School of Public Health

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https://hdl.handle.net/10566/10

With some exceptions, our work focuses on five inter-related programme areas – HIV/AIDS, TB, maternal and child health, public health nutrition, and non- communicable diseases – and three health systems areas which cut across all programmes – namely human resource development, health information systems and health promotion

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Broadening understanding of accountability ecosystems in sexual and reproductive health and rights: A systematic review
(Public Library of Science, 2018) Van Belle, Sara; Boydell, Vicky; George, Asha S.; Brinkerhof, Derrick W.; Khosla, Rajat
BACKGROUND Accountability for ensuring sexual and reproductive health and rights is increasingly receiving global attention. Less attention has been paid to accountability mechanisms for sexual and reproductive health and rights at national and sub-national level, the focus of this systematic review. METHODS We searched for peer-reviewed literature using accountability, sexual and reproductive health, human rights and accountability instrument search terms across three electronic databases, covering public health, social sciences and legal studies. The search yielded 1906 articles, 40 of which met the inclusion and exclusion criteria (articles on low and middle- income countries in English, Spanish, French and Portuguese published from 1994 and October 2016) defined by a peer reviewed protocol. RESULTS Studies were analyzed thematically and through frequencies where appropriate. They were drawn from 41 low- and middle-income countries, with just over half of the publications from the public health literature, 13 from legal studies and the remaining six from social science literature. Accountability was discussed in five health areas: maternal, neonatal and child health services, HIV services, gender-based violence, lesbian/gay/bisexual/transgender access and access to reproductive health care in general. We identified three main groupings of accountability strategies: performance, social and legal accountability. CONCLUSION The review identified an increasing trend in the publication of accountability initiatives in Sexual and Reproductive Health and Rights (SRHR). The review points towards a complex `accountability ecosystem' with multiple actors with a range of roles, responsibilities and interactions across levels from the transnational to the local. These accountability strategies are not mutually exclusive, but they do change the terms of engagement between the actors involved. The publications provide little insight on the connections between these accountability strategies and on the contextual conditions for the successful implementation of the accountability interventions. Obtaining a more nuanced understanding of various underpinnings of a successful approach to accountability at national and sub national levels is essential.
Can community action improve equity for maternal health and how does it do so? Research findings from Gujarat, India
(BMC, 2018) George, Asha S.; Mohan, Diwakar; Gupta, Jaya; LeFevre, Amnesty E.; Balakrishnan, Subhasri; Ved, Rajani; Khanna, Renu
BACKGROUND: Efforts to work with civil society to strengthen community participation and action for health are particularly important in Gujarat, India, given that the state has resources and capacity, but faces challenges in ensuring that services reach those most in need. To contribute to the knowledge base on accountability and maternal health, this study examines the equity effects of community action for maternal health led by Non-Government Organizations (NGOs) on facility deliveries. It then examines the underlying implementation processes with implications for strengthening accountability of maternity care across three districts of Gujarat, India. Community action for maternal health entailed NGOs a) working with community collectives to raise awareness about maternal health entitlements, b) supporting community monitoring of outreach government services, and c) facilitating dialogue with government providers and authorities with report cards based on community monitoring of maternal health. METHODS: The study combined qualitative data (project documents and 56 stakeholder interviews thematically analyzed) with quantitative data (2395 women's self-reported receipt of information on entitlements and use of services over 3 years of implementation monitored prospectively through household visits). Multivariable logistic regression examined delivery care seeking and equity. RESULTS: In the marginalised districts, women reported substantial increases in receipt of information of entitlements and utilization of antenatal and delivery care. In the marginalized and wealthier districts, a switch from private facilities to public ones was observed for the most vulnerable. Supportive implementation factors included a) alignment among NGO organizational missions, b) participatory development of project tools, c) repeated capacity building and d) government interest in improving utilization and recognition of NGO contributions. Initial challenges included a) confidence and turnover of volunteers, b) complexity of the monitoring tool and c) scepticism from both communities and providers. CONCLUSION: With capacity and trust building, NGOs supporting community based collectives to monitor health services and engage with health providers and local authorities, over time overcame implementation challenges to strengthen public sector services. These accountability efforts resulted in improvements in utilisation of public sector services and a shift away from private care seeking, particularly for the marginalised.
The crowded space of local accountability for maternal, newborn and child health: A case study of the South African health system
(Oxford University Press, 2020) Mukinda, Fidele Kanyimbu; van Belle, Sara B.; George, Asha S.
Global and national accountability for maternal, newborn and child health (MNCH) is increasingly invoked as central to addressing preventable mortality and morbidity. Strategies of accountability for MNCH include policy and budget tracking, maternal and perinatal death surveillance, performance targets and various forms of social accountability. However, little is known about how the growing number of accountability strategies for MNCH is received by frontline actors, and how they are integrated into the overall functioning of local health systems. We conducted a case study of mechanisms of local accountability for MNCH in South Africa, involving a document review of national policies, programme reports, and other literature directly or indirectly related to MNCH, and in-depth research in one district. The latter included observations of accountability practices (e.g. through routine meetings) and in-depth interviews with 37 purposely selected health managers and frontline health workers involved in MNCH. Data collection and analysis were guided by a framework that defined accountability as answerability and action (both individual and collective), addressing performance, financial and public accountability, and involving both formal and informal processes. Nineteen individual accountability mechanisms were identified, 10 directly and 9 indirectly related to MNCH, most of which addressed performance accountability.
Forms and Functioning of Local Accountability Mechanisms for Maternal, Newborn and Child Health: A Case Study of Gert Sibande District, South Africa
(University of the Western Cape, 2021) Mukinda, Fidele Kanyimbu; Schneider, Helen
The value of accountability as a key feature of strengthening health systems and reducing maternal, newborn and child mortality is increasingly emphasised globally, nationally and locally. Frontline health professionals and managers play a crucial role in promoting maternal, newborn and child health (MNCH) services in an equitable and accountable manner. They are at the interface between higher-level health system management and communities, facing demands from both sides and often expected to perform beyond their available means. Although accountability is a central topic in the governance of MNCH literature, it has mostly been approached at global and national levels, with little understanding of how accountability is integrated into the routine functioning of local health systems. This PhD explores the forms and functioning of accountability at the district level focusing on MNCH as a programmatic area with long-established institutional mechanisms (structures and processes) in South Africa (SA). The thesis is presented in the form of four empirical papers (published or submitted), exploring different dimensions of accountability, which are embedded in a series of narrative chapters. In this thesis, accountability is understood as a set of relations between an accountholder and ‘accountor’ (or duty bearer), in which the latter provides information or justification for actions or decisions taken, and faces the resulting consequences of his/her actions (reward or sanction). Accountability mechanisms are the means to regulate accountability relationships and include broad strategies, interventions or instruments. These mechanisms can take various forms including performance, financial and public accountability, and operate both vertically (accountability inside bureaucratic hierarchies, or towards external stakeholders and/or the community), or horizontally (between peers, ‘neighbour’ units, departments or ministries in a national health system). Drawing conceptually on the field of governance and considering the complexity of the accountability phenomenon, I adopted a case study approach to the PhD research, using a combination of policy document review, interviews (with managers, providers, community representatives and members of labour unions) and field observations, conducted iteratively over 16 months. The study was conducted in Gert Sibande District, one of the three South African health districts in Mpumalanga Province, with an in-depth focus on two of the seven sub-districts in the District. The research found that frontline health professionals have a clear understanding and conceptualisation of accountability in the SA health policy context, despite the reported inability to define accountability by health professionals described in the literature. Respondents referred to accountability as responsibility, answerability and virtue, and also argued for strengthening accountability mechanisms as critical to addressing maternal and child mortality. While deeming accountability as important, frontline professionals experienced the existing accountability mechanisms as ‘too much’ and indicated the desire for the streamlining of existing mechanisms. In this regard, the study documented numerous mechanisms at district level, almost all related to performance accountability in MNCH. These included a performance management system, quality assessment and accreditation processes, quarterly reviews, and death surveillance and response processes. The existence of multiple and overlapping accountability mechanisms engenders operational confusion and ‘accountability overload’ for frontline providers, encouraging empty bureaucratic compliance, while critical gaps – notably in community accountability – remain. In practice, at their best, some mechanisms operate following a reciprocal1 pathway of capacity building with resource provision (from management) and expectation for better performance (from providers). There were, however, contextual variations in the implementation and practice of the mechanisms between sub-district settings. The fieldwork observations and interviews were also able to document how formal institutionalised mechanisms are embedded within a complex system of informal accountability relationships and social norms (‘accountability ecosystem’) that enables or constrains the ability of frontline professionals to fulfil their tasks. In addition, using a Social Network Analysis approach, the research identified key actors and their involved network, which form the relational backdrop to the functioning of accountability mechanisms for MNCH. By revealing complex relationships and collaboration patterns among frontline health professionals, the study was able to show the multi-level action and multiple actors required to achieve MNCH goals.
Forms and functioning of local accountability mechanisms for maternal, newborn and child health: A case study of Gert Sibande district, South Africa
(University of Western Cape, 2021) Mukinda, Fidele Kanyimbu; Schneider, Helen
The value of accountability as a key feature of strengthening health systems and reducing maternal, newborn and child mortality is increasingly emphasised globally, nationally and locally. Frontline health professionals and managers play a crucial role in promoting maternal, newborn and child health (MNCH) services in an equitable and accountable manner. They are at the interface between higher-level health system management and communities, facing demands from both sides and often expected to perform beyond their available means. Although accountability is a central topic in the governance of MNCH literature, it has mostly been approached at global and national levels, with little understanding of how accountability is integrated into the routine functioning of local health systems.
Globalisation and health inequalities: can a human rights paradigm create space for civil society action?
(Elsevier Ltd, 2012) London, Leslie; Schneider, Helen
While neoliberal globalisation is associated with increasing inequalities, global integration has simultaneously strengthened the dissemination of human rights discourse across the world. This paper explores the seeming contradiction that globalisation is conceived as disempowering nations states' ability to act in their population's interests, yet implementation of human rights obligations requires effective states to deliver socio-economic entitlements, such as health. Central to the actions required of the state to build a health system based on a human rights approach is the notion of accountability. Two case studies are used to explore the constraints on states meeting their human rights obligations regarding health, the first drawing on data from interviews with parliamentarians responsible for health in East and Southern Africa, and the second reflecting on the response to the HIV/AIDS epidemic in South Africa. The case studies illustrate the importance of a human rights paradigm in strengthening parliamentary oversight over the executive in ways that prioritise pro-poor protections and in increasing leverage for resources for the health sector within parliamentary processes. Further, a rights framework creates the space for civil society action to engage with the legislature to hold public officials accountable and confirms the importance of rights as enabling civil society mobilization, reinforcing community agency to advance health rights for poor communities. In this context, critical assessment of state incapacity to meet claims to health rights raises questions as to the diffusion of accountability rife under modern international aid systems. Such diffusion of accountability opens the door to 'cunning' states to deflect rights claims of their populations. We argue that human rights, as both a normative framework for legal challenges and as a means to create room for active civil society engagement provide a means to contest both the real and the purported constraints imposed by globalisation.
Health system responsiveness: A systematic evidence mapping review of the global literature
(BMC, 2021) Khan, Gadija; Kagwanja, Nancy; Whyle, Eleanor
The World Health Organisation framed responsiveness, fair financing and equity as intrinsic goals of health systems. However, of the three, responsiveness received significantly less attention. Responsiveness is essential to strengthen systems’ functioning; provide equitable and accountable services; and to protect the rights of citizens. There is an urgency to make systems more responsive, but our understanding of responsiveness is limited. We therefore sought to map existing evidence on health system responsiveness.
Local dynamics of collaboration for maternal, newborn and child health: A social network analysis of healthcare providers and their managers in Gert Sibande district, South Africa
(Kerman University of Medical Sciences, 2021) Mukinda, Fidele Kanyimbu; Van Belle, Sara; Schneider, Helen
: Accountability for maternal, newborn and child health (MNCH) is a collaborative endeavour and documenting collaboration dynamics may be key to understanding variations in the performance of MNCH services. This study explored the dynamics of collaboration among frontline health professionals participating in two MNCH coordination structures in a rural South African district. It examined the role and position of actors, the nature of their relationships, and the overall structure of the collaborative network in two sub-districts.Cross-sectional survey using a social network analysis (SNA) methodology of 42 district and sub district actors involved in MNCH coordination structures. Different domains of collaboration (eg, communication, professional support, innovation) were surveyed at key interfaces (district-sub-district, across service delivery levels, and within teams).
Perceptions and experiences of frontline health managers and providers on accountability in a South African health district
(Springer Nature, 2020) Mukinda, Fidele Kanyimbu; van Belle, Sara B.; Schneider, Helen
Public primary health care and district health systems play important roles in expanding healthcare access and promoting equity. This study explored and described accountability for this mandate as perceived and experienced by frontline health managers and providers involved in delivering maternal, newborn and child health (MNCH) services in a rural South African health district. Methods: This was a qualitative study involving in-depth interviews with a purposive sample of 58 frontline public sector health managers and providers in the district office and two sub-districts, examining the meanings of accountability and related lived experiences. A thematic analysis approach grounded in descriptive phenomenology was used to identify the main themes and organise the findings. Results: Accountability was described by respondents as both an organisational mechanism of answerability and responsibility and an intrinsic professional virtue. Accountability relationships were understood to be multidirectional - upwards and downwards in hierarchies, outwards to patients and communities, and inwards to the 'self'.
Understanding internal accountability in Nigeria’s routine immunization system: perspectives from government officials at the national, state, and local levels
(Kerman University of Medical Sciences, 2017) Erchick, Daniel J.; George, Asha S.; Umeh, Chukwunonso; Wonodi, Chizoba
BACKGROUND: Routine immunization coverage in Nigeria has remained low, and studies have identified a lack of accountability as a barrier to high performance in the immunization system. Accountability lies at the heart of various health systems strengthening efforts recently launched in Nigeria, including those related to immunization. Our aim was to understand the views of health officials on the accountability challenges hindering immunization service delivery at various levels of government. METHODS: A semi-structured questionnaire was used to interview immunization and primary healthcare (PHC) officials from national, state, local, and health facility levels in Niger State in north central Nigeria. Individuals were selected to represent a range of roles and responsibilities in the immunization system. The questionnaire explored concepts related to internal accountability using a framework that organizes accountability into three axes based upon how they drive change in the health system. RESULTS: Respondents highlighted accountability challenges across multiple components of the immunization system, including vaccine availability, financing, logistics, human resources, and data management. A major focus was the lack of clear roles and responsibilities both within institutions and between levels of government. Delays in funding, especially at lower levels of government, disrupted service delivery. Supervision occurred less frequently than necessary, and the limited decision space of managers prevented problems from being resolved. Motivation was affected by the inability of officials to fulfill their responsibilities. Officials posited numerous suggestions to improve accountability, including clarifying roles and responsibilities, ensuring timely release of funding, and formalizing processes for supervision, problem solving, and data reporting. CONCLUSION: Weak accountability presents a significant barrier to performance of the routine immunization system and high immunization coverage in Nigeria. As one stakeholder in ensuring the performance of health systems, routine immunization officials reveal critical areas that need to be prioritized if emerging interventions to improve accountability in routine immunization are to have an effect.
Understanding internal accountability in Nigeria’s routine immunization system: Perspectives from government officials at the national, state, and local levels
(Kerman University of Medical Sciences, 2017) Erchick, Daniel J.; George, Asha S.; Umeh, Chukwunonso; Wonodi, Chizoba
BACKGROUND: Routine immunization coverage in Nigeria has remained low, and studies have identified a lack of accountability as a barrier to high performance in the immunization system. Accountability lies at the heart of various health systems strengthening efforts recently launched in Nigeria, including those related to immunization. Our aim was to understand the views of health officials on the accountability challenges hindering immunization service delivery at various levels of government. METHODS: A semi-structured questionnaire was used to interview immunization and primary healthcare (PHC) officials from national, state, local, and health facility levels in Niger State in north central Nigeria. Individuals were selected to represent a range of roles and responsibilities in the immunization system. The questionnaire explored concepts related to internal accountability using a framework that organizes accountability into three axes based upon how they drive change in the health system. RESULTS: Respondents highlighted accountability challenges across multiple components of the immunization system, including vaccine availability, financing, logistics, human resources, and data management. A major focus was the lack of clear roles and responsibilities both within institutions and between levels of government. Delays in funding, especially at lower levels of government, disrupted service delivery. Supervision occurred less frequently than necessary, and the limited decision space of managers prevented problems from being resolved. Motivation was affected by the inability of officials to fulfill their responsibilities. Officials posited numerous suggestions to improve accountability, including clarifying roles and responsibilities, ensuring timely release of funding, and formalizing processes for supervision, problem solving, and data reporting. CONCLUSION: Weak accountability presents a significant barrier to performance of the routine immunization system and high immunization coverage in Nigeria. As one stakeholder in ensuring the performance of health systems, routine immunization officials reveal critical areas that need to be prioritized if emerging interventions to improve accountability in routine immunization are to have an effect.

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