Health
Policy and Planning, 2016, 1–7
doi:
10.1093/heapol/czw057
Methodological
musings
Sparking,
supporting and steering change: grounding an accountability framework with
viewpoints from Nigerian routine immunization and primary health care
government officials
Asha S. George,1,* Daniel J
Erchick,1 Mustafa Mahmud Zubairu,2 Inuwa Yau Barau2 and Chizoba
Wonodi1
1Johns Hopkins
Bloomberg School of Public Health, Baltimore, MD, USA and 2National
Primary Health Care Development Agency, Abuja, Nigeria
*Corresponding
author: Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street,
Rm. E-8612, Baltimore MD 21205, USA. E-mail. ageorg22@jhu.edu
Accepted on 12 April 2016
Abstract
Existing
accountability efforts in Nigeria primarily serve as retrospective policing. To
enable ac-countability to guide change prospectively and preemptively, we drew
from a literature review to develop a framework that highlights mutually
reinforcing dimensions of accountability in health systems along three
counterbalancing axes. The axis of power sparks change by wielding ‘sticks’
that curb the potential abuse of power, but also by offering ‘carrots’ that
motivate constructive agency. The axis of ability supports change by enabling
service delivery actors with formal rules that appropriately expand their
authority to act, but also the informal norms and inputs for im-proved
performance. Last, the axis of justice orients the strategic direction of change,
balancing political representation, community ownership and social equity, so
that accountability measures are progressive, rather than being captured by
self-interests. We consulted Nigerian government officials to understand their
viewpoints on accountability and mapped their responses to our evolv-ing
framework. All government officials (n ¼ 36) participating in three zonal
workshops on routine immunization filled out questionnaires that listed the top
three opportunities and challenges to strengthening accountability.
Thematically coded responses highlighted dimensions of account-ability within
the axes of ability and power: clarifying formal roles and responsibilities;
transpar-ency, data and monitoring systems; availability of skilled health personnel
that are motivated and supervised; addressing informal norms and behaviours;
and availability of inputs regarding fund-ing and supplies. Other dimensions of
accountability were mentioned but were not as critical from their viewpoints:
managerial discretion; sanctions and enforcements; political influence and
com-munity engagement. Strikingly, almost no respondents mentioned social
equity as being an im-portant aspect of accountability, although a few
mentioned broad development concerns that re-flected community perspectives.
Reframing accountability as a means of sparking, supporting and steering change
can highlight different dimensions of health systems that need reform,
particularly depending on the positionality of the viewpoints consulted.
Key words: Accountability, immunization,
organizational change, power, social justice
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The Author 2016. Published by Oxford
University Press in association with The London School of Hygiene and
Tropical Medicine.
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All rights reserved. For permissions, please
e-mail: journals.permissions@oup.com
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Key messages
•
Nigeria has low levels of immunization coverage
with large regional variations and poor performance underpinned by
accountability problems.
•
We conceptualized accountability as dynamic
dimensions framed by three counterbalancing axes: power to spark change;
ability to support change; justice to steer change.
•
Government officials largely identified similar
challenges and opportunities to strengthen accountability, mainly within the
axes of ability and power.
•
Accountability dimensions highlighted by
government officials included clarifying formal roles and responsibilities;
supervision, data and monitoring systems; availability of skilled and motivated
health personnel; addressing informal norms and behaviours; availability of
inputs regarding funding and supplies.
•
Other dimensions of accountability were
mentioned but were not as critical from their viewpoints: managerial
discretion; sanctions and enforcements; political influence and community
engagement.
•
Strikingly, almost no government officials
mentioned social equity as being an important aspect of accountability,
although a few mentioned broad development concerns that reflected community
perspectives.
Introduction
In Nigeria, accountability lies at the heart of various
health systems strengthening efforts (Federal Ministry
of Health Nigeria and World Health Organization 2013; Garba and Bandali
2014), including those related to
immunization. These efforts aim to overcome vari-ous factors that contribute to
poor performance across governance, service delivery, finance, human resources
and logistical elements of immunization systems. Studies of Nigeria’s
immunization system have identified poor performance in the form of
uncoordinated re-sponsibility and authority for service delivery across levels
of gov-ernment; inadequate and delayed funding; unpredictable vaccine
availability; infrequent supervision; poor staff capacity and manage-ment; and inaccurate
and incomplete reporting and data manage-ment (National Primary Health Care Development Agency et al. 2011; Stokes-Prindle et al. 2012; National Primary Health Care Development Agency 2013c); and payment for services that are meant to be free (Onwujekwe et al. 2012).
In response to this context, the
first National Vaccine Summit, with over 1000 participants from government,
business and civil so-ciety, raised the profile of immunization and called for
increased ac-countability for routine immunization in 2012. Following the
summit, the National Routine Immunization Strategic Plan 2013–15 included accountability
as one of three implementation strategies (National Primary Health Care Development Agency 2013b). Developed in 2013, by the country’s immunization
leaders and de-velopment partners, the Accountability Framework for Routine
Immunization in Nigeria defines roles, responsibilities, timelines and
monitoring and reporting structures for routine immunization (National Primary Health Care Development Agency 2013a). It also identifies rewards and sanctions to
enforce these responsibilities, and creates a dashboard for monitoring and
feedback on key per-formance indicators within the routine immunization system.
This national framework mirrors
classical definitions of account-ability encompassing answerability and
enforceability (Schedler et al. 1999). People can be held accountable if
they are transparent about their actions and decisions, including the reasoning for
those actions and decisions (answerability). And if found to be in error, they
must be held responsible through sanctions and redress (en-forceability). These
core elements have been translated into service delivery processes such as
setting standards, gaining information, eliciting justification, rendering
judgment and imposing sanctions (Joshi 2010). Framed in this way, accountability
is mainly a retro-spective policing mechanism. However, to guide change
prospectively and preemptively, accountability
needs to support the responsiveness of health systems. To do so, a more
holistic under-standing of its complex nature, imbued with power relations is
required (Goetz 2001; Cornwall 2000; Molyneux et al. 2012; Cleary et al. 2013; George 2003; Murthy and Klugman 2004; Yamin 2010).
Reframing accountability in
health systems
To guide further work on accountability that goes
beyond the bare bones of answerability and enforceability, we developed a
frame-work (Figure 1) that fleshes out multiple dimensions of
accountabil-ity informed by a literature review about how and why internal
accountability initiatives work. In this framework, the following additional
dimensions of accountability are considered:
•
Actual
managerial discretion, decision space and authority com-bined with capacity or
inputs to respond or take action (Brinkerhoff and
Bossert 2013)
•
Informal
norms and behaviour, culture of service delivery, trust and legitimacy (George 2009; Cleary et al. 2013).
•
Role of
actors external to health sector: political class, commu-nity level and social
equity (George 2003; Molyneux et al. 2012;
As these myriad,
multi-dimensional elements of accountability interact with one another and are
hard to conceptualize coherently, we organized them according to three axes
that bind elements of ac-countability and mark how they drive change in health
systems. The ‘axis of power’ sparks change by wielding ‘sticks’ that curb their
po-tential abuse of power or neglect of duty, but also by offering ’car-rots’
that motivate the constructive agency of service delivery actors. The ‘axis of
ability’ supports change by enabling service delivery actors with formal rules
outlining rights, responsibilities and stand-ards that appropriately expand
their authority to act, but also the in-formal norms and inputs that also
support change in performance. Last, there is the ‘axis of justice’ that steers
the strategic direction of change by balancing political representation,
community ownership and social equity, so that accountability efforts support
progressive change, rather than being captured by self-interests.
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Figure 1. Conceptual framework: dynamic
dimensions of accountability in health systems along the axes of power, ability
and justice.
Examining
accountability from the viewpoint of government health officials
Since our aim was to further guide accountability
reforms in Nigeria, we wanted the development of this framework to be in-formed
by key health system stakeholders in Nigeria. Despite the ris-ing attention to
accountability in health systems and in development more broadly, most of the
attention has focused on external ac-countability, i.e. ways in which
communities can demand more ac-countability, responsiveness and redress from
health services (Community of
Practitioners on Accountability and Social Action in Health 2014; Murthy and
Klugman 2004; Garba and Bandali 2014). This is of vital importance, as
health services are ultimately meant to improve and
respond to the health needs and rights of indi-viduals and communities seeking care.
Nonetheless, understanding how government officials who are in positions of
technical and man-agerial leadership perceive accountability also plays a
foundational role in improving accountability (George 2009; Cleary et al. 2013; Dixon et al. 2010). They are vital partners in ensuring that account-ability
efforts result in responsive health systems.
We sought to understand how
government officials in Nigeria, as an important, but not exclusive,
stakeholder, viewed opportuni-ties and challenges to improve accountability by
seeking their view-points through a workshop questionnaire. The Nigerian
National Primary Health Care Development Agency convened zonal work-shops in
2013 with health officials working in routine immunization to collect input for
the National Routine Immunization Strategic Plan 2013–15, which included
accountability as one of three imple-mentation strategies. Workshop attendees
included key immuniza-tion personnel from different parts of the immunization
system (e.g. cold chain, finance) and different levels of the health system
(e.g. zone, state, ward, health facility), alongside civil society mem-bers,
traditional leaders and select local government representatives. At the end of
the workshop, all participants were asked to fill out questionnaires, including
two open-ended questions asking them to
list three main challenges and opportunities to
improve accountabil-ity in routine immunization.
Responses were copied into an
Excel sheet, which were then coded thematically according to our conceptual
framework. The coding was undertaken by the lead author and verified
independ-ently by the second co-author. Particularly rich quotes were cited
verbatim to further highlight respondent viewpoints of certain elem-ents of
accountability. The analysis, therefore, captures not just counts of the most
frequently cited elements, but also nuances in terms of what these themes meant
to respondents. Outlier and miss-ing responses are also taken into account in
the analysis.
Workshop findings were discussed
by the research team, which combined academics outside of Nigeria with
researchers and gov-ernment officials in Nigeria, and shared with Ministry of
Health counterparts before being finalized. Although other co-authors played
central roles in organizing the workshop, those coding the data had no or
minimal participation in the workshops. Having a mixed team composition,
including Nigerians with extensive experi-ence with immunization systems,
helped to anchor the framework and ground the interpretation of workshop
responses within the working context of health systems in low- and
middle-income coun-tries. Nonetheless, these remain preliminary analyses meant
to spur further research on understanding dimensions of accountability in
health systems and how particular stakeholders may perceive them.
We focused on responses from
government officials only, work-ing at national (10), state (19) and local (7)
levels, comprising of ei-ther technical immunization officers (14) or managers
or directors of primary health care (22). A total of 36 participants gave 235
re-sponses (123 challenges, 112 opportunities), 9 responses were dropped (3
challenges, 6 opportunities) because they were too broad to provide meaningful
insight into accountability challenges or opportunities (e.g. challenge: ‘poor
management and weak govern-ance’), resulting in a final of 226 (120 challenges,
106 opportunities) responses for analysis.
Figure 2. Spider diagram representing Nigerian
government official responses regarding accountability challenges and
opportunities in routine immunization systems (n ¼ 36), 2013.
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Opportuni es for
rou ne immuniza on by accountability
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Challenges for
rou ne immuniza on by accountability sphere
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sphere (axes of ability, jus ce and power)
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(axes of ability, jus ce and power)
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Power
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Inputs
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Ability
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n=38, 28%
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Ability
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Inputs
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n=32, 23%
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Jus ce
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Jus ce
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Power
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n=28, 26%
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Power
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Power
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Ability
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n=42, 40%
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Processes
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Ability
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Inputs
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Inputs
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n=65, 47%
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n=53, 50%
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Processes
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Processes
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n=9, 7%
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Processes
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n=5, 5%
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Roles and norms
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Jus ce
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Roles and norms
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Roles and norms
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Roles and norms
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n=35, 25%
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n=24, 17%
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Jus ce
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n=20, 19%
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n=11, 10%
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Figure 3. Nigerian government official responses
regarding accountability challenges and opportunities in routine immunization
systems, with the axis of ability further disaggregated (n ¼ 36), 2013.
Many of the leading challenges in
accountability as reported by participants largely mirrored what they reported
as opportunities to improve accountability in routine immunization. Results for
chal-lenges and opportunities to accountability are, therefore, presented
together within each axis of accountability in order of priority re-ported
(ability, power, justice) (Figures 2 and 3).
Nigerian government officials views of accountability dimensions along
the axis of ability
The leading challenge to improving accountability
was the lack of clarity with regards to formal roles and responsibilities
within the routine immunization system (Table 1). This ranged from lack of the list of activities
that stakeholders were meant to carry out, to the absence of a harmonized plan,
to low awareness of the overarching
framework that would orient individuals as to their
specific respon-sibilities for routine immunization. In terms of opportunities
to improve accountability, clarity with regards to roles and responsibil-ities
was identified as the most important priority. Respondents mentioned the
importance of ‘molding people more alive to their responsibilities’, ‘giving a
sense of belonging,’ and creating a system where ‘every stakeholder is
committed and each of their roles is spelt out correctly’.
The second most important aspect
of accountability for govern-ment officials working in routine immunization was
their con-strained capacity to effect change due to the lack of availability of
qualified and motivated human personnel. Related to this are how informal roles
and behaviours within the health system also chal-lenge accountability. In particular,
managers mentioned compla-cency, poor attitudes, lack of self-discipline and
poor commitment. A few managers mentioned the lack of a shared sense of
responsibil-ity, or basis for collaboration, and one manager mentioned explicit
conflict among cadres. At the same time, informal
behaviours, such as collaboration, humility, sharing responsibilities and
changing atti-tudes, were recognized by respondents as important for improving
accountability, but officials did not prioritize it as an area to strengthen
accountability, in comparison to other axes or elements of accountability.
Another set of elements within
the axis of ability that challenges accountability in routine immunization is
the availability of inputs to ensure performance, whether funds to support
supervision visits or outreach initiatives, or equipment to maintain the cold
chain for vaccination. The importance of demand for immunization in terms of
community mobilization was also mentioned as an important, al-beit not a
leading challenge to accountability. Collectively, inputs played a substantial
role in supporting the capacity of the health sys-tem to respond to
accountability needs.
Interestingly, for this group of
government officials, the lack of managerial discretion was only mentioned by a
few respondents as a challenge to accountability. One noted that in general
‘bureaucracy’ was a problem. Another respondent noted that too many initiatives
were donor driven, leading to duplication of efforts and an inability to hold
government officials accountable. Immunization officers were felt to be not
sufficiently involved in budgeting decisions, and that ‘placing the right
person in the right place’ was a key opportun-ity to strengthen accountability.
Nigerian government officials views of accountability dimensions along
the axis of power
The second leading challenge to improving
accountability in routine immunization identified by government officials
across all spheres was transparency, in terms of weak monitoring and evaluation
sys-tems. Although one respondent mentioned too many data collection tools,
another noted that, in particular, tracking of financing was a key challenge to
improving accountability. Apart from these out-liers, most respondents noted
that data collection and management was overall very weak, preventing managers
from following up on problems or provide adequate supervision. The lack of
supervision, whether supportive or not, was also highlighted as an important challenge
in improving accountability. In terms of opportunities, managers noted the
importance of not only improving monitoring and database management, but also
transparency so that actors are aware of the ‘full information [transmitted] to
and from health facilities,’ including those related to funding and
responsibilities. The importance of having a ‘clear route to track performance
or to identify defaulters for appropriate appraisal’ was also noted.
Other elements related to
sparking change, such as motivation and incentives, or sanctions and
enforcement, were mentioned by managers but not as frequently as other leading
challenges. In terms of opportunities, managers mentioned the importance of
combining sanctions with rewards, including checks and balances. Only one
re-spondent mentioned ‘compliance by higher levels of management’.
Nigerian government officials views on accountability dimensions along
the axis of justice
Some officials noted the importance of community
engagement and involvement in routine immunization, with one respondent noting
in particular the importance of community ownership over the pro-gramme as
challenges to accountability. Similarly, in terms of
opportunities, respondents emphasized the
importance of involving and engaging communities in planning routine
immunization activities.
Several respondents mentioned a
lack of political commitment by political leaders to routine immunization as a
challenge, but this paled in comparison to the other challenges listed in the
two other axes. One respondent mentioned including traditional leaders within
the accountability framework as an opportunity to strengthen ac-countability
and another noted that political commitment would help unlock funding at the
local level.
Only one respondent mentioned the
importance of ‘reaching the unreached’, categorized as a concern for social
equity. Other inputs that were not previously considered by our framework but
were mentioned by officials as important, and that reflect community
per-spectives, were the availability of comprehensive health care services and
the importance of broader infrastructure and security.
Accountability in health systems to support constructive change:
priorities and positionalities
Our reconceptualization of accountability as a
means of sparking, supporting and steering change within health systems along
the axes of power, ability and justice, broadens and integrates the range of
actions that health system actors can undertake to improve account-ability in
health systems. It also brings into focus existing levers of change within
health systems that are ideally marshalled by man-agers to support constructive
change to ensure responsive health sys-tems (Figure 1).
How did managers themselves view
these varied dimensions of accountability? Nigerian government officials
responsible for rou-tine immunization and primary health care highlighted
challenges and opportunities to strengthen accountability along the axes of
ability and power: clarifying formal roles and responsibilities; trans-parency,
data and monitoring systems; availability of skilled health personnel that are
motivated and supervised; addressing informal norms and behaviours; and
availability of inputs regarding funding and supplies. Other elements of
accountability were mentioned but were not as critical from their viewpoints:
managerial discretion; sanctions and enforcements; political influence and
community en-gagement. Strikingly, almost no respondents mentioned social
equity as being an important aspect of accountability, although a few
men-tioned broad development concerns that reflected community perspectives.
Previous reviews on external
accountability have also found that the definitions of roles or standards for
interaction majorly influ-enced the effectiveness of health committees (McCoy et al. 2012; Molyneux et al. 2012). In Nigeria, these issues are critical for in-
ternal accountability, particularly considering its
federalized struc-ture. Responsibility for tertiary, secondary and primary
health care fall to national, state and local governments, respectively, and
poor coordination contributes to misaligned accountability structures. Even
within states, multiple line-ministries are involved in the ad-ministration of
primary care health services. This situation contrib-utes to the lack of
clarity on roles and responsibilities and inhibits the quality of supervision
and ability to enforce sanctions on front-line health workers and managers (National Primary Health Care Development
Agency 2012; Stokes-Prindle et al. 2012). Concerns about the lack of
guidelines, lack of public availability of proced-ures, and weak monitoring
were also highlighted as key challenges
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Table 1. Top three accountability dimensions
(challenges, opportunities) highlighted by 36 government officials in
Nigeria, 2013
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Axis
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Power
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Ability
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Justice
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Purpose
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Carrots and sticks to spark change
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Fuel to support change
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To steer the direction of change
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Elements
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•
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Monitoring and transparency (12, 16)
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Formal roles and responsibilities (16, 16)
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Community ownership (6, 4)
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Learning and supervision (10, 12)
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Human resources (13, 11)
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Social equity, comprehensive services
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Motivation and incentives (8, 7)
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Funds (8, 9)
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and broader development (6, 4)
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Sanctions and enforcement (6, 6)
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Informal roles and behaviours (8, 4)
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Political leadership (6, 3)
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Cold chain and logistics management (7, 3)
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Community demand (6, 5)
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Vaccines, supplies and equipment (5, 3)
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Managerial discretion and budgeting (4, 3)
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Another area highlighted as an
urgent area for reform to improve accountability was the need for greater
transparency and better monitoring systems for routine immunization (Dunkle et al. 2014). Poor data collection and insufficient data
review create difficulties in identifying the nature and location of problems
for senior man-agers. Although the power of information to spark change is
allur-ing, it is not without its own capacity or resource requirements and
potential unintended consequences. Health systems are already over-burdened
with unwieldy routine information systems that remain remain under-utilized and
of poor quality (Green 2000; Ngulube
2005; O’Meara 2011). Accountability processes should support existing capacity, rather than further distort reporting
within routine information systems (Aitken 1994; George 2009).
Government officials in this
consultation highlighted the lack of skilled and motivated health personnel,
just as other Nigerian pol-icymakers assessing health system priorities have
done (Uneke et al. 2013). Nigeria has more than the average
health worker density re-ported for Sub-Saharan Africa (Federal Ministry of Health Nigeria 2007) and is line with overall proportions of
human resources for health as other countries with similar
gross domestic product (GDP) per capita (Joint Learning Initiative 2004). Nonetheless, there are large
regional disparities, and varied governance across different re-gions further
challenges public sector health workforce management (Oxford Policy Management 2011). Salaries are generally low, often
delayed and working conditions frequently lack essential equipment, are
deficient in drug supply, have poor amenities, inadequate super-vision and weak
management (World Bank 2010).
Although many deficiencies are
glaring in terms of the quality and responsiveness of primary health care in
Nigeria, and managers did mention the importance of sanctions and enforcement,
they did not list this as important as other elements of accountability.
Individuals seeking care may see this as more of a priority than man-agers (Stoffregen et al. 2010; Yamin 2010). Or it could be that man-
agers are wary that sanctions might be misused or
hold little threat in an environment saturated with favoritism (George 2009).
Although elements within the axis
of power and ability were listed by regional managers as important aspects of
accountability, it is striking that the axis of justice, which orients for whom
ac-countability is designed for, in terms of political representation,
community ownership or social equity, figured relatively less fre-quently among
government official’s responses. This could be be-cause social equity is
implicit in their work. There has been a focus on providing services to those
who are hardest to reach with regards to routine immunization in Nigeria (Onwujekwe et al. 2012; National Primary Health
Care Development Agency 2013b). Further research is needed on how this
aspect figures as a value for
health workers and managers, rather than assuming
that it is com-mon basis for mobilizing progressive change in health systems (Cleary et al. 2013).
This article presents an
exploratory analysis of government offi-cial’s perspectives on accountability
from a workshop questionnaire. More in-depth research is required to further
elaborate this initial analysis and future research is required to further
explore how the positionality of stakeholders affects how they perceive and
prioritize accountability dimensions and axes. This would enable us to parse
out whether there may be regional differences due to varied health systems
contexts in different regions, and understand whether com-munities or other
stakeholders value the same elements and axes as health workers and managers
do. Other methodologies that are more suited to identifying stakeholder
prioritization are also recommended.
Conclusion
Accountability can be understood as three dynamic,
interacting axis of power, ability and justice, with each axis sparking,
sustaining and steering change within health systems. Our preliminary efforts
to elicit government official’s viewpoints on accountability “highlights”
certain dimensions of accountability (clarifying roles and responsibil-ities,
improving transparency and monitoring, strengthening supervi-sion and ensuring
the availability of service delivery inputs) that have previously been
neglected by the literature on accountability and cur-rent accountability
initiatives. Future research is needed to verify whether these dimensions of
accountability are specific to those of government officials responsible for
primary care or can be general-ized to other stakeholders within health
systems.
Acknowledgements
The study team would like to thank respondents who
responded to questions in the zonal workshops. In addition, we are thankful to
research assistance provided by Ankita Meghani and Crystal Ng.
Funding
This project was made possible by a grant from the
Bill & Melinda Gates Foundation to the International Vaccine Access Center
(IVAC) at the Johns Hopkins Bloomberg School of Public Health.
Ethics review
The study was reviewed and exempted by Johns
Hopkins School of Public Health’s Institutional Review Board.
Conflict of interest statement. None declared.
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