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Abstract
Introduction Accountability is a complex idea to unpack and involves different processes in global health practice. Calls for accountability in global health would be better translated to action through a better understanding of the concept and practice of accountability in global health. We sought to analyse accountability processes in practice in global health funding, research collaborations and training.
Methods This study is a literature review that systematically searched PubMed and Scopus for articles on formal accountability processes in global health. We charted information on processes based on accountability lines (‘who is accountable to whom’) and the outcomes the processes were intended for (‘accountability for what’). We visualised the representation of accountability in the articles by mapping the processes according to their intended outcomes and the levels where processes were implemented.
Results We included 53 articles representing a wide range of contexts and identified 19 specific accountability processes for various outcomes in global health funding, research collaborations and training. Target setting and monitoring were the most common accountability processes. Other processes included interinstitutional networks for peer checking, litigation strategies to enforce health-related rights, special bodies that bring actors to account for commitments, self-accountability through internal organisational processes and multipolar accountability involving different types of institutional actors. Our mapping identified gaps at the institutional, interinstitutional and broader system levels where accountability processes could be enhanced.
Conclusion To rebalance power in global health, our review has shown that analysing information on existing accountability processes regarding ‘who is accountable to whom’ and ‘accountability for what’ would be useful to characterise existing lines of accountability and create lines where there are gaps. However, we also suggest that institutional and systems processes for accountability must be accompanied by political engagement to mobilise collective action and create conditions where a culture of accountability thrives in global health.
- Health policy
- Health systems
- Public Health
- Health policies and all other topics
Data availability statement
Data sharing not applicable as no datasets generated and/or analysed for this study. All data relevant to the study are included in the article and online supplemental files.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
The importance of accountability to address power asymmetries in global health is widely recognised.
However, accountability is a complex concept that is challenging to unpack and has different permutations in practice.
WHAT THIS STUDY ADDS
This systematic literature review and mapping of accountability processes in global health funding, research collaborations and training identified 19 specific processes for accountability at the institutional, interinstitutional and broader system levels to address different categories of intended outcomes.
Accountability processes were characterised by internal, unidirectional, bidirectional and networks of accountability lines involving a variety of duty bearers and claims holders who foster accountability in the global health system.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
We argue that calling for more accountability in global health should be accompanied by conceptual clarity on what it entails to institutionalise more accountability processes across all levels of the global health system.
To bring power to account in global health, our findings suggest the need to assess the lines of accountability and create them when there are gaps, articulate the intended outcomes of accountability, politically engage with the duty bearers and claims holders, while combining organisational and system processes for accountability with the creation of the conditions where a culture of accountability thrives.
Introduction
“What need we fear who knows it, when none can call our power to account?”
Lady Macbeth in William Shakespeare’s tragedy, Macbeth (c. 1603–1607)
There is a lesson to be learnt here from Lady Macbeth: the lack of accountability leads to abuse of power. Such is the case in global health where power asymmetries that shape inequitable relations between actors in the system ought to be dismantled.1 Decolonisation and accountability are among the fundamental principles to address power asymmetries and transform global health systemically. However, neither decolonising global health2–4 nor accountability in global health5 6 have specific definitions; both are brought to bear by global health actors in a multiplicity of ways based on what these notions mean for them.
The idea of accountability in global health is quite complex to unpack but some scholars have previously interrogated the concept to seek clarity, such as Bruen et al7 who identified participation, transparency, evaluation and redress or enforcement processes as some of the features of accountability, which have become more contested in the changing dynamics of global health cooperation. Outside of global health, accountability has been discussed extensively in other disciplines, such as in political science, public administration, organisational sociology, ethics and development studies. For example, Van Belle and Mayhew8 explored the varying interpretations of accountability in these disciplines and suggested that—in its most basic interpretation—accountability involves a relationship between one (the duty bearer) who is obliged to accept responsibility for actions towards another (the claims holder) who has a stake or is affected by the actions of the former. However, accountability has permutations far beyond a bilateral relationship especially given the current multiplicity of actors in global health that include the state, civil society networks, academia, philanthropies, multinational corporations, public–private partnerships and the media.7–9 In the context of health systems, Brinkerhoff has sought conceptual clarity by discussing financial, performance and political accountability as three types of accountability whose purpose are to reduce abuse, assure compliance with procedures and standards and improve performance.9 However, there is a gap between ideal accountability that is able to fulfil its purpose and accountability that is possible in practice9 as global health governance is impacted by vague lines of accountability between‘duty bearers’ and ‘claims holders.10’ We only need to look at the COVID-19 pandemic as an example of the consequence of vague accountabilities that prevented agile decision-making at all levels of global health.11 Analysing the processes of accountability as implemented in global health practice, including clarity on ‘who is accountable to whom’ and ‘accountability for what,’ could help bring the practice of accountability closer to ideal where processes make it possible for those with power to be answerable to those who demand accountability.12
Three areas of global health practice
Global health funding, research collaborations and training are useful entry points for illustrating manifestations of power differentials in global health and the accountability processes that address these differentials. For example, in global health funding, influential philanthropies such as the Bill & Melinda Gates Foundation (BMGF) have become incredibly powerful in setting the global health agenda and drowned out the voice of Ministries of Health (MOHs) and civil society,13 but have no clear lines of accountability to its beneficiary countries and communities. Bilateral donors like the USA, consistently the biggest source of development assistance for health,14 15 have maintained their influential positions in shaping the global health agenda but are mainly accountable to their governments rather than the recipient countries and institutions in the Global South most affected by the projects they support and advance. In the sheer volume of financing needed to address global health challenges, new public–private partnerships, like the Global Fund to Fight AIDS, Tuberculosis and Malaria (ie, the Global Fund)7 and Gavi, the Vaccine Alliance (ie, GAVI)16 have emerged as important players yet with blurred lines of accountability in the global health system. Systemic corruption in global health is also a problem that severely affects the poor and most vulnerable when money meant to address their needs are diverted for private gains.17 The tracking of the flows of money by academics and civil society to examine whether financing effectively benefits the Global South or only promotes the interests of the private sector and the technocracy in the North has been described as one example to make global health funding players accountable.18–20
In global health research collaborations, examples of power asymmetries include authorship parasitism when up to 15% of articles reporting research from sub-Saharan Africa still had no author based in the country where the study was done.21 Power imbalances were brought to the fore when Indonesia refused to share specimens of avian influenza A(H5N1) to WHO reference laboratories on the basis that institutions in the Global North monopolise the data and develop medical technologies that countries like Indonesia could otherwise not access or afford.22 While it is recognised that many researchers and institutions in the South have benefited from international research collaborations with the North, the accountability of partners from both sides of these collaborations would be instrumental in rebalancing power.5 Some have suggested that funders and communities could help foster the accountability of research collaborations by assessing how the partnerships align with the needs of communities and to what extent they treat local experts on equal footing with foreign or Western-trained scholars.23
In global health training, concerns have been raised about the potential harm of short-term student visits from universities in the North to communities in the South, especially when students lack the skills yet are allowed to deliver healthcare to local populations, or when students are insensitive to local culture and beliefs.24 Some have suggested that training institutions could be held to account for their global health programmes when they are evaluated based on the extent to which they enable community participation in their student immersion programmes, or include the work of Global South scholars in their curriculum.25 26 Reflexivity also has a role in fostering accountability through the critical examination of individual positionalities and the colonial legacies that shape how stakeholders relate in the global health space.27 Finally, accountability in global health is not only about addressing power asymmetries between North and South, but also about the power relations within them; thus, accountability applies to global health actors everywhere.28
Purpose of this review
Accountability in global health, when vague, could ironically disempower the call for more accountability. There is a risk for accountability to become another buzzword,9 29 or rhetoric that is not accompanied by changes in the practice of global health actors.30 It is, for instance, deceiving when some actors could claim progress in rebalancing power in global health despite the absence of processes that hold themselves and others accountable for what they do in their respective spaces of practice. We consider concept and practice to be mutually reinforcing. On the one hand, the notion of accountability in global health will be clarified when there is better understanding of its different processes in practice. On the other hand, accountability processes will be better put in practice when there is clearer understanding of what accountability in global health requires.
In setting the stage for this review and conceptual analysis,31 we argue that conceptual clarity is essential to institutionalise more accountability processes in practice and build a culture of accountability as part of transforming global health. Our objective here was not to answer an effectiveness question (eg, Are accountability processes in global health effective?). We also did not seek a universal definition of ‘accountability in global health.’ Universal definitions are elusive and, as shown by a previous attempt to define the notion of global health itself as ‘public health somewhere else’,32 may achieve the opposite of intent—that is, restrict rather than expand global health’s reach when the definition is inadequate,33 34 or exacerbate inequities when the definition reinforces the privilege of an exclusive group of stakeholders who can be called global health practitioners.35 Reflexive of our power as scholars, we also recognise that we neither facilitated stakeholder participation nor have the normative mandate to impose a ‘standard’ of accountability for the compliance of global health actors.
Research question and objective
We aimed to contribute to the conceptual clarity of accountability in global health by mapping the formal processes of accountability for institutional actors in global health funding, research collaborations and training. Discussions of accountability in global health in the literature is dispersed but also offer a strategic opportunity to analyse information on the different processes to hold power to account. We sought to explore the research question: What are the formal accountability processes in practice in global health funding, research collaborations and training based on who is accountable to whom as described in the literature and for what outcomes? To the best of our knowledge, this work is the first analysis of accountability processes in global health based on a systematic search of the literature. Previous reviews on accountability in global health were narrative6 7 9 12 while another narrative review explored accountability approaches in non-health disciplines.8
Methods
We referred to Koplan et al36 who differentiated ‘global health’ from ‘international health’ and ‘public health’ by its attributes of transcending national boundaries, requiring global cooperation, combining both prevention in populations and clinical care in individuals, deploying a broad range of disciplines beyond the health sciences, with the main goal to achieve health equity for all people among nations. We also referred to the systematic review by Salm et al37 that described global health as a multiplex approach that is ethically oriented, guided by justice and a mode of governance and political decision-making to solve problems across borders. These attributes of global health were used to organise our search strategy for global health in the literature.
We selected global health funding, research collaborations and training as the focus of this review because of the frequency of power asymmetries in these areas based on our familiarity with the issues and our own experience as scholars in global health. Global health funding covers the raising, allocation, management and spending of money for initiatives to improve health and well-being across national borders. Global health research collaborations cover joint health research activities involving institutions between countries, whether North-South, North-North or South-South partnerships. Global health training covers capacity strengthening efforts in global health, including the pedagogical approaches used and how trainees are selected and supported during their formation.
Review type
Our review is a conceptual analysis, which is a purpose specific type of literature review appropriate for exploring the attributes of a concept and synthesising the literature about a topic of interest.31 38 A conceptual analysis maps a sample of the literature from which recommendations could be drawn for further research to develop a theoretical model.31 38 Our literature search was systematic to allow for an update or an expansion of the review at a later stage. We referred to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR)39 in reporting our methods and results (online supplemental file 1 Box 1 provides the components of our methodology.
Supplemental material
Components of the review methodology including the search strategy
Research question
What are the formal accountability processes in practice in global health funding, research collaborations and training based on who is accountable to whom as described in the literature and for what outcomes?
Population-Concept-Context framework
Population
Institutional global health actors operating at global, national or community levels as intergovernmental, governmental, private for-profit or not-for-profit institutions:
Traditional global health actors (eg, WHO, Ministries of Health).
Multilateral (eg, The World Bank) and bilateral development agencies (eg, US Agency for International Development).
International and national funding agencies (eg, US National Institutes of Health).
Philanthropies (eg, Bill & Melinda Gates Foundation).
Research, training or service institutions (eg, universities, research institutes, think tanks).
Private sector (eg, pharmaceutical industry).
Non-government organisations (eg, Médecins San Frontières).
Civil society organisations (eg, Transparency International).
Public–private partnerships (eg, Gavi, the Vaccine Alliance).
Multisectoral institutional arrangements (eg, The Global Fund to Fight AIDS, Tuberculosis and Malaria).
Concept
Accountability process in practice in global health funding, research collaboration and/or training described as a formal process or interaction (ie, who is accountable to whom?) that holds institutional global health actors accountable for certain outcomes (ie, accountability for what?).
Context
Any geographical or income context (ie, either in the Global North or South) where activities involved multiple countries or transcended national boundaries in the case of activities in a single country.
Inclusion criteria
Any article type or any study design.
Published in English with no year restrictions.
Reported work in global health funding, research collaboration and/or training.
Described a formal accountability process in the text of the manuscript.
Exclusion criteria
Discussed topics apart from global health funding, research collaboration and training.
Described work only in a single country or in a purely domestic context.
Mentioned accountability only briefly.
Discussed the accountability of individual rather than institutional actors.
Discussed accountability processes only in broad terms or in purely theoretical or non-practical terms.
Discussed accountability processes that are only recommended and not yet in practice.
Search strategy
PubMed
(((accountability(Title/Abstract)) OR (accountability(MeSH Terms))) AND (global health(MeSH Terms))) AND ((financing, organized(MeSH Terms)) OR (research(MeSH Terms)) OR (information science(MeSH Terms)) OR (schools(MeSH Terms)))
Scopus
((TITLE(accountability) OR ABS(accountability) OR KEY (accountability)) AND KEY (global AND health)) AND (KEY(financing) OR KEY (research) OR KEY (information AND science) OR KEY (schools))
Population-Concept-Context
We used the population-concept-context (PCC) framework40 to organise our search strategy. Our population included ‘global health actors’ as described by Szlezák et al41 defined as institutions that may operate at global, national or community levels and influence the global health system as intergovernmental, governmental, private for-profit or not-for-profit institutions. We were interested in organisations rather than individual global health actors because they play a critical role in the institutionalisation and sustainability of accountability processes in global health. Institutional actors encompassed the traditional actors (eg, WHO and MOHs), multilateral (eg, World Bank) and bilateral (eg, US Agency for International Development) development agencies, national funding agencies (eg, US National Institutes of Health), philanthropies (eg, BMGF), research, training or service institutions (eg, universities, research institutes, think tanks), the private sector (eg, pharmaceutical industry), non-government organisations (eg, Médecins San Frontières), civil society organisations (eg, Transparency International), public–private partnerships (eg, GAVI) and multisectoral institutional arrangements (eg, the Global Fund).
Our concept was any formal process for ensuring accountability in global health funding, research collaborations or training. We were interested in formal accountability processes12 already in practice because they represent ‘real-world’ experience rather than purely conceptual approaches. We identified an accountability process as a formal process or interaction (ie, who is accountable to whom?) that holds institutional global health actors accountable for certain outcomes (ie, accountability for what?)9 through formal lines of accountability between actors (interinstitutional level), or a web of several interacting actors (broader system level), or internally through self-accountability (institutional level).
Our context was any geographical or income context (ie, either in the Global North or South) involving multiple countries. In the case of activities in a single country, activities described should transcend national boundaries (eg, a programme in one country that was supported by a foreign funding source, or involved a collaboration with an institution in another country).
Search strategy
We searched PubMed (MEDLINE) to cover the biomedical and health-related literature and Scopus (Elsevier) to widen our coverage to include the social sciences literature. Based on our PCC framework, a search strategy was developed on PubMed using the building blocks approach42 by an author who is a global health specialist with training in systematic reviews. The search query deployed the MeSH terms for accountability (“accountability”) and global health (“global health”) combined with the MeSH terms for funding (“financing, organized”), research collaborations, including publications (“research” or “information science”) and training (“schools”). We also searched for the word “accountability” in the Title or Abstract. We converted the PubMed search strategy to a query string using keywords on Scopus. The complete search strategies are in box 1.
Inclusion criteria
We included publications:
Of any article type or any study design.
In English with no year restrictions.
That reported work in global health funding, research collaborations and/or training.
That described a formal accountability process in the text.
All article types (including commentaries) were considered to map the representation of accountability in global health in the literature. The assessment of whether an article described an accountability process was based on the authors’ use of the word ‘accountability’ and its derivatives ‘accountable,’ and/or ‘account’ to describe an accountability process in the text. We assumed that authors who explicitly located their work, or part of their work, within the domain of accountability would use the word accountability in their text.
Exclusion criteria
We excluded publications that:
Discussed topics apart from global health funding, research collaborations or training (eg, a conference paper on hospital accreditation as an accountability process for the quality of hospital care43).
Described work in one country or in a purely domestic context (eg, a case study of primary healthcare in El Salvador without any role for international cooperation44).
Mentioned accountability only briefly (eg, a mixed-methods study on how to improve research mentorship in the Global South that used the word accountability only twice in the text45).
Discussed the accountability of individual rather than institutional actors (eg, a commentary on the ethics of coauthorship for individual authors46).
Discussed accountability processes only in broad terms, or in purely conceptual terms (eg, a discussion of the role of justice in international genomics research in Africa47).
Discussed accountability processes that are only recommended and not yet in practice (eg, a qualitative study that proposed how to strengthen the accountability of non-government organisations working in maternal and child health48).
Discussed concepts related to accountability (eg, transparency, responsibility, justice) but did not explicitly use the terms of accountability in the text.
Screening process
We performed the search from inception in 2022 until 27 January 2023, which yielded 287 records (PubMed, 192; Scopus, 95). We imported records to Covidence (Covidence, Melbourne VIC, Australia), which detected 35 duplicates that were removed before screening. Two coauthors independently screened the titles and abstracts of 252 unique records using Covidence and excluded 126 articles based on the criteria. During full text screening, the reviewers located the words ‘accountability,’ ‘accountable,’ and ‘account’in the text to examine to what extent accountability processes were described by the article. We further excluded 74 articles during full text screening. One article49 not identified during the search but recommended by an expert as a relevant reference for this review was added, resulting in 53 articles for data charting and analysis. Conflicts in the inclusion or exclusion of an article during screening where discussed by two reviewers until agreement was reached.
Data charting and analysis
We abstracted textual data using a data charting form in Microsoft Excel (Microsoft, Redmond, Washington, USA) on the following items that were adapted from Van Belle and Mayhew8 and Murthy12:
Authors, year of publication, DOI and title.
Article type.
Research questions or research objectives.
Accountability for what outcomes?
Which actor is made accountable (ie, duty bearer), and by whom (ie, claims holder)?
Accountability processes.
The data charting form is provided as online supplemental file 2. Relevant texts from the manuscripts were copied verbatim and added to the data charting form independently by two reviewers. The two sets of charted data were later merged and reconciled through discussion. Our data charting was organised based on the accountability processes described by Bruen et al,7 which provided an initial typology of accountability processes (deductive qualitative approach). The list of accountability processes was iterated as other accountability processes were identified (inductive qualitative approach).
We mapped accountability processes following examples from a scoping review on rehabilitation care models50 to present results in a visual manner.51 We visualised the frequency of accountability processes according to the levels of accountability lines and in sequential order of publication year. We also visualised accountability processes according to the categories of outcomes that the processes were intended for. Mapping was performed twice on Microsoft Excel and the outputs were compared to ensure consistency.
Reflexivity statement
We acknowledge our positions as authors all currently based in European institutions. The perspective from the Global South was included in the research process through the involvement of the first author who is originally from the Philippines and who performed the initial phase of this work while based in Malaysia.
Patient and public involvement
This literature review had no direct involvement of patients or the public.
Results
The results of our screening of articles are summarised by the PRISMA flow diagram in figure 1.
PRISMA flow diagram for this review.
Key information obtained from each of the 53 articles included in the analysis are summarised in table 1.
Summary of articles included in the analysis
The articles were published between 2005 and 2022, with more than half (27, 52%) between 2018 and 2022.49 52–77 Their titles suggest a wide coverage of topics and issues in global health, among others: the accountability of international global health actors (eg, the Global Fund, World Bank),7 56 62 69 78–81 governance and corruption in global health funding,67 70 71 78 82 the promotion and realisation of health as a human right,57 83–88 accountability through rankings, countdowns and monitoring of health outcomes,53–55 60 68 72 75 76 89–94 the social accountability of schools of health professions through networking or accreditation,61 64 73 95–97 as well as litigation and legal accountability49 57 84 85 98 and ethical research and community participation.63 66 74 99 100
About one-third (18, 34%) were research articles, specifically 12 case studies,53 56 71 79 84 85 89 97 99–102 3 qualitative studies,63 72 93 2 quantitative studies62 90 and 1 mixed-methods study.60 The others were commentaries (14, 26%),55 59 61 65 73 75 76 78 83 86–88 91 98 review articles (12, 23%), specifically 10 narrative reviews,7 54 64 69 70 77 80 92 95 96 1 systematic review67 and 1 scoping review,49 and the rest were policy or practice articles (6, 11%).57 58 66 68 74 81 There were two news articles,82 94 one from the British Medical Journal and another from Advances in Nutrition and one correspondence52 in The Lancet. Most of the articles had a global scope (27, 51%)7 49 53 55 57–60 65 67 70 71 75–77 80 81 83 85–87 90 91 93 94 96 102 or covered multiple countries from both the Global North and South (22, 42%).52 54 56 61–64 66 68 69 72–74 78 88 89 92 95 97–100 Only four articles focused on a single country.79 82 84 101
The articles varied in their objectives. Some articles reported on the accountability processes for international partnerships through interinstitutional networks. Some articles also situated their discussion of accountability in human rights, or the Sustainable Development Goals and Universal Health Coverage. In terms of which institutional actor was made accountable, more than half of articles discussed processes to bring national governments to account as the duty bearer (27, 51%).49 53 54 56 57 60 62 65 68 70 74 75 77 79 82–90 92 93 101 102 Other articles discussed the accountabilities of research and training institutions (10),59 61 63 64 73 95–97 99 100 multilateral or international global health institutions (9),66 67 69 71 72 78 80 81 91 multiple institutional actors (4)7 55 76 94 and the private sector (3).52 58 98 On the other hand, partnerships and networks of institutions were the claims holders in almost one-third of articles (16, 30%),54 55 61 64 66 68 75 89 91–97 102 followed by multiple institutional actors (12),7 12 58 69 71 72 74 76 77 80 86 87 101 civil society organisations (11),49 57 70 79 81 83–85 88 90 98 the same institutions through self-accountability or when the institution had internal processes to make itself accountable (6),52 59 67 73 78 100 multilateral or international global health institutions (5),53 56 60 62 82 and other actors (3).63 65 99
Accountability processes
We identified 19 specific accountability processes and grouped them into three levels where these processes were implemented, that is, at institutional, interinstitutional and broader system levels. Accountability processes at institutional and interinstitutional levels were mostly organisational or programmatic efforts to foster accountability, while the processes at the broader system level comprised multimodal approaches. We enumerate the specific processes for accountability below:
(a) Institutional level—lines of accountability within an institutional actor (ie, internal or self-accountability).
Transparency in process or information
For example, the institution gives the public access to information about its performance to hold itself accountable.
Oversight by an independent body
For example, the institution taps an external independent body to review its performance and make itself accountable.
Monitoring by an internal body
For example, the institution creates an internal body to monitor its performance and bring itself to account.
System for filing complaints/whistleblowing
For example, the institution has a process in place for filing complaints or requesting for investigations to hold its staff accountable.
Participatory decision-making in the organisation
For example, the institution ensures that different stakeholders participate in decision-making within the organisation to make itself accountable.
Clear accountability lines or rules
For example, the institution has clearly outlined the procedures and rules on ‘who reports to who’ to hold its staff and partners accountable.
(b) Interinstitutional level—lines of accountability between institutional actors (ie, unidirectional or bidirectional accountability).
Stakeholder participation or engagement
For example, a group of institutions ensure the participation of stakeholders in their activities to bring one another to account.
Peer evaluation or monitoring or accreditation
For example, institutions agree to hold one another accountable by reviewing one another’s performance.
Adoption of guidelines, framework or shared principles
For example, a group of institutions adopt a set of principles to guide their activities to which they agree to hold one another accountable.
Networks or consortia with shared commitment
For example, a group of institutions formalise a network and agree to abide by a set of targets and assess one another based on their commitments to hold themselves accountable.
Conditions for funding
For example, a donor holds the recipient accountable through the grant (or withdrawal) of funding based on performance.
Clear accountability lines or rules
For example, two institutions have clear rules on how one holds the other accountable for performance.
(c) Broader system level—lines of accountability among several interacting institutional actors in the broader system (ie, web or network of accountability)
Setting and monitoring targets or indicators
For example, multiple global health actors set targets and monitor outcomes to hold one another accountable for performance.
Multisectoral collaborations, vibrant civil society, advocacy
For example, civil society, advocates and other stakeholders make global health actors accountable for outcomes.
Enabling policy environment
For example, global health actors in the system have an enabling policy framework to facilitate the attainment of outcomes and hold one another accountable for performance.
System for litigation or taking legal action
For example, global health actors use the procedures in the legal system to bring other actors to account for their failures.
Declared commitments to shared outcomes
For example, multiple global health actors declare their commitment to a set of outcomes and hold one another accountable for performance.
Moral suasion or investigation by special bodies
For example, a special body is constituted to assess global health actors in the system and hold them accountable for certain outcomes.
Power to grant or withhold funds
For example, Congress or Parliament uses its power to grant or withhold funds based on performance.
Figure 2 is a map of accountability processes described in each article in order of publication year. The most common accountability process among the articles was the setting of targets and monitoring of indicators (24, 45%) followed by multisectoral collaborations (20, 38%) and stakeholder participation (14, 26%). The least reported accountability processes included participatory decision-making (4, 8%), clear accountability rules within (4, 8%) and between institutions (4, 8%) and the power to grant or withhold funds (4, 8%). Overall, there were more accountability processes at the broader system level followed by processes at the interinstitutional level and at the institutional level.
Accountability processes described in each article by publication year.
Figure 3 presents a map of accountability processes clustered according to the categories of outcomes they were meant for (ie, accountability for what) based on how the authors discussed accountability. Good financial management and zero corruption in global health institutions was the most common target outcome of accountability processes in the articles (11, 21%), followed by maternal and child health outcomes (8, 15%), realisation of health as a human right (7, 13%), socially accountable schools (6, 11%) and ethical global health research collaborations (5, 9%). The categories of outcomes could also overlap. For example, the category ‘maternal and child health outcomes,’ which draws on a human rights perspective, was grouped as distinct from the broader ‘realisation of health as a human right,’ depending on how the authors framed their discussion of accountability. We observed a pattern in the frequency of accountability processes such that most of the processes described for good financial management and zero corruption were at the institutional level. Maternal and child health and health as a human right had accountability processes located mostly at the broader system level. Socially accountable schools and ethical global health research collaborations had accountability processes mostly at the interinstitutional level.
Accountability processes described in each article and clustered according to their desired outcomes.
Discussion
The objective of this review was to explore accountability in global health by analysing formal accountability processes in practice in global health funding, research collaborations and training based on ‘who is accountable to whom’ and ‘accountability for what.’
Accountability processes at all levels
Our analysis showed that monitoring of indicators53 54 60 68 75 76 89 90 92–94 was the most common accountability process in our sample of articles. Many global health actors who advocate for accountability often talk about target setting and tracking as processes to make global health organisations accountable for their commitments to attain a set of outcomes. However, other accountability processes in practice were less described in the articles, such as the use of legal procedures and litigation strategies which were reported to be useful in bringing the tobacco industry to account,98 reducing health inequities,83 minimising corruption in global health,70 and promoting health-related rights,85 including maternal and child health88 and sexual and reproductive health and rights.49 The establishment of formal networks or consortia of global health organisations that commit to shared principles and provide a platform for institutional ‘peer-checking’ was an accountability process described as useful, such as the International Health Partnership that makes donors accountable for the harmonisation and effectiveness of development assistance,91 Global Health 50/50 that brings organisations to account for gender equality in the workplace,55 and the Training for Health Equity Network that makes medical schools accountable for improving the health of the communities they serve.61 64 95–97 It is interesting to note that our review identified a number of articles on medical schools’ social accountability, defined in this context as ‘the obligation of schools to direct their education, research and service activities towards addressing the priority health concerns of the community, region or nation they have a mandate to serve.61’ Other processes for accountability reported to be useful include the creation of special bodies that mobilise support and ensure accountability at the highest levels, such as the United Nations Independent Accountability Panel for women’s, children’s and adolescent’s health.65 Self-accountability to keep organisations in check was also noteworthy, such as the internal procedures for accountability in the Global Fund.7 62 71 82 Our review also found that scientific journals52 and a vibrant civil society working with multiple actors in the system49 57 58 70 74 77 79–81 83–88 90 92 93 98 101 play critical roles as claims holders in fostering accountability.
Our mapping showed the frequency of accountability processes across institutional, interinstitutional and broader system levels in our sample of articles. The articles on good governance and zero corruption in global health institutions (see figure 3) focused mostly on accountability processes at the institutional level (eg, organisational policy on transparency, process for investigating complaints, internal monitoring of performance) with few processes described at the broader system level. On the basis of this finding, more accountability processes at the broader system level could be considered to ensure good financial management in global health, for example, through a global system to monitor corruption in global health organisations, or utilisation of the legal system to sue organisations for financial misconduct, or civil society mobilisation to demand good governance in global health. Conversely, accountability processes for attaining maternal and child health outcomes and the realisation of health-related rights at the broader system level could be complemented by additional accountability processes at the institutional and interinstitutional levels. The social accountability of schools, which had accountability processes mostly at the interinstitutional level, could also be complemented by implementing accountability processes at the institutional and broader system levels.
Drawing and rethinking accountability lines
At least 26 articles described multipolar accountability lines involving a web of linkages among various institutional actors that make one another accountable.7 54 57 58 66 68 69 71 72 75–77 80 83–87 89 91–94 98 101 102 Brinkerhoff9 has previously suggested that there is no ideal amount of accountability linkages. However, he also cautioned that too few linkages make it easier to evade responsibility, while too many linkages confuse the lines of accountability. It would not have been possible to ascertain the locations, directions and frequency of the lines of accountability without examining the processes of accountability, as we have demonstrated in our analysis. Our review has shown that analysing information from existing accountability processes described in the literature regarding ‘who is accountable to whom’ and ‘accountability for what’ is a useful approach to characterise existing lines of accountability and create the lines where there are gaps. There is also a risk that the direction of accountability lines would favour those that already hold the power in global health and, thus, do not sufficiently promote accountability towards communities and the people,9 which is similar to elite capture or when power becomes concentrated in the hands of the few during decentralisation.103 104 Thus, it is also important for any analysis of accountability to rethink the directions of the lines of accountability to avoid reinforcing power asymmetries and instead put more pressure on duty bearers by shifting power towards the claims holders.
Creating the conditions for a culture of accountability
Our analysis of accountability processes was mainly based on an institutionalist paradigm8 to understand formal institutional and programmatic processes to identify accountability deficiencies across the levels of the global health system.12 105 Interrogating formal organisational procedures and instruments as well as organisational social norms and culture could help influence institutional actors to make accountability a core element of strategic management to gain public trust.106 107 However, we also acknowledge that the issue of accountability in global health is not a purely technocratic exercise to be addressed by organisational and systems thinking alone. Accountability processes do not lead to their intended outcomes without the appropriate context.108 There is a need to create the conditions for a culture of accountability to thrive in global health and it will require critical engagement with the broader social and political dimensions of accountability. This article is primarily intended to engage the readership of BMJ Global Health, which includes researchers, policymakers, funders, clinicians, frontline healthcare workers and other global health stakeholders. We see our role as scholars to engage readers to think about how to strengthen accountability in their respective spheres of influence in global health. The accountability processes identified by our review may serve as entry points for meaningful debates on how to compel powerful institutional actors to answer for their actions.
Limitations and future research
Our search strategy would have missed articles that discussed concepts related to accountability, such as monitoring, transparency, policy fidelity and implementation, compliance, quality assurance, etc, but did not use the word ‘accountability.’ However, we were interested in articles where the authors located themselves explicitly within the accountability discourse, signalled by the authors’ use of the word accountability in their text. A future scoping review could expand from our work by searching more databases and the grey literature and including non-English articles for consideration. The question of the effectiveness of accountability processes was beyond our scope, and our findings do not provide evidence to support the suggestion that more accountability processes lead to better accountability. Our hypothesis is that multiple accountability processes may act synergistically in a multipronged accountability strategy. This hypothesis could be empirically tested in future studies that assess accountability processes based on their ability to deter power abuse6 and enable answerability and enforceability12 105 in the event of wrongdoing.
Conclusion
Accountability in global health has numerous permutations in practice and is an elusive concept to unpack. It must be interrogated to serve as a better instrument to address power asymmetries in global health funding, research collaborations and training. We hope to meaningfully engage in thinking about accountability through our analysis of accountability processes in the global health literature. Global health actors who call for reforms in global health should refrain from using ‘accountability’ loosely without ensuring that processes to foster accountability are de facto put in place. Global health is evolving in the postpandemic era; there is a window of opportunity to strengthen accountability and rebalance power. In the end, Lady Macbeth’s allusion to a culture of impunity in our Introduction should be proven wrong! Institutional and systems enhancement, rethinking the lines of accountability and politically engaging with the duty bearers and claims holders are necessary steps towards creating the conditions where a culture of accountability thrives in global health.
Supplemental material
Data availability statement
Data sharing not applicable as no datasets generated and/or analysed for this study. All data relevant to the study are included in the article and online supplemental files.
Ethics statements
Patient consent for publication
Ethics approval
This work did not involve the use of patient-level data and thus did not require ethics review.
Acknowledgments
We thank Dr. Emma Rhule for her constructive comments to improve the manuscript and the United Nations University International Institute for Global Health for providing the infrastructure for initiating this work.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Handling editor Stephanie M Topp
Twitter @harvylight, @OriaJames1, @AnnikaFrahsa
Contributors HJL conceptualised the study, developed the methodology and performed the literature searches. HJL and OJ performed article screening and data charting. HJL led data analysis and interpretation with inputs from AF. AF provided the infrastructure for the completion of this work. HJL wrote the first draft of the manuscript with inputs from OJ and AF. OJ and AF contributed revisions to the manuscript. HJL acts as the guarantor of this work. All authors hold themselves accountable for the final version of the manuscript.
Funding This work was supported by the United Nations University and the Lindenhof Foundation. Publication of this article was supported by the open access fund of the University of Bern and swissuniversities.
Disclaimer The funders had no role in study design, data collection and analysis, preparation of the manuscript or decision to publish
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.