CITATION: The crowded space of local accountability for maternal, newborn and child health: a case study of the South African health system
Fidele Kanyimbu Mukinda, Sara Van Belle, Asha George, Helen Schneider
Health Policy and Planning, czz162, https://doi.org/10.1093/heapol/czz162
Published: 22 December 2019 Article history

Global and national accountability for maternal, newborn and child health (MNCH) is increasingly invoked as central to addressing preventable mortality and morbidity. Strategies of accountability for MNCH include policy and budget tracking, maternal and perinatal death surveillance, performance targets and various forms of social accountability. However, little is known about how the growing number of accountability strategies for MNCH is received by frontline actors, and how they are integrated into the overall functioning of local health systems. We conducted a case study of mechanisms of local accountability for MNCH in South Africa, involving a document review of national policies, programme reports, and other literature directly or indirectly related to MNCH, and in-depth research in one district. The latter included observations of accountability practices (e.g. through routine meetings) and in-depth interviews with 37 purposely selected health managers and frontline health workers involved in MNCH. Data collection and analysis were guided by a framework that defined accountability as answerability and action (both individual and collective), addressing performance, financial and public accountability, and involving both formal and informal processes. Nineteen individual accountability mechanisms were identified, 10 directly and 9 indirectly related to MNCH, most of which addressed performance accountability. Frontline managers and providers at local level are targeted by a web of multiple, formal accountability mechanisms, which are sometimes synergistic but often duplicative, together giving rise to local contexts of ‘accountability overloads’. These result in a tendency towards bureaucratic compliance, demotivation, reduced efficiency and effectiveness, and limited space for innovation. The functioning of formal accountability mechanisms is shaped by local cultures and relationships, creating an accountability ecosystem involving multiple actors and roles. There is a need to streamline formal accountability mechanisms and consider the kinds of actions that build positive cultures of local accountability.


  • Frontline health managers and providers are subject to multiple accountability processes designed nationally and practiced locally, in addition to locally emerging accountability mechanisms.
  • There may be duplication, overlap, conflict or synergy among these multiple accountability mechanisms at local level, which often involve the same groups of actors.
  • Formal accountability mechanisms operate within local cultures of informal relationships, networks and underlying norms, some of which may become formalized over time.
  • The informal dimensions of the accountability ecosystem provide a significant backdrop to formal mechanisms and may be key to understanding local variation in maternal, newborn and child health outcomes.
  • A more holistic systems perspective to accountability is needed, rather than the current siloed approach of multiple individual accountability mechanisms.

The vast majority of deaths can be attributed to health system failures often in the context of severe resource constraints and poverty. These failures include, amongst others, insufficient or inadequate distribution of healthcare facilities to ensure coverage, the dearth of skilled health providers and ‘know-how’, drug stock-outs, lack of essential life-saving equipment, and inadequate referral, emergency transport, and monitoring and supervision systems.

1. ‘Financial accountability’ refers to tracking and reporting on allocation, disbursement and utilization of financial resources using auditing, budgeting and accounting tools.
2. ‘Performance accountability’ refers to demonstrating and accounting for performance in light of agreed-upon performance targets.
3. ‘Public accountability (political/democratic)’ refers to procedures, and mechanisms that seek to ensure that government delivers on promises, fulfils the public trust, aggregates and represents citizens’ interests, and responds to ongoing and emerging societal needs and concerns.

COMMENT (Neil PW): I am clearly not an expert, but why does accountability have to be so complex and, consequently, so ineffective? Instead of byzantine structures of ‘Financial accountability’, ‘Performance accountability’ and ‘Public accountability (political/democratic)’, why can’t we have a straightforward “Health system accountability” which measures simply the fulfilment of frontline health workers’ basic needs? Such a measure would be informed by, and responsive to, the expressed needs of frontline health workers. There are various ways of categorising these needs, one of which is the HIFA acronym SEISMIC. Skills, Equipment, Information, Systems, Medicines, Incentives,  Communication facilities. http://www.hifa.org/about-hifa/hifa-universal-health-coverage-and-human-rights

Best wishes, Neil

Let’s build a future where people are no longer dying for lack of healthcare information – Join HIFA: www.hifa.org