. The longest duration of follow-up in our study was two years [ 33 ]. Rifkin [ 35 ] proposes that concepts such as citizen participation and social accountability are better framed as processes, as opposed to interventions, in order to emphasize their long-term nature.

This review provides a comprehensive assessment of facilitating and limiting factors of social accountability interventions in sub-Saharan Africa published over the past 17 years. Strengths include the systematic approach to searching the literature and inclusion of a broad range of study designs. Limitations of the review include restriction of the search to English language studies. There are many French speaking countries in sub-Saharan Africa, where we believe important research on citizen-led accountability has been conducted. Our search was limited to peer-reviewed articles published in scholarly journals, therefore reports from NGOs and CSOs that may have described social accountability initiatives were not considered. Lastly, although every effort was made to be thorough in our search, there is a possibility that we have not included every single social accountability intervention study in our analysis.

Achievement of the post-2015 development goals are contingent upon strong accountability frameworks that involve continuous monitoring and review. Citizen voice has been a key driver in promoting accountability and transparency globally and ensuring health systems respond to the people’s needs.

Health system fragility and related bottlenecks in Sub-Saharan Africa constrain the achievement of the objectives of global health initiatives and thereby the SDGs. The findings of this review suggest that participatory and deliberative approaches to health policy in sub-Saharan Africa require the engagement of community members and social accountability tools throughout the policymaking cycle. This requires strong institutional support in the form of resources, data, education, and citizen empowerment. Relationship-building between community and leaders in the health sector is vital to fostering a mutual and trustworthy relationship, particularly in contexts of rampant corruption and government mistrust. Social accountability can be mutually beneficial for citizens and health providers, officials, and government. By focusing on citizens as the ultimate beneficiaries of health policies and programs, social accountability provides a mechanism for the empowerment and engagement of citizens with their health system. Future studies implementing social accountability interventions should include sufficiently long periods of follow-up to determine the sustainability of such programs. Stakeholders at national, subnational, regional, and local levels all have a role to play in supporting social accountability initiatives.

Abbreviations

Community health workers

Citizen report card

Civil society organizations

Evidence for action

Global health initiatives

Health facility committees

Millennium development goals

Maternal and newborn health

Non-governmental organizations

Sustainable development goals

World Health Organization

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Table S1. Characteristics of Included Studies. A summary of the 14 studies included in our review including study design, facilitator(s) and description of accountability initiative, outcome measure(s), key outcomes, and enabling and limiting factors. (DOCX 32 kb)

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Table S2. Quality of Included Studies. A summary of our quality assessment of the 14 studies included in our review. (DOCX 19 kb)

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Danhoundo, G., Nasiri, K. & Wiktorowicz, M.E. Improving social accountability processes in the health sector in sub-Saharan Africa: a systematic review. BMC Public Health 18 , 497 (2018). https://doi.org/10.1186/s12889-018-5407-8

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Principles Of Health And Social Care Essay Examples

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Introduction

In this assignment on principles of health and social care practice, I will explain how principles of support are applied to ensure the holistic care and safeguard of a service user as well as other staff members. I will highlight the benefits of person centred care and discuss the ethical issues and dilemmas that may arise when providing support and protection to users of healthcare services from a carer’s perspective. Whilst implementing the policies, legislations and regulations i will also indentify where these policies and procedures can be developed and evaluate its impact on organizational policy and practice. I will also incorporate the effectiveness of inter-professional working system from a personal perspective and make recommendations for development of organizational policies and implement these organizational policies.

Application of Support Principles

In order to understand what are principles of care one needs to understand what is meant by the term principles and the different types applied in health and social care. Principles may be defined as “A fundamental truth or proposition that serves as the foundation for a system of belief or behaviour or for a chain of reasoning” (Oxford Dictionary, 2013). There are many principles of support which are set by relevant authorities for healthcare providers and health workers which they must adhere to when providing care (Day and Wigens, 2006). ABC care home caters to the needs of vulnerable adults with neurological conditions. The principles of support that are strictly implemented in this care home are anti discriminatory practice which is working in accordance with the Equality act 2010 (NMC 2004). Staff are encouraged to promote equality and defy practices which involves discriminatory acts and procedures .Empowering clients to make informed choices by obtaining informed consent, is a common practice in this care home (Hearnden 2008). Thus promoting independence and supporting service users in making an autonomous decision which is “The ability of the individual to exercise self determination; plan to their own actions and act on the plans without interference from other” (NMC 2004). For instance if a service user refuses to take their medication we have to accept their decision and make a coherent report or a record of such incidents in case of any complications as carers are accountable for their own actions and to avoid ambiguity. Individual rights and diversity are respected in this care home by care providers as they try their utmost to fulfill the religious and cultural needs of clients by offering praying rooms, various food options e.g. kosher, halal, vegetarian etc. The ABC staff is required to observe the confidentiality code of conduct when providing care (Day and Wigens, 2006). Staff in ABC are obliged to implement this and refrain from giving information to anyone unless actively part of care.

Protecting Clients from Harm

Safeguarding is a process of shielding vulnerable service users from any type of abuse or exploitation (Nolan Y, 2005). The key concepts of this principle are empowerment, protection, prevention, impartial responses, partnership and accountability. Abuse has been described as “The physical, psychological, emotional, financial or sexual maltreatment, or neglect of a vulnerable adult by another person. Health care staffs play a significant role in the protection of themselves, service users and other members of staff from harm and are responsible for ensuring that the support and services delivered is safe and of a high standard (Nolan Y, 2005). The most widespread prevention interventions for vulnerable adults include training and education of both the service users and staff on. Staff must adhere to the health and safety act 1974(HSE) in order to achieve this, which involves appropriate risk assessment tools e.g. waterlow score for the prevention of pressure sores in patients who are bed bound, control of Substances Hazardous to Health (COSHH regulation,2012), correct manual handling operations 1992, food and safety act regulations, 1990. The “No Secrets Guide” sets out a practice code that aims to protect vulnerable adults. This code explains how providers and commissioners of health care and social care should work in union to create and implement local procedures and policies. They should for instance; they should collaborate effectively with the public, private and voluntary sectors and should also make consultation with service users, their representatives or their carers. The local departments of social services should coordinate and oversee development of procedures and policies (Nolan Y, 2005). In ABC staffs are expected to access information and indentify signs of harm which may put a service user or a collegue at risk of being harmed or abused hence why any incidents that take place within health care settings must be documented and reflected upon to prevent it from reoccurring in the future.

Person-Centered Approach Benefits

The person-centred approach essentially guides social care and health practice. It is a model of care that is based on Carl Rogers’ early therapeutic work and mainly emphasizes on protecting client’s individual rights as well as making decisions that are tailored to meet their unique needs (Edwards, 2012). While the term :person-centre approach” is widely used in other social care and other health systems, many of them find themselves actually relying on political and financial considerations when actually planning the type of healthcare to avail to clients (Moon, 2008). However, ABC being such a renowned care centre should give priority to clients by enacting various legislations that will protect the person centred approach. By doing this, it will be found that several benefits and advantages will be realized. Such benefits will include customer satisfaction, ability and capability to reach and serve individuals from a wide and diverse range of financial and ethnic backgrounds and finally there will the realization of more case outcomes that are more effective (Moon, 2008). Effective communication is the foundation of healthcare, it’s been described as “Effective communication is a reciprocal, interactive process in which sender and recipient have responsibilities to ensure that a message has been received and understood” (Hugman, 2009, p.15). Communication is an important aspect of life and we as human beings use this process on a daily basis it may be direct or indirect. Effective communication is a critical element which determines the quality of care that is received by the service user, this is achieved by maintaining coherent and open communication between members of staff as well as the client. This idea is further supported by the NMC which states that “You must communicate effectively and share your knowledge, skills and expertise with other members of the team as required, for the benefit of the patient and clients” (NMC, 2004). Thus following these principles contribute to a Person centred approach (PCA) which is adopting various techniques to empower service users to plan their own expectations and receive services they require ( Tudor L, 2004).

Ethical Dilemma and Conflicts

As seen from the case study, ABC provides care to people of various vulnerabilities. One group of these people is the elderly people. The elderly are a group that is particularly very hard to work with. The social care and health setting is rife with many potential conflicts and ethical dilemmas (Edwards, 2012). For instance, when dealing with elderly people, some potential ethical dilemmas include potential legal; violations by the client or by colleagues (McLean, 2010). For instance, a patient may be a chain smoker which may consequently result in lung cancer. In spite of doctor’s advice and recommendations, he may continue smoking. The patient then starts suffering from acute pains and the doctor prescribes some pain killers which ultimately fail to work. However, the doctor is faced with an ethical dilemma of prescribing stronger painkillers because he is wary of their adverse effects. The medical are at a dilemma because they cannot stand to see the elderly patient screaming in pain. Another potential ethical dilemma or conflict may involve an instance where a selection between two case alternatives that do not meet the needs of the clients is necessary. Another ethical dilemma that may be experienced may be reporting of illegal or unethical behavior on the client’s part. Finally, an ethical dilemma when working with the elderly patients may involve the negotiation of responsibilities and roles when working with such vulnerable clients. Since the health and social care field is very sensitive one, ABC should follow the ethical policies and guidelines that have been formulated by the relevant heath and social care authorities (NMC, 2004). This will greatly help in the avoidance of work related ethical dilemmas that may compromise the provision of quality care. One particular way through which ethical dilemmas and conflicts can be mitigated for pain related scenarios like the one explained above is through the availability of appropriate pain assessment techniques (McLean, 2010). The aspects of pain that each pain assessment tool should address include pain intensity, location, temporal pattern, treatment and relieving factors, pain history, beliefs and pain interference. In terms of monitoring pain intensity, it advisable to use simple visual analogue scales (McLean, 2010). Where patient communication is impaired, the pain assessment tools utilized should be ones that really on the observation of pain behaviour, for instance PAINAD and the Abbey pain scale and not on patient communication. I addition, the pain assessment tool utilized should be one that is in the patient’s language (McLean, 2010).

Policies, Codes, Regulations and Codes Implementation

Within the health and social care environment, relevant authorities continually evaluates the various policies, legislations as well as codes and regulations to ensure that they are relevant as well as specific to the different cultural, religious, financial and ethnic backgrounds of the clients (McLean, 2010). As shown earlier, this is hugely applicable as ABC extends it services to clients from various ethnic, religious and financial backgrounds. The Health and Social Care Act of 2012 serves as a legislation guide to many health and social acre providers. (Department of Health, 2012). This act maintains and applies polices and regulations on providers of social care and health, professional accountability and field organization (Department of Health, 2012). ABC has for a considerable length of time utilized the stipulations of this act and has implemented it across its structures. As a result, the implementation of the act has resulted in greater health and social care as well s increased efficiency of the two.

Local Policies and Procedures

Local policies and procedures are developed in accordance with national policy requirements.”Legislation determines the policy framework for health and social care organizations, professionals, carers, clients and patients or service users" (Richards, 2003 p.180). The local policies and procedures may however vary according to the needs of the particular population. For instance, regions that have population of lower or higher economic status may vary their or adapt their social care and health policies accordingly (Department of Health, 2012). Since ABC serves a population exhibiting different financial statuses, it should develop local policies and procedures that cater for the different financial statuses of the population.. ABC should in no way try to enact local policies and procedures that contradict those set by national health authorities such as the Department of Health or the National Health Service. However, the setting up of local policies and procedures by ABC serve to inform the national policy by highlighting the local procedures and policies. By adapting the local procedures and policies, so as to satisfy community needs, the national health authorities are able to avail higher quality service on a national scale (Department of Health, 2012).

Impact of policy, legislation, regulation, and codes of practice on policies and practices of ABC Care Home

Policy, legislation and code reforms have a great impact on social and health care practise at ABC care home. The policy, legislation and code protect both practitioners and clients and also offers practical guidelines about the best practises in relation to social care and health care needs (Department of Health, 2012). The main aim of evaluating legislation, code and policy of practise is so as to make sure that the standards present are updated, relevant and clear to the practitioners and clients and also ensure that there is ethical and safe care of all people (NMC, 2004).

Theories that underpin work as a care worker in ABC Care Home

The importance of theory to the field of social care and health care practice cannot be overemphasized. Theory directs almost all practice. The general models and theories of care that are utilized in the healthcare setting dictate its policy reform and legislation (Department of Health, 2012). In addition, the deliverance of care that is based on theory helps in guiding future social care and healthcare research. One of the major theories that underpin my work as a social care worker at ABC is the humanistic theory. This theory emphasizes mainly on each clients individual needs in formulating the nature of care services, the protection of the individual rights of the clients as well as their dignity and autonomy (Edwards, 2012). Additionally, the use of the theory places great value on effective client-practitioner-colleague communication and also in the establishment of efficient inter-professional working environments. Another theory that would have great in my work at ABC is the social learning theory. This particular theory underlines the significance of learning through observation and modeling. This is through adherence to a given care plan (Bandura, 1979). For instance, it is very likely that ABC has a specific care plan which every worker is supposed to abide by. By understanding the importance of this method of learning, I as a care giver can be able to empower clients and also avail the best care to all persons regardless of their backgrounds. The final theory that would underline my work at ABC is the anti-oppressive theory coupled with anti-discriminatory practice (Bandura, 1979). The anti-oppressive theory relates to a certain professionalism style that emphasizes on social justice and the importance of individual rights. On the other-hand, anti-discriminatory practice relates to a type of social work that serves individuals from a diverse range of ethnic and social backgrounds and does not deny or limit service based on these characteristics (Bandura, 1979). Since, ABC serves a individuals from different backgrounds, the applicability of this theory is very clear.

How social processes impact on service users in ABC Care Home

Social processes can greatly impact social care and health care in variety of ways. For instance, at ABC, service user or client involvement is a key to all practises. Such practise has essentially promoted a care model that is more patient centred and that accounts for both the care givers and the patient perspectives. Research conducted has also revealed that user involvement improves services in areas such as cancer care amongst other disciplines within the health care and social care context (King's Fund, 2011). Here at ABC. I have found that forming partnerships with social care and health care professionals and users generally improves the inter-professional working environment and also reinforces the individual impact on both care and policy. In addition, involving users and social processes accounting in directing policy in healthcare has essentially shifted the existent model from one that is more reactive oriented to one that is more proactive (Hearnden, 2008). By incorporating the service users at ABC, the management has for instance been able to anticipate various cultural changes and thus has been able to meet the need of an increasingly miscellaneous population. Use of the person centred care model and user involvement has helped to avoidance of social exclusion (King's Fund, 2011).

The effectiveness of inter-professional working for service users in ABC Care Home

Everywhere across the country, health care and social care has been increasingly trending towards an inter-professional working model. An inter-professional working model promotes worker and professional’s collaboration so as to effectively meet the needs of all clients (Trodd and Chivers, 2011). ABC has implemented this policy into its structure and has a result enacted care that helps in the fostering of working relationships with other similar professional working organisations. The effectiveness of this care model is very conspicuous as it has resulted in level of care that is relatively high (Nolan, 2005). The inter-professional care model has been accompanied by the collaborative education model. Incorporating the inter-professional model into academic programmes has led to a more patient centred and holistic health care system (Department of Health, 2012). Knowledge sharing has essentially created more effective and efficient care plans. However, the inter-professional model has been most effective in the transcending the professional boundaries and therefore led to the creation of collaboration efforts that have resulted in more effective and efficient care model (Mendelstem, 2009).

Role, responsibilities, accountabilities and duties in resolving the failings mentioned by CQC

My roles, responsibilities, accountabilities and duties in resolving the failures mentioned by CQC would be several. First of all, I will be required to work within a team environment availed by the inter-professional model that would allow myself and other professionals to share knowledge and resources need to resolve some of the mentioned failings. I will also be required to maintain the professional standards and ethical codes that are related to social care and health care practise. I will also be responsible for demonstrating principles and values set forth by CQC in regards to professional practise. To effectively perform and fulfil these roles, responsibilities, duties and accountabilities, I will to have educated myself on such matters. (Nolan 2005 doing this will also require me to have effective non-verbal and verbal communication, respect other’s contributions as well as share professional duties and responsibilities (Nolan 2005). Own contribution to the development and implementation of organisational policy in ABC Care Home to rectify the shortcomings pointed out by CQC The report by CQC has established several failings and there is no doubt that a revamped organisation policy is required to solve these short comings. As a worker, my individual contribution to this policy is very well defined. First, I will be primarily responsible for the safeguarding the different vulnerable groups served by the ABC (Mendelstem, 2009). Therefore, I actively inspect the new policy to ensure that it indeed protects the service users. Another personal contribution in the course of protecting user’s rights will be obtaining some of the resources needed for the promotion of best standards of practise at ABC. My final contribution will be through my engagement in ethical practise where I will effectively manage the case loads and also continue increasing my professional knowledge so as to contribute to an improved overall organisation quality (Edwards, 2012).

Recommendations to develop own contributions to meeting good practice requirements in ABC care home in the future

The most vital aspect here is professional and educational development so as to meet effective practise requirements (Rushton, 2005). By receiving further training, both academic wise and professional wise, professionals such as me will be able to sharpen their skills and thus will be able to effectively meet changing needs of an increasingly diverse population (Rushton, 2005). In addition, integrating evidence based practise will facilitate the achievement of higher quality care. A combination of these measures or strategies will enable me together with other professionals to better safeguard the rights of vulnerable users and will also result in a working environment that is more collaborative and that adheres to the best standards of practise (Rushton, 2005).

1: Nursing & Midwifery Council (2004) Code of Professional Conduct: Standards for Conduct, Performance and Ethics. London: NMC. 2. The National Archives (1998) The Data Protection Principles. [Online] Available at: http://www.legislation.gov.uk/ukpga/1998/29/schedule/1 Accessed on: (28/11/2013) 3. Hugman, B. (2009). Healthcare communication. London: Pharmaceutical Press. 4. Department of Health (2012) No Secrets: Guidance on Developing and Implementing Multi-Agency Policies and Procedures to Protect Vulnerable Adults from Abuse. London: HMSO 5. Bandura, A. (1971) . Social learning theory General Learning. Press: New York. 6. Nolan, Y. 2005. Health and social care. China: Everbest printing vo Ltd. 7. Guidance on Abuse of Vulnerable Adults (Management Executive, 8. Trodd, L. and Chivers, L. (2011). Interprofessional Working in Practice Learning and working together for children and families. Maidenhead: Open University Press. 9. Mendelstem, M. (2009). Safeguarding vulnerable adults and the law. London: Jessica Kingsley. Publishers. 10. Edwards, A. (2012). Putting patients first. British Medical Journal, 344, pp. 233-240. 11. King's Fund. (2011). The future of leadership and management in the NHS. [online] Available at: http://www.kingsfund.org.uk/publications/future-leadership-and-management-nhs. Accessed 28 February 2013. 12. Hearnden, M. (2008). Coping with differences in culture and communication in health care. Nursing Standard, 23(11), pp. 49-57. 13. Day, J. and Wigens, L. (2006) Inter-professional working: An essential guide for health and social care professionals. London: Nelson Thornes.14. Moon, J.A. (2008). Reflection in learning and professional development: theory and practice. London: Routledge Falmer. 15. McLean, S. (2010). Autonomy, Consent and the Law. London: Routledge-Cavendish.16. Rushton, A. (2005). Formative assessment: a key to deep learning. Medical Teacher, 26(6), pp. 509-513.

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