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Accountability mechanisms and the value of relationships: experiences of front-line managers at subnational level in Kenya and South Africa
  1. Nonhlanhla Nxumalo1,
  2. Lucy Gilson2,3,
  3. Jane Goudge1,
  4. Benjamin Tsofa4,
  5. Susan Cleary2,
  6. Edwine Barasa4,
  7. Sassy Molyneux4,5
  1. 1 Centre for Health Policy/MRC Health Policy Research Group, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
  2. 2 School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
  3. 3 Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
  4. 4 Center for Geographical Medicine, KEMRI-Wellcome Trust Programme, Nairobi, Kenya
  5. 5 Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
  1. Correspondence to Dr Nonhlanhla Nxumalo; Nonhlanhla.Nxumalo{at}


Resource constraints, value for money debates and concerns about provider behaviour have placed accountability ‘front and centre stage’ in health system improvement initiatives and policy prescriptions. There are a myriad of accountability relationships within health systems, all of which can be transformed by decentralisation of health system decision-making from national to subnational level. Many potential benefits of decentralisation depend critically on the accountability processes and practices of front-line health facility providers and managers, who play a central role in policy implementation at province, county, district and facility levels. However, few studies have examined these responsibilities and practices in detail, including their implications for service delivery. In this paper we contribute to filling this gap through presenting data drawn from broader ongoing research collaborations between researchers and health managers in Kenya and South Africa. These collaborations are aimed at understanding and strengthening day-to-day micropractices of health system governance, including accountability processes. We illuminate the multiple directions and forms of accountability operating at the subnational level across three sites. Through detailed illustrative examples we highlight some of the unintended consequences of bureaucratic forms of accountability, the importance of relational elements in enabling effective bureaucratic accountability, and the ways in which front-line managers can sometimes creatively draw upon one set of accountability requirements to challenge another set to meet their goals. Overall, we argue that interpersonal interactions are key to appropriate functioning of many accountability mechanisms, and that policies and interventions supportive of positive relationships should complement target-based and/or audit-style mechanisms to achieve their intended effects. Where this is done systematically and across key elements and actors of the health system, this offers potential to build everyday health system resilience.

  • Health Policy
  • Health Systems
  • Qualitative Study

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  • Handling editor Seye Abimbola

  • Contributors All authors were involved in conceptualising this paper and in conducting the analyses. NN, SM and LG were responsible for initiating the drafting and revisions of this paper. NN, SM, LG, JG, SC, EB and BT read and commented on successive paper drafts. NN, SM and LG were involved in the revisions of the final draft. All authors were also involved in the underlying data collection and analysis processes in the different learning sites. NN, SM and LG read and approved the final manuscript. NN and JG work together. SM, EB and BT work together. LG and SC work together. The work that provided the foundation for this paper is continuing; data already collected remain available to the researchers only.

  • Funding This research is an output from the Resilient and Responsive Health Systems (RESYST) Consortium funded by the UK Aid from the Department for International Development (DFID) for the benefit of low-income/middle-income countries.

  • Disclaimer The views expressed and information contained in this article are not necessarily those of or endorsed by the DFID, which can accept no responsibility for such views or information or for any reliance placed on them.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval Ethical approval was obtained from the London School of Hygiene & Tropical Medicine (LSHTM) (LSHTM ethics ref: 6542), the University of the Witwatersrand’s Human Research Ethics Committee (clearance certificate no M131136), Kenya Medical Research Institute (KEMRI) (ref: SERU 2205), and the University of Cape Town (UCT) (HREC ref 039/2010). Signed consent was obtained for all interviews conducted.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data are available.

  • Author note NN, LG, JG, BT, SC, EB and SM are members of the Resilient and Responsive Health Systems (RESYST) Consortium.

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