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    Accountability Brinkehoff 2004

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    Vaida Bankauskaite

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    {dol:10.1093/heapol/ezh052 HEALTH POLICY AND PLANNING; 19(6): 371-379 Accountability and health systems: toward conceptual clarity and policy relevance DERICK W BRINKERHOFF Research Triangle Institute, Washington, DC, USA Improved accountability is often called for as an element in improving health system performance. At first glance, the notion of better accountability seems straightforward, but it contains a high degree of complex ity. accountability is to be more than an empty buzzword, conceptual and analytical clarity is required. This atticle elaborates a definition of accountability in terms of answerability and sanctions, and distinguishes three types of accountability: financial, performance and political/democratic. An analytic framework for ‘mapping accountability is proposed that identifies linkages among health sector actors and assesses capacity to demand and supply information and exercise oversight and sanctions. The article describes three account- ability purposes: reducing abuse, assuring compliance with procedures and standards, end improving performancellearning. Using an accountability lens can: (1) help to generate a system-wide perspective on health sector reform, (2) identify connections among individual improvement interventions, and (3) reveal Health Policy and Planning 19(6), © Oxford University Press, 2004; al rights reserved. ‘gaps requiring policy attention. These results can enhance system performance, i and contribute to sound policymaking, prove service delivery Key words: accountability, health systems, performance improvement Introduction ‘Around the world governments face pressures to provide health services effectively, efficiently and equitably. Reform ‘and strengthening efforts in industrialized and developing/transitioning countries have adopted similar approaches to getting health systems to perform better: downsizing, privatization, competition in service delivery, performance measurement and indicators, and citizen participation (see, for example, MePake and Mills 2000). All these approaches converge in emphasizing accountability as a core element in implementing health reform and improv- ing system performance. ‘The current concern with accountability and health systems reflects several factors. First is dissatisfaction with health system performance in both industrialized and, developing/transitioning countries. Discontent has focused fon costs, quality assurance, service availability/access, equi- table distribution of services, abuses of power, financial mismanagement and corruption, and lack of responsiveness. Secondly, accountability has taken on a high degree of importance because the size and scope of health care bureau- cracies in both the public and private sectors accord health system actors significant power to affect people's lives and well-being, Further, health care constitutes a major budgetary expenditure in all countries, and proper account- ing for the use of these funds is a high priority ‘All health systems contain accountability relationships of different types. Health ministries, insurance agencies, public ‘and private providers, legislatures, finance ministries, regu- latory agencies and service facility boards are all connected to cach other in networks of control, oversight, cooperation and reporting. However, the accountability interests of these actors vary. For example, legislatures have quite a different accountability focus from that of health regulatory agencies, ‘The former are interested in clear accounting for the use of taxpayer resources as well as demonstrating responsiveness to their constituencies. The latter are primarily interested in whether providers meet procedural and quality standards. Health ministries combine a wide variety of accountability ‘concerns. If the ministry's mandate includes paying providers, there is usually a unit responsible for payment for services, with an accountability focus on financial accounting ‘and value for money. The health ministry also has policy responsibility and thus has accountability interests and pres- sures related to public health outcomes and issues. Frequently, it is the perception of failed or insufficient accountability that furnishes the impetus for change. For example, among the rationales for health sector decentral- ization reforms is the need to establish stronger account- ability linkages among citizens, policymakers and service providers. Hutchinson et al. (1999, p. 103) note this dynamic in Uganda's reform; prior to the creation of decentralized health committees, ‘citizens unhappy with the perform- ance of health workers or priority setting by local politicians hhad few mechanisms for redressing their grievances or improving services’. ‘Uganda is just one example of how accountability is front and centre on the stage of current health system improvements ‘and policy prescriptions. However, as a guide to the specifies ‘of what to do to improve health systems, simply calling for ‘more accountability is less than helpful. On the surface, the notions of checks and restraints on power and discretion, of increased oversight and scrutiny, or of closer connections between service users and providers seem straightforward. However, for accountability to inform policy and 372 programmes effectively, further conceptual work needs to be done. Calls for more accountability are often efforts by inter- ested actors to change the focus and purpose of account- ability, rather than simply to do ‘more of the same’ (Romzek 2000, 'p. 35). Accountability risks becoming another ‘buzzword in a long line of ineffectual quick fixes, or, worse, a one-size-its-all bludgeon that encourages excess and over- regulation. ‘This article focuses on accountability as it relates to health systems and policy in developing/transitioning countries. The analysis reviews and synthesizes the literature on the topic, noting areas of convergence and of ongoing debate. The article addresses the definition and clarification of account- ability, examining how the term can be more precisely defined and made more operationally relovant. It then offers ‘an analytic framework for accountability and health service delivery systems that highlights the following questions, ‘What are the various purposes and targets for accountability? What are the linkages among accountability actors, and what is their capacity to exercise accountability? Defining accountability Despite its popularity, accountability is often ill-defined. For example, Mulgan (2000, p. 555) calls accountability a ‘complex and chameleon-like term’. As Schedler (1998, p. 13) notes, ‘accountability represents an underexplored concept whose meaning remains evasive [sic], whose boundaries are fuzzy, and whose internal structure is confusing’. General definitions of accountability include the obligation of indi- viduals or agencies to provide information about, andlor justification for, their actions to other actors, along with the imposition of sanctions for failure to comply and/or to engage in appropriate action. Answerabi The essence of accountability is answerability; being account- able means having the obligation to answer questions regard- ing decisions andior actions (see Schedler 1999). Two types cf accountability questions can be asked. The first type asks simply to be informed; this can include budget information and/or narrative description of activities or outputs. This type of question characterizes basic monitoring and implies a one- way transmission of information from the accountable actor(s) to the overseeing actor(s). The second type of ‘question moves beyond reporting of facts and figures, and asks for explanations and justifications (reasons); that is, it inquires not just about what was done but why. Justification questions incorporate information transmission, but go beyond to dialogue between the accountable and the over- seeing actors. This dialogue can take place in a range of venues, from internal to a particular agency (for example, ‘medical personnel answering to their hierarchical superiors), between agencies (for example, facilites reporting to health insurance funds), to more public arenas (for example, parlia- mentary hearings where health ministers answer 10 legis lators, or community meetings where local health officials answer to residents). The justification aspect of answerability Tinks to the World Health Organization's notion of and sanctions Derick W Brinkerhoff ‘stewardship’ in its contribution to government responsive- ness and good governance (see Saltman and Ferroussier- Davis 2000; Travis et al. 2002), Further, such dialogue can ‘build citizen trust by signalling that government actors are interested in citizens’ views and well-being (see Gilson 2003), The availability and application of sanctions for illegal or inappropriate actions and behaviour uncovered through answerability constitute the other defining clement of accountability. The ability of the overseeing actor(s) to impose punishment on the accountable actor(s) for failures and transgressions gives ‘teeth’ to accountability. Answer. ability without sanctions is generally considered to be weak accountability. Most health policy sanctions are based upon regulatory power, for example in the United States, Medicare's authority to levy fines on hospitals that improp- ctly code patient discharges. The courts intervene with legal sanctions 10 enforce accountability between provider and patient, and patient and payer, but this relates to a different level of accountability from the health system overall Other examples of regulatory frameworks that are intended to create incentives and increase accountability include: (1) licensing and accreditation of physicians, aurses, other categories of health care providers, and facilities (for example, Salmon etal. 2003); (2) healthcare financing and payment schemes that lnk funding to the amount and quality of services provided (see Maceira 1998; Gauri 2001); and (3) quality assurance policies that establish standards and bench marks, practice guidelines and compliance mechanisms to improve quality of care, service utilization and client satis faction (or example, Hermida and Robalino 2002). Account- ability is achieved ‘through the application of the laws, standards and procedures these frameworks put in place, Which shape the incentives for various actors to comply. Legal and regulatory sanctions are at the care of enforcing accountability, but sanctions can be thought of more broadh ‘They include, for example, professional codes of conduct, which do not have the status of law. It should be noted that some of the regulatory frameworks noted above include normative elements similar to codes of conduct. Licensing and accreditation, linked to human resource development, Often incorporate professional socialization to the norms and ‘values related to patient care and commitment to service. ‘Quality assurance emphasizes a set of core values, not simply the achievement of service provision targets at a given level of quality (see Silimperi et al. 2002). These kinds of incen- tives are intended to reward good behaviour and action and deter bad behaviour and action, without necessarily involv- ing recourse to regulatory enforcement, Another category of such incentives relates to the use of ‘market mechanisms for performance accountability; these ‘underlie reforms to separate service provision from payment, and to introduce privatization of, and competition among, service providers. Health systems reform in many countries seeks to establish these types of incentives often through contracting (see Maccira 1998; England 2000). For example, if public health clinies, under a capitated health services contract system, are required to compete for clients on the Accountability and health systems ‘basis of publicly available information on quality and performance, accountability is enforced through the ability of clients to switch from low qualityiperforming clinics to high quality/performing ones. The ability of health clinic users {0 hold clinics accountable by exercising their exit ‘option creates incentives for responsiveness and service quality improvement (see, for example, Paul 1992). Of course, as discussed further below, information asymmetry poses a classic barrier in that clients may not have sufficient {information to judge quality and performance, and thus may rnot demand the right’ kind of health care (Gauri 2001). This ‘can dampen the effectiveness of exit for accountability. A related set of ‘softer’ sanctions concerns public exposure ‘or negative publicity. This creates incentives to avoid damage to the accountable actor's reputation or status. For example, investigative panels, the media and civil society watchdog organizations use these sanctions to hold government officials accountable for upholding ethical and human rights standards. Selépolicing among health care providers is another example of the application of this type of sanction, ‘where professional codes of conduct are used as the standard (see, for example, Cruess and Cruess 2000). However, in ‘many countries, the medical profession is a powerful actor that tends more toward self-protection than self-policing, The soft sanction of self-policing is insufficient for improved accountability in the absence of transparency, informed health service users and regulatory enforcoment (Brugha and Zwi 1998), Sanctions without enforcement significantly diminish accountability. Lack of enforcement and/or selective enforce- ment undermine citizens’ confidence that government agencies are accountable and responsive, and contribute to the creation of a culture of impunity that ean lead public officals to engage in corrupt practices. Enforcement ‘mechanisms are critial, from broad legal and regulatory frameworks to internal facility monitoring systems. As discussed below, institutional capacity is also important; the best regulatory frameworks and enforcement mechanisms will remain ineffective if there is not sulfcient capacity among the institutions with accountability roles (see, for ‘example, Standing and Bloom 2003). In health sector reform, ccapacity-building efforts are directed at health ministries, insurance funds, and accreditation and licensing boards. At the facility level, hospital and clinic management systems improvement can address accountability enforcement; and at the local level, community empowerment initiatives often target capacity to exercise oversight and to provide feedback to service providers (for example, Cornwall et al. 2000) A lively debate regarding enforcement concerns the extent to which service delivery markets can be created such that accountability is automatically enforced when poor quality providers are eliminated as purchasers select higher quality, ‘more entrepreneurial providers.! To deal with information and expertise asymmetries, insurance fund agencies often serve as the agents of individual citizens in negotiating with providers. Through the terms of contracting arrangements, funding agencies are able to require participating providers to meet service and quality standards, and to report on costs a3 as well as a variety of other indicators, thus joining answer- ability and sanctions. Armed with this database, the agencies ‘ean enforce both financial and performance accountability through the negotiation of contract provisions and fees. Accountability for what? Defining accountability more precisely also relates to speci= fying accountability for what? Three general categories ‘emerge from answering this question. The first addresses the ‘most commonly understood notion of accountability, finan- cial accountability. The literature in this area deals with ‘compliance with laws, rules and regulations regarding finan- cial control and management. The second type of account- ability is for performance. The literature here is arguably the largest, encompassing public sector management reform, performance measurement and evaluation, and service delivery improvement? The third category focuses on politicalldemocratic accountability. Literature here ranges {rom theoretical and philosophical treatises on the relation- ship between the state and the citizen, to discussions of governance, increased citizen participation, equity issues, twansparency and openness, responsiveness and trust. building Financial accountability Financial accountability concerns tracking and reporting on allocation, disbursement and utilization of financial resources, using the tools of auditing, budgeting and account- ing. The operational basis for financial accountability begins Wwith internal agency financial systems that follow uniform accounting rules and standards. Beyond individual agency boundaries, finance ministries, and in some situations planning ministries, exercise oversight and control functions regarding line ministries and other executing agencies. Since ‘many executing agencies contract with the private sector or ‘with non-governmental organizations (NGOs), these over- sight and control functions extend to cover public procure ‘ment and contracting. For example as noted above, insurance fund agencies play a Key role in financial accountability in hhealth systems that pay providers for predetermined packages of basic services. As purchasers of services, these agencies are able to use their clout to exercise sanctions for financial accountability through contracting arrangements, Provider payment systems can be important mechanisms for enforcing increased financial accountability and cost control among participating private providers (see Bovbjerg and Marsteller 1998; Maceira 1998). Legislatures pass the budget law that becomes the basis for health ministry spending targets, for which they are held accountable within the rules governing budget execution, Accountability sanctions available to legislatures include reductions in ministry funding, holding hearings on ministry spending, and/or launching audit investigations, Obviously, a critical issue for the viable functioning of financial account- ability is the institutional eapacity of the various public and private entities involved. Health policymakers, for instance, need the ability to track and compare drug prices across ‘various types of facilities to identify price variation that is not 374 attributable to local cost factors. They also need the capacity to detect and sanction malfeasance and corruption, for example, procurement fraud, overbilling, falsified staffing levels and so on (for example, Di Tella and Savedotf 2001), ‘At the facility level, for example, hospital managers need to be able to account for the disposition of the funds they receive from various sources, and to enforce compliance from their staff, Performance accountability Performance accountability refers to demonstrating. and accounting for performance in light of agreed-upon perform- lance targets. At the health system level, the focus ison the _ , ouipuls and results of public agencies and ~pfogranimes, not on individual service encounters belween patients i providers Health system performance accout ability is linked to financial accountability in that the finan- cial resourees to be accounted for are intended to produce goods, services and benefits for citizens, but it is distinct in that financial accountability’s emphasis is largely on procedural compliance whereas performance accountability concentrates on results. For example, provider payment schemes that maximize efficiency, quality of care, equity and ‘consumer satisfaction demand strong financial and manage~ ‘ment information systems that ean produce both financial and performance information, Performance accountability is connected to politicalidemocratie accountability in that among the criteria for performance are responsiveness to citizens and achievement of service delivery targets that meet their needs and demands. As Saltman and von Otter (1995) point out, however, there can be conflicting pressures between the pursuit of efficient health system performance and democratic principles of equitable service provision, which in many countries has politicized the search for accountability PoliticalV/democratic accountability In essence, political’democratic accountability has to do with ensuring that government delivers on electoral promises, fulfils the public trust, aggregates and represents citizens’ interests, and responds to ongoing and emerging societal needs and concerns. As a result, effective politicalldemo- cratic accountability enhances the legitimacy of government in the eyes of citizens. The political process and elections are the main avenues for this type of accountability. In many countries, both developing and developed, health care issues often figure prominently in political campaigns. Building health facilities or providing affordable drugs can be attract- ive options for politicians in generating electoral support. Elected officials and legislatures, then, are key to political/democratie accountability, and through their over- sight of ministers and other agency heads they link to the health bureaucracy at various levels, depending upon the extent of decentralization. As previously noted, a central concern here is the highly political nature of health system performance, particularly concerning the issue of equity. An Important government responsibility is to remedy health eare market failures both through regulation and resource allo- cation, which involves inherent tensions between economic Derick W Brinkerhoff and social decision criteria (Saltman and van Otter 1995 Bovbjerg and Marsteller 1998). In developing countries, these tensions are exacerbated by a lack of resources and ‘capacity; even if government provides fiscal subsidies, facili- ties and caregivers are frequently maldistributed, poorly equipped, and in rural areas, scarce or nonexistent (see Bloom 200). Politicalidemocratic accountability also relates to building trust among citizens that government acts in accordance with agreed-upon standards of probity, ethics, integrity and professional responsibility (Gilson 2003). These standards reflect national Values and culture, and bring ethical, moral and on occasion religious issues into the accountability ‘equation at both agency and facility levels. For example, in ‘some countries, caring for the sick is a religious duty, and in response health care providers feel an obligation to deliver services. What this means for politicalldemoeratic account- ability is that health systems whose providers reflect such alues ean contribute to increased levels of citizen trust, not simply in health care providers, but also in the state's interest in their welfare (see Tendler and Freedheim 1994), Analyzing accountability and health systems Applying the above classification of types of accountability to health services delivery will develop a clearer picture of ‘what accountability issues emerge, and of where gaps, contradictions and conflicts may lie. These issues can then be assessed in terms of three purposes of accountability? The first purpose is to control the misuse and abuse of public resources and/or authority. This relates directly to financial accountability. The second is to provide assurance that resources are used and authority is exercised according to appropriate and legal procedures, professional standards and societal values. This purpose applies to all three types of accountability. The third is to support and promote improved service delivery and management through feedback and Tearning; the focus here is primarily on performance account- ability. These three purposes overlap to some extent, but in ‘some cases pursuit of one can lead to conflicts with another. Perhaps the most recognized tension is between account- ability for control, with its focus on uncovering malfeasance and allocating ‘blame’, and accountability for improvement, which emphasizes discretion, embracing error as a source of learning, and positive incentives. ‘There are numerous challenges to achieving these account- ability purposes in the health sector, as noted by a variety of ‘observers. Among these are the following. First, health services are characterized by strong asymmetries among service providers, users and oversight bodies in terms of information, expertise and access to services. Regarding information, central oversight bodies can experience difi- ‘culties in monitoring provider performance since providers ‘often control the necessary information (sce, for example, Millar and McKevitt 2000). Concerning expertise, for ‘example, service users ‘may be ignorant of treatments and ‘medicines that could harm them, and thus need some form ‘of protection’ (Shaw 1999, p. 12). Regarding access, providers can exercise significant gatekeeper power, for Accountability and health systems ‘example, determining who receives what care, despite official procedures. Health service users, especially the poor, are in ‘a weak position to confront this power. Secondly, there are often divergences between public and private interests and incentives, which can constrain efforts to increase accountability (see Bennett et al. 1997). For example, Shaw (1999) notes differences between public and private sector providers in terms of the extent to which they receive and face incentives to act upon service user feedback, ‘The difficulties of creating performance incentives for public sector providers insulated from client accountability are well recognized (see, for example, Goetz and Gaventa 2001), as are the challenges facing incentives design for the private sector (see Bennett et al. 1997; Brugha and Zs 1998). Another divergence of public versus private interests arises between policymakers focused on assuring some minimum level of care available to all and individual service users with ‘an interest in receiving the maximum amount of care neces- sary to address their health need. This divergence can influ- ‘ence accountability enhancement in that it creates conilicting demands for accountability. At the system level, account- ability is targeted at allocative decisions and the institutional arrangements to assure resources allocated are used appro- priately. At the service provider level, the accountability relationship is between patient and provider, and the grounds for accountability focus on the quality of service, professional ethics, and not the cost (see, for example, Emmanuel and Emmanuel 1996; Fuchs 1996). ‘Thirdly, institutional capacity gaps often constrain or under- ‘mine efforts to increase accountability for all three purposes. Table 1, Accountability types, purposes and health service delivery 375 ‘The inability of health facilities to track and report on budgets, collection of fees, pharmaceutical purchases and supply inventories, vehicles and equipment, and so on, limits possiblities for accountability for control and assurance purposes. It results in waste in the health system and can create fertile ground for corruption. Further, weak capacity to exervise oversight of facility and practitioner performance /hampers efforts at accountability for the purpose of perform- ‘ance improvement. This capacity gap is aggravated by the difficulty in isolating the contributions of various health system actors to achieving performance goals. Many developing/transitioning countries that have moved away from predominantly public provision of health care toward private sector models have weak regulatory capacity, making it difficult to exercise quality assurance (see Standing and Bloom 2003) Disparities between the sanctions that exist ‘on paper’ and ‘capacity to enforce them pose equally serious accountability problems, Facilities that lack the ability to identify who ‘works there, where they are at a given time, and what they are doing cannot take the first steps toward holding staff ‘accountable for performance. Insurance funds that are ‘unable to develop a database on costs of care that can inform negotiations with private providers cannot use contracts as an effective sanction for either financial or performance accountability. ‘Table 1 presents illustrative health system issues associated with the three types of accountability: financial, performance and political/democratic. It identifies the dominant purposes of accountability associated with these issues: controlling abuse, assuring conformity with standards and norms, and ‘Type ofaccountability _Mustrative health system issues, Dominant purposes of accountability Financial (Cost accounting/budgeting for: “Personnel = Operations = Pharmaceutcalssuppl ‘Definition of hase bencits packages Contract oversight Performance performance Quality ofeare Service provider behaviour Regulation by professional bodies Contracting out PolticalMemocratic Service delivery equityfaimess ‘Transparency Responsiveness to citizens Service user trast apute resolution Control and assurance are dominant. + Focusis on compliance with prescribed input and procedural standards; cost control resource efictency measures; elimination of wast, fraud ‘and corruption. Allocation of resources needed for effective system» Assurance and improvementiearming are dominant. ‘Assurance purpose emphasizes adherence to the legal, regulatory, and policy framework; professional service delivery procedures, norms, and values; and quality of care standards and audits. ‘Improvemenvlearning purpose focuses on ‘benchmarking, standard setting, quality ‘management, operations research, motitoring and evaluation (M&E). ‘Control and assurance purposes are emphasized Control relates to citizen/voter satisfaction, use of taxpayer funds, addressing market failure and Aistribution of services (disadvantaged populations). + Assurance focuses on principal-agent dynamics for ‘oversight availability and dissemination of relevant information; adherence to quality standards, professional norms, and societl values, 376 Derick W Brinkerhoft supporting improved performance/learning. This ereates a framework for categorizing and taking stock of health system reforms in terms of accountability ‘A focus on accountability can lead to an increased under- standing of health system operations, clearer identification of the pressures and incentives facing health system actors, and better reform design and implementation. This systemic focus helps to identify factors that influence the success potential of interventions intended to achieve one or another of the three purposes. For example, tackling corruption in the health sector is not likely to be sustainable without some degree of political’democratic accountability, which creates and strengthens the incentives for health policymakers to respond {0 citizens’ needs and demands, However, few policy designs and strategies for health sector reform and system strengthening use accountability as an integral theme. Rather, they focus on one or another aspect of health system reform, and treat accountability (if ‘mentioned at all) as a secondary or corollary dimension. For ‘example, there is a large literature on community part pation in health services reform and delivery, some of which notes that among the rationales for, and results of, ‘community participation is increased targeting of services on ‘community needs and more accountability (see, for example, Cornwall et al. 2000). Another topic area where account- ability issues are mentioned concerns health system governance and institutional structures: for example, national, district and local health council, hospital boards, medical review boards and professional certilication bodies: decentralization, and so on (sce, for example, Mills 1994; Savage et al. 1997; Gershberg 1998; NPPHCN 1998; Salmon et al. 2003). fn the health economics and financing literature, as noted above, accountability implications ean be identified in the context of analyses of health care markets, prineipal- agent issues arising from information asymmetries, public- private mix, demand-driven services and user fees, priority-setting, and separation of payment from provision 3 ‘Accountability also figures, sometimes implicitly, sometimes ‘explicitly, in the. quality’ assurance/quality. improvement literatures Once types and purposes of accountability have been unpacked, a next step in integrating a focus on accountability into health policy and systems strengthening is to develop a clearer picture of accountability relationships and connec- tions. This begins with enumerating a list of health system actors, and then proceeds with mapping the linkages among them. Mapping accountability linkages Figure 1 offers an assessment matrix to map accountability linkages and to examine actors’ interactions. The matrix tracks the patterns of answerability and sanctions in terms of ‘Demand information, impose sanctions “Heath ve wero MOH ‘Agencies of esualne Funding geaces Paint ‘Local gow oficial | NGOs Hospital Beane Health coueis Professions associations Uaioe eal are providers Tocernstinal donors ‘Supply information, respond to sanctions code: Heath care providers ‘Capac tosuppy infomation or respond to sanctions: Weak -. Madiom ©, Six (Capacity to demand infomation or impose sapton: Weak V, Medium 2, Soe Figure 1. Health sector actors accountability matrix Accountability and health systems which actors are in a position to demand information and impose sanctions, and which actors are charged with supplying information and are subject to sanctions. To adequately capture the complexity of accountability linkages, separate tables for answerability and sanctions would be prepared, which would take into consideration the distinc- tions between these two elements of accountability and the different implications for the design of system improvements For reasons of economy, Figure {illustrates both information

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