“Tell me how you will measure me, and I will tell you how I will behave” – Eliyahu M. Goldratt
When thinking about accountability, it is not wrong to think of things that can be measured and as in Goldratt’s quote above, measurement systems can help people to tailor their behaviour and performance accordingly, to focus on specific goals. However, accountability goes much further than measurement systems. Putting in place accountability measures can help reinforce certain types of behaviour, as long as the right measurement criteria is used.
Accountability can be broadly defined as “measures to ensure that the person or organisation with authority to provide a service actual delivers that service, i.e., that providers and policy-makers are answerable for their actions, and to demonstrate that they have delivered” (Aidspan, 2015).
This was the central theme of the two-day conference organised by the Sustainable Development Goals Center for Africa in Kigali, Rwanda, 8th – 9th March 2018. The conference, titled “Every Life Matters – Building and Strengthening Accountability in African Health Systems” had the purpose of defining an accountability framework to achieve Sustainable Development Goal 3 (SDG 3): Good Health and Well-being.
In order to achieve SDG 3, the conference deliberated on the accountability frameworks that need to be put in place between different stakeholders such as governments, healthcare practitioners and institutions, development partners and patients.
Putting in place accountability systems and strengthening existing accountability measures is urgently needed in many African countries. Failures in healthcare delivery have gone unsanctioned and all too often excuses are made for poor service delivery. We have all heard stories of failures in the provision of routine healthcare. These failures are often attributed to external factors, which are seen as uncontrollable, and as has become the norm, responsibility and accountability is abdicated.
The conference brought together government officials, multilateral agencies, development partners and civil society organisations from across the African continent to deliberate on why many African countries have still not managed to overcome many of the health challenges that well-resourced countries have been able to overcome. Now more than ever, there needs to be an uncompromised focus to improve on the health indices in many African countries. We are still at a stage where despite advances in modern technology, according to the World Health Organisation, out of the 830 daily maternal deaths, 550 occur in sub-Saharan Africa. During his recent visit to Nigeria, Bill Gates reiterated the abysmal health indices in Nigeria when he mentioned that Nigeria was one of the most dangerous places in the world to give birth. Many of the deaths are avoidable and often patients have no recourse when there is clear evidence of negligence on the part of healthcare practitioners.
With these challenges front and centre, the morning session kicked off on Day 1 of the conference, with opening remarks from a cross section of speakers from the private sector, government officials and development partners. This was followed by a high-level panel discussion on in country accountability mechanisms. Dr. Belay Begashaw, the Director General of the Sustainable Development Goal Center for Africa (SDGC/A) reminded the delegates and speakers what the conference theme meant. “‘Every Life Matters’ means doing things responsibly with human beings at the centre of it all,” he said.
The importance of accountability was highlighted by Dr. Takao Toda, the Vice President for Human Security and Global Health, Japan International Cooperation Agency (JICA), and he opined that, “The first and the most important accountability is people’s accountability to the people themselves”. Ms Zouera Youssoufou, the Chief Executive Officer, Dangote Foundation, spoke about the diverse solutions to solving Africa’s development challenges and the requirement of an accountability framework and the role of the private sector. “The government needs to recognise the potential of the private sector. The private sector can bring in additional capacity such as appropriately trained medical personnel,” she said.
The rest of the 2-day conference then focused on three key themes of accountability, with delegates attending one of the three breakout sessions to brainstorm and define appropriate mechanisms for oversight and the building of accountability frameworks.
Theme 1: What is the accountability framework necessary to ensure achievement of SDG 3 throughout Africa?
Health for All , a key theme for the upcoming World Health Day requires effective accountability systems within African countries. SDG3 is all encompassing and looks at ensuring good health and wellbeing for all people of all ages, irrespective of financial status.
As a continent we are aware of the significant inequalities across countries and within those same countries. A summary of recommendations to achieve SDG 3 were made. In the first instance, people are and should be accountable to:
- Body politic, decision makers e.g. at national level and institutions.
- Technocrats and administrators
- Peers within the sector, professional bodies and associations. They should be there to give confidence to patients, build peer networks and ensure good ethics for professional bodies, focusing on people
- Citizens and the public
In building an accountability framework, it was determined that it was better to focus on results and not inputs, looking at programmes that worked in the past. The focus on accountability would need to be country focused, with national workshops for different countries to see what their framework would look like.
Theme 2: How can data, research and development engender greater, stronger, long-lasting accountability systems and mechanisms in health in African nations?
Healthcare professionals/doctors know their roles and responsibilities, but the general population in many African countries often are not aware what their rights are. Therefore, there is a need for more transparency in service delivery so patients know their rights. In addition, if patients have a complaint there needs to be a system for them to seek recourse. This could be through a quasi-judicial system. Public service announcements and more civil society advocacy could also help bridge the divide between patients and healthcare professionals.
A challenge that is often encountered in data collection is the reliability and accuracy of the data, so how do you encourage people to provide accurate data without the risk that there would be repercussions on them? Data should be used to ensure accountability and for positive reinforcement and not as a “stick” to punish healthcare practitioners or the data providers. Engagement would mean winning the heart and minds of people, especially when reporting accurate data results, with feedback provided to improve services.
A bottom-up approach could focus on the micro level of data, with data disaggregated to the top with Community Health Workers (CHEWs) providing the data to local governments. This human-centred approach would also help ensure that norms and cultures of the communities are well understood, as CHEWs have a better understanding of the unique challenges in their communities. When the data is collected, there would need to be a feedback mechanism to the data providers so they understand how the data they provide is used.
Theme 3: Establishing Appropriate Remedies and Other Accountability Mechanisms to Ensure Proper Functioning of a Healthcare System.
In deliberating about remedies and accountability mechanisms, the following themes came through. Health accountability means putting in place governance structures at the national level, and in most cases, accountability needs to go both ways from patients to health practitioners or from government to communities and vice versa. Accountability is also not always about enforcement, but needs to be seen as creating incentives for people to be accountable, as it is in their best interest.
The following five thematic areas were identified:
Human rights need to be protected as well as access to healthcare – if a patient demands accountability from healthcare practitioners, there should be no repercussions on them. In addition, duty bearers and health practitioners should also have some form of protection too.
- Strengthening the capacity for health accountability – awareness needs to be created at the community level so that people know their rights and with Continuous Professional Development (CPD), health practitioners need to be reminded of their responsibilities
- Strengthening incentive systems to enhance health accountability – the setting up of mechanisms to protect health workers from litigation
- Innovation and new approaches to health accountability – engaging the private sector to be part of the health accountability process, using digital health in monitoring and evaluation and peer to peer accountability
- Strengthening legal frameworks for health accountability – freeing health councils and professional associations from conflicts of interest, neither should be involved in health care provision. The same applies for health service providers and medical insurance companies.
The conference then drew to a close with participants agreeing to the following call-to-action:
- All stakeholders in Africa need to champion an agenda for improved healthcare systems and commit to the launch of further inclusive national dialogues and building national roadmaps.
- Health professionals to demonstrate conviction to the current agenda and to drive changes necessary to improve accountability in their health systems.
- Citizens must be the focus of accountability mechanisms, and their voices need to be listened to when they demand quality care and treatment, leveraging the media to strengthen accountability.
- Politicians and government officials need to show strong political commitment to ensuring accountability, routing out corruption and pushing for appropriate legal frameworks to be enforced. Professional bodies need to be strengthened and empowered to maintain the highest professional standards, holding their members to account.
- Increased investment in health system data capacity, especially citizen-driven data and for government to enable open data policies making data more accessible.
- Developing a comprehensive Pan –African health system accountability plan, supported by governments and development partners, by mid 2019.
- Pledge for more financial resources to achieve the envisaged goals and support for a new fund for African Health Systems to promote SDG 3 in Africa. Governments also have to commit to increase their funding for health system in their countries.
An unspoken theme that cut through the talks, delegate discussions and thematic sessions was the need for human solidarity. In the spirit of the SDGs, tackling poverty unites African countries with a common goal, to provide their people with a more positive future and equality of opportunity, an issue at the heart of the 2030 Agenda. Human solidarity requires that people are accountable to each other, and by putting in place accountability frameworks for African healthcare systems, should promote a culture of solidarity and help to ensure that African countries understand their collective responsibilities to their population.
As we approach World Health Day on the 7th April, the closing slogan of the 2-day conference seems quite fitting; “All you do for me without me is against me”. It highlights how health is a human right, and patient care needs to be front and centre, focusing on positive health outcomes. Health for all means that everyone should have access to quality healthcare that reflects their individual needs, irrespective of their income level.