Accountability refers to the processes by which those with power in the health sector engage with, and are answerable to, those who make demands on it, and enforce disciplinary action on those in the health sector who do not perform effectively. This paper reviews the practice of accountability to citizens on gender and health, assesses gaps, and recommends strategies. Four kinds of accountability mechanisms have been used by citizens to press for accountability on gender and health. These include international human rights instruments, legislation, governance structures, and other tools, some of which are relevant to all public sector services, some to the health sector alone, some to gender issues alone, and some to gender-specific health concerns of women. However, there are few instances wherein private health sector and donors have been held accountable. Rarely have accountability processes reduced gender inequalities in health, or addressed 'low priority' gender-specific health needs of women. Accountability with respect to implementation and to marginalized groups has remained weak. This paper recommends that: (1) the four kinds of accountability mechanisms be extended to the private health sector and donors; (2) health accountability mechanisms be engendered, and gender accountability mechanisms be made health-specific; (3) resources be earmarked to enable government to respond to gender-specific health demands; (4) mechanisms for enforcement of such policies be improved; and (5) democratic spaces and participation of marginalised groups be strengthened.
Governance and participation in health
There is increasing interest among health policymakers, planners and donors in how corruption affects health care access and outcomes, and what can be done to combat corruption in the health sector. Efforts to explain the risk of abuse of entrusted power for private gain have examined the links between corruption and various aspects of management, financing and governance. Behavioural scientists and anthropologists also point to individual and social characteristics which influence the behaviour of government agents and clients. This article presents a comprehensive framework and a set of methodologies for describing and measuring how opportunities, pressures and rationalizations influence corruption in the health sector. The article discusses implications for intervention, and presents examples of how theory has been applied in research and practice. Challenges of tailoring anti-corruption strategies to particular contexts, and future directions for research, are addressed.
There is growing concern that health policies and programmes may be contributing to disparities in health and wealth between and within households in low-income settings. However, there is disagreement concerning which combination of health and non-health sector interventions might best protect the poor. Potentially promising interventions include those that build on the social resources that have been found to be particularly critical for the poor in preventing and coping with illness costs. In this paper we present data on the role of one form of social resource— community-based organisations (CBOs)—in household ability to pay for health care on the Kenyan coast. Data were gathered from a rural and an urban setting using individual interviews (n = 24), focus group discussions (n = 18 in each setting) and cross-sectional surveys (n = 294 rural and n = 576 urban households). We describe the complex hierarchy of CBOs operating at the strategic, intermediate and local level in both settings, and comment on the potential of working through these organisations to reach and protect the poor. We highlight the challenges around several interventions that are of particular international interest at present: community-based health insurance schemes; micro-finance initiatives; and the removal of primary care user fees. We argue the importance of identifying and building upon organizations with a strong trust base in efforts to assist households to meet treatment costs, and emphasize the necessity of reducing the costs of services themselves for the poorest households.
The increasing use of participatory research (PR) approaches to address pressing public health issues reflects PR's potential for bridging gaps between research and practice, addressing social and environmental justice and enabling people to gain control over determinants of their health. This critical review of the PR literature culminates in the development of an integrative practice framework that features five essential domains and provides a structured process for developing and maintaining PR partnerships, designing and implementing PR efforts, and evaluating the intermediate and long-term outcomes of descriptive, etiological, and intervention PR studies. the paper reviews the empirical and nonempirical literature in the context of this practice framework to distill the key challenges and added value of PR. Advances to the practice of PR over the next decade will require establishing the effectiveness of PR in achieving health outcomes and linking PR practices, processes, and core elements to health outcomes.
Tanzania initiated the Local Government Reform Programme in 1996. The objective of the reform is decentralisation by devolution, and to strengthen local authorities' ability to deliver quality and accessible services in cooperation with local communities, civil society organisations, the private sector, and other development actors. This report describes various forms of coordination and cooperation in four districts, using maternal health as an entry point and example. Four districts with relatively low maternal mortality rates were selected: Ileje, Misungwi, Serengeti, and Moshi rural. The objective of the study is to identify if, and in what ways, these districts perform better than others when it comes to cooperation on maternal health, and to identify best practices and disseminate the practices to other districts.
Local democracy and the involvement of local communities in the provision of social services are central issues in the local government reforms that are presently being implemented in many developing countries. At the same time, institutions that run parallel to local authorities, such as social funds and various user-committees, are established to improve accountability and participation. By focusing on actual political processes rather than administrative, legal, and fiscal aspects of decentralisation, this article traces the breakdown of two development projects in Tanzania to the existence of parallel structures, and suggests that user-committees and social funds should be integrated in local authority structures to avoid fragmentation of participation and to enhance local democracy.
Expectant mothers in Pallisa and Budaka districts have moved closer to realising their right to adequate reproductive health services, following the launch of HEPS Uganda's Community Empowerment and Participation on Maternal Health Project. The Project, falling within the empowerment, lobbying and advocacy themes of the EU's DSCBP, specifically targets expectant mothers, health care providers, district health officials and other local government leaders as well as community opinion leaders.
In the HIV/AIDS pandemic, it is older people, particularly grandmothers, who are shouldering most of the emotional and financial burden as carers. Yet their vital role is going unrecognised. This report calls for a major shift in the response to HIV/AIDS. Some of the recommendations include: public recognition of the value, contribution and rights of older women carers to reduce stigma and discrimination against them more sophisticated analysis and understanding of the role of older women and men in caring for adults and children living with HIV, so that urgent; support can be targeted at these older carers; better support to access existing services home-based care policies and programmes that address the specific economic, health and psychosocial needs of older women carers and support them in their care giving roles.
This study set out to understand how the policy of user involvement is interpreted in health service organisations and to identify factors that influence how user involvement is put into practice. The design was that of an ethnographic study using participant observation, interviews, and collection of documentary evidence. Set in a multiagency modernisation programme to improve stroke services in two London boroughs, participants comprised of service users, National Health Service managers, and clinicians. Author conclusions include that user involvement may not automatically lead to improved service quality. Healthcare professionals and service users understand and practise user involvement in different ways according to individual ideologies, circumstances, and needs. Given the resource implications of undertaking user involvement in service development there is a need for critical debate on the purpose of such involvement as well as better evidence of the benefits claimed for it.
There is no standard definition of a community. The term “community” has been used to describe interactions among people in primarily geographic terms. But it is now accepted that people who live in close proximity to one another do not necessarily constitute a community, since they may differ with respect to value systems and other cultural characteristics that are more relevant to the social concept of community. Some have argued that the defining feature of a community is the common identity shared by its members. Thus, a single individual may belong simultaneously to different religious, vocational, or ethnic communities, or communities with distinct values and aspirations may inhabit a single geographic area. Even though community is determined largely by shared traditions and values, communities are not static and may accommodate multiple and even conflicting interpretations of their own traditions and values. Outsiders may also define community differently from insiders. The extent to which a community reflects these features is a measure of its cohesiveness. The authors argue that different levels of community cohesiveness or specific features may warrant different research protections.