1. Accountability and Health Systems Performance Theory and Practice

3. Concepts What is Accountability ? Accountability at what level? Health Systems Accountability for what? Who is accountable to whom? Health Systems How to enhance accountability? Can improved accountability enhance development outcomes?

4. Stewardship (Standards, Oversight and Information Financing (collecting, pooling and purchasing) Goals / Outcomes Better Health Outcomes (Individual, Population) Fairness in Financing (Equity and Safety Nets) Responsiveness (to people’s non-medical expectations) Resource Management (Human Resources, Infrastructure and supply of Essential Medicines and Commodities) Delivery of Health services ( Public/NGO/Private), Framework for Health Systems Based on WHO Inputs Household Behaviours ( Water, Sanitation, Childcare, Nutrition), Services

5. Answerability to decisions and/or actions in terms of proper use of resources (internal) and responsiveness to clients (external) To be effective accountability should be accompanied by Sanctions/Incentives Without sanctions, the accountability becomes weak What is accountability?

6. Accountability at what level of the Health System? At all levels of Health Systems Health Facility Individual Health Provider

7. Financial : Tracking and reporting on allocation, disbursement and use of financial resources, especially those earmarked for sub national levels Performance: Achieving agreed performance targets for service delivery and results Political: Government delivering its promises to improve health care thru services responsive to clients, and meeting emerging societal needs and market failures Accountability for what?

8. Tools and Purpose of Financial Accountability Tools Accounting to link finances with outputs Public Expenditure Reviews Interim Finance Reports Public Expenditure Tracking Surveys Audit Reports – Internal & External Value Chain Analysis Forensic Audits Purpose: Control and assurance are dominant Focus on: 1.compliance with established procedures/norms 2.Efficient use of resources and reduction of waste, fraud and corruption.

9. Tools and Purpose of Performance Accountability Tools Service charters Facility Surveys Household surveys Service quality assessments (Require Norms/Standards) Supervision checklists Performance audits Peer Reviews Purpose: Assurance and Improvement are dominant Focus on: 1.Assurance to quality standards, norms, and values 2.Continues improvement thru Benchmarking, Standard setting, M&E, Operational research, Performance linked incentives, Service contracts

10. Tools and Purpose of Political Accountability Tools Benefit Incidence (Fairness in Financing) Client Satisfaction Surveys (Responsiveness) Household Surveys (Equity) Regulation (Mandatory compliance) Accreditation (Voluntary compliance) Purpose: Control and Assurance are dominant Focus on: 1.Control: Effective use of tax payers’ money and address market failures 2.Assurance related to Principal-Agent relation ship for delivering health services and meeting social commitments made (improving health status of poor and indigent population)

11. Enhancing Accountability Clients Poor/Non-poor Provider Frontline/ Organizations Politicians &Policy Makers Direct Client Power Indirect Voice Indirect Compact

12. Accountability Enhancement Strategies Long Route of Accountability (Indirect):  Control focus assuring compliance with procedures/standards to reduce fraud, misuse and corruption (Government oversight) Administrative Rules and operating procedures Professional norms and ethics Regulation, Licensing and accreditation Monitoring/Auditing and Reporting Sanctions for non compliance: Legal framework and judicial system Short Route of Accountability (Direct):  Participatory focus by providing voice to Citizens (Client Power)

13. Direct route of Accountability

14. Empowering Clients to monitor and discipline Providing information on rules, services and user fees Citizen’s Report Cards on Services Strong citizen’s representation in Facility Management Committees and District Health Boards Co-producing health and nutrition services User associations hire and pay health staff- CDF Community Pharmacies Demand side financing Conditional Cash Transfers in PROGRESSA, Mexico Educational scholarships for Girls in Bangladesh Examples of Effective Short Route of Accountability

15. Transparency Accountability Participation Information Disclosure Disclosure of project documentation (project websites, info shop, operational portals,) Right to Information Acts Citizen charters Demystification and Dissemination Community radio programming Community awareness-building campaigns Grievance Redress Mechanisms Formal measures: Ombudsman Citizen grievance committees Complaint boxes Citizen juries Beneficiary/multi- stakeholder involvement in design and Implementation Multi-stakeholder committees Participatory planning and budgeting Structured consultation processes Community-driven development Third Party Monitoring Integrity pacts/social contracts Local oversight committees Participatory expenditure tracking Community scorecards, citizen report cards Consumer satisfaction surveys Social audits Elements of Social Accountability

16. One way Transmission of information on facts and figures from accountable actors to overseeing authority (Transparency): monthly performance reports, expenditure reports; publication of performance information Two Way Communication providing explanations and justifications (reasons) for good/poor performance and could range from internal to public arenas (Stewardship): Maternal death audit, Response to Audit Queries; Parliamentary hearing; Social Audits Sharing Information: Critical for Promoting Accountability

17. Who is Accountable to Whom? ActorIssuesOptions for improving accountability Users  Information asymmetry  Access to care  Equity  Providing information about services and rights  Demand side financing – Conditional cash transfers  Giving voice – Facility Management committees, social audits  Providing Choices: Flexibility to choose/ exit service providers Providers  Individuals vs. teams  Public vs. private  Incentives  Establishing Service Standards and Protocols  Clearly defined Competencies  Supportive supervision & Peer reviews  Performance based financing

18. Who is Accountable to Whom? ActorIssuesOptions for improving accountability Unions  Preserving status quo and limiting accoutnabity  Engaging early as allies  Demonstrating positive changes Facility Boards  Products of decentralization and responsiveness  Composition and devolution important variables for effectiveness  Ensuring representative boards with non professionals and community  Delegating responsibilities for staffing use of resources allocated and generated Civil Society and NGOS  Financial and Performance Accountability if contracted for service delivery  Democratic accountability while playing watch dog role  Representativeness and legitimacy of key members  Capacity limitations  Umbrella NGOs  Accreditation system  Voluntary disclosure of information about sources and uses of grants

19. Who is Accountable to Whom? ActorIssuesOptions for improving accountability Ministry of Health  Transparency and Participation  Capacity for effective oversight  Role clarity: financing (Buying results) vs. provision  Increased transparency in budgeting, use of funds and sharing results  Enhanced Oversight:  Periodic Public Expenditure Reviews and Tracking Studies  Citizens charters & Social Audits  Increased participation of consumer groups/CSOs in key policymaking bodies  Decentralization and hospital autonomy Int. donors Accountability to tax payers/member countries leading to  conditionality  Parallel financing  Parallel procurement  Aid Harmonization to move towards one plan, One Budget and One M&E (3 Ms of IHP+)

20. None of these solutions are fast are easy. But, success is clearly possible. “It does not matter how slowly you go so long as you do not stop” Confucius WDR 2004