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Accountability mechanisms and the value of relationships: experiences of front-line managers at subnational level in Kenya and South Africa

Resource constraints, value for money debates and concerns about provider behaviour have placed accountability ‘front and centre stage’ in health system improvement initiatives and policy prescriptions. There are a myriad of accountability relationships within health systems, all of which can be tra...

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Autores principales: Nxumalo, Nonhlanhla, Gilson, Lucy, Goudge, Jane, Tsofa, Benjamin, Cleary, Susan, Barasa, Edwine, Molyneux, Sassy
Formato: Online Artículo Texto
Lenguaje:English
Publicado: BMJ Publishing Group 2018
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6038841/
https://www.ncbi.nlm.nih.gov/pubmed/30002921
http://dx.doi.org/10.1136/bmjgh-2018-000842
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author Nxumalo, Nonhlanhla
Gilson, Lucy
Goudge, Jane
Tsofa, Benjamin
Cleary, Susan
Barasa, Edwine
Molyneux, Sassy
author_facet Nxumalo, Nonhlanhla
Gilson, Lucy
Goudge, Jane
Tsofa, Benjamin
Cleary, Susan
Barasa, Edwine
Molyneux, Sassy
author_sort Nxumalo, Nonhlanhla
collection PubMed
description Resource constraints, value for money debates and concerns about provider behaviour have placed accountability ‘front and centre stage’ in health system improvement initiatives and policy prescriptions. There are a myriad of accountability relationships within health systems, all of which can be transformed by decentralisation of health system decision-making from national to subnational level. Many potential benefits of decentralisation depend critically on the accountability processes and practices of front-line health facility providers and managers, who play a central role in policy implementation at province, county, district and facility levels. However, few studies have examined these responsibilities and practices in detail, including their implications for service delivery. In this paper we contribute to filling this gap through presenting data drawn from broader ongoing research collaborations between researchers and health managers in Kenya and South Africa. These collaborations are aimed at understanding and strengthening day-to-day micropractices of health system governance, including accountability processes. We illuminate the multiple directions and forms of accountability operating at the subnational level across three sites. Through detailed illustrative examples we highlight some of the unintended consequences of bureaucratic forms of accountability, the importance of relational elements in enabling effective bureaucratic accountability, and the ways in which front-line managers can sometimes creatively draw upon one set of accountability requirements to challenge another set to meet their goals. Overall, we argue that interpersonal interactions are key to appropriate functioning of many accountability mechanisms, and that policies and interventions supportive of positive relationships should complement target-based and/or audit-style mechanisms to achieve their intended effects. Where this is done systematically and across key elements and actors of the health system, this offers potential to build everyday health system resilience.
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spelling pubmed-60388412018-07-12 Accountability mechanisms and the value of relationships: experiences of front-line managers at subnational level in Kenya and South Africa Nxumalo, Nonhlanhla Gilson, Lucy Goudge, Jane Tsofa, Benjamin Cleary, Susan Barasa, Edwine Molyneux, Sassy BMJ Glob Health Research Resource constraints, value for money debates and concerns about provider behaviour have placed accountability ‘front and centre stage’ in health system improvement initiatives and policy prescriptions. There are a myriad of accountability relationships within health systems, all of which can be transformed by decentralisation of health system decision-making from national to subnational level. Many potential benefits of decentralisation depend critically on the accountability processes and practices of front-line health facility providers and managers, who play a central role in policy implementation at province, county, district and facility levels. However, few studies have examined these responsibilities and practices in detail, including their implications for service delivery. In this paper we contribute to filling this gap through presenting data drawn from broader ongoing research collaborations between researchers and health managers in Kenya and South Africa. These collaborations are aimed at understanding and strengthening day-to-day micropractices of health system governance, including accountability processes. We illuminate the multiple directions and forms of accountability operating at the subnational level across three sites. Through detailed illustrative examples we highlight some of the unintended consequences of bureaucratic forms of accountability, the importance of relational elements in enabling effective bureaucratic accountability, and the ways in which front-line managers can sometimes creatively draw upon one set of accountability requirements to challenge another set to meet their goals. Overall, we argue that interpersonal interactions are key to appropriate functioning of many accountability mechanisms, and that policies and interventions supportive of positive relationships should complement target-based and/or audit-style mechanisms to achieve their intended effects. Where this is done systematically and across key elements and actors of the health system, this offers potential to build everyday health system resilience. BMJ Publishing Group 2018-07-06 /pmc/articles/PMC6038841/ /pubmed/30002921 http://dx.doi.org/10.1136/bmjgh-2018-000842 Text en © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted. This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
spellingShingle Research
Nxumalo, Nonhlanhla
Gilson, Lucy
Goudge, Jane
Tsofa, Benjamin
Cleary, Susan
Barasa, Edwine
Molyneux, Sassy
Accountability mechanisms and the value of relationships: experiences of front-line managers at subnational level in Kenya and South Africa
title Accountability mechanisms and the value of relationships: experiences of front-line managers at subnational level in Kenya and South Africa
title_full Accountability mechanisms and the value of relationships: experiences of front-line managers at subnational level in Kenya and South Africa
title_fullStr Accountability mechanisms and the value of relationships: experiences of front-line managers at subnational level in Kenya and South Africa
title_full_unstemmed Accountability mechanisms and the value of relationships: experiences of front-line managers at subnational level in Kenya and South Africa
title_short Accountability mechanisms and the value of relationships: experiences of front-line managers at subnational level in Kenya and South Africa
title_sort accountability mechanisms and the value of relationships: experiences of front-line managers at subnational level in kenya and south africa
topic Research
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6038841/
https://www.ncbi.nlm.nih.gov/pubmed/30002921
http://dx.doi.org/10.1136/bmjgh-2018-000842
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