The development of a new accountability measurement framework and tool for global health initiatives

Strengthening provider accountability: A scoping review of accountability/monitoring frameworks for quality of RMNCH care

Increasing health providers' accountability is an important element in improving quality of care (QoC) for reproductive, maternal, neonatal, and child health (RMNCH), so as to improve health outcomes of the population in many low- and middle-income countries (LMICs). Implemented RMNCH monitoring initiatives vary in their settings, methods of data collection, and indicators selected for monitoring. The purpose of this study is to evaluate the monitoring/accountability frameworks used by key global monitoring initiatives and provide insights for countries to develop context-customized indicators for RMNCH monitoring and accountability in middle-income countries. The authors conducted a scoping review of key global monitoring initiatives on their monitoring/accountability framework and associated indicators. Data was extracted into a spreadsheet template for analysis. Monitoring/accountability frameworks corresponding to the selected global RMNCH initiatives were described, analyzed, and then categorized the monitoring indicators used by the initiatives according to the type of indicators, quality domains, monitoring levels, and type of services. The results showed that all frameworks regarded developing quality indicators and their monitoring as important elements of accountability and emphasized the role of health systems blocks as inputs for QoC. The researchers demonstrated the importance of measuring quality through both condition-specific and general health system indicators. However, given the different purposes of global monitoring initiatives, the indicators they used varied. We found a lack of indicators measuring QoC of reproductive health. In terms of quality domains, the timeliness and efficiency of RMNCH services were neglected, as few of these indicators were selected for monitoring. Global monitoring initiatives provide valuable frameworks for countries to understand which key indicators need to be tracked to achieve global objectives and develop the foundation for their own accountability/monitoring systems. Gaps in quality indicator design and use emphasize countries need to build on what the global initiatives have achieved to systematically examine quality concerns, develop a tailored and effective accountability/monitoring framework, and improve population health.

From Pre-Implementation to Institutionalization: Lessons From Sustaining a Perinatal Audit Program in South Africa

INTRODUCTION

Maternal and perinatal death surveillance and response (MPDSR), or related forms of maternal and perinatal death audits, can strengthen health systems. We explore the history of initiating, scaling up, and institutionalizing a national perinatal audit program in South Africa.

METHODS

Data collection involved 56 individual interviews, a systematic document review, administration of a semistructured questionnaire, and 10 nonparticipant observations of meetings related to the perinatal audit program. Fieldwork and data collection in the subdistricts occurred from September 2019 to March 2020. Data analysis included thematic content analysis and application of a tool to measure subdistrict-level implementation. This study expands on case study research applied to 5 Western Cape subdistricts with long histories of implementation.

RESULTS

Although established in the early 1990s, the perinatal audit program was not integrated into national policy and guidelines until 2012 but was then excluded from policy in 2021. A network of national and subnational structures that benefited from a continuity of actors evolved and interacted to support uptake and implementation. Intentional efforts to demonstrate impact and enable local adaptation allowed for more ownership and buy-in. Implementation requires continuous efforts. Even in 5 subdistricts with long histories of practice, we found operational gaps, such as incomplete meeting minutes, signaling a need for strengthening. Nevertheless, the tool used to measure implementation may require revisions, particularly in settings with institutionalized practice.

CONCLUSION

This article provides lessons on how to initiate, expand, and strengthen perinatal audit. Despite a long history of implementation, the perinatal audit program in South Africa cannot be assumed to be indefinitely sustainable or final in its current form. To monitor uptake and sustainability of MPDSR, including perinatal audit, we need research approaches that allow exploration of context, local adaptation, and underlying issues that support sustainability, such as relationships, leadership, and trust.

Towards applying the essential public health functions for building health systems resilience: A renewed list and key enablers for operationalization

The COVID-19 pandemic, climate change-related events, protracted conflicts, economic stressors and other health challenges, call for strong public health orientation and leadership in health system strengthening and policies. Applying the essential public health functions (EPHFs) represents a holistic operational approach to public health, which is considered to be an integrated, sustainable, and cost-effective means for supporting universal health coverage, health security and improved population health and wellbeing. As a core component of the Primary Health Care (PHC) Operational Framework, EPHFs also support the continuum of health services from health promotion and protection, disease prevention to treatment, rehabilitation, and palliative services. Comprehensive delivery of EPHFs through PHC-oriented health systems with multisectoral participation is therefore vital to meet population health needs, tackle public health threats and build resilience. In this perspective, we present a renewed EPHF list consisting of twelve functions as a reference to foster country-level operationalisation, based on available authoritative lists and global practices. EPHFs are presented as a conceptual bridge between prevailing siloed efforts in health systems and allied sectors. We also highlight key enablers to support effective implementation of EPHFs, including high-level political commitment, clear national structures for institutional stewardship on EPHFs, multisectoral accountability and systematic assessment. As countries seek to transform health systems in the context of recovery from COVID-19 and other public health emergencies, the renewed EPHF list and enablers can inform public health reform, PHC strengthening, and more integrated recovery efforts to build resilient health systems capable of managing complex health challenges for all people.

Social accountability and health systems' change, beyond the shock of Covid-19: drawing on histories of technical and activist approaches to rethink a shared code of practice

BACKGROUND

Recognition of the value of "social accountability" to improve health systems performance and to address health inequities, has increased over the last decades, with different schools of thought engaging in robust dialogue. This article explores the tensions between health policy and systems research and practice on the one hand, and health equity-focussed activism on the other, as distinct yet interacting processes that have both been impacted by the shock effects of the Covid-19 pandemic. This extended commentary brings multidisciplinary voices seeking to look back at health systems history and fundamental social-institutional systems' behaviors in order to contextualize these current debates over how best to push social accountability efforts forward.

ANALYSIS

There is a documented history of tension between long and short processes of international health cooperation and intervention. Social accountability approaches, as a more recent strategy to improve health systems performance, intersect with this overarching history of negotiation between differently situated actors both global and local on whether to pursue sustained, slow, often community-driven change or to focus on rapid, measurable, often top-down interventions. Covid-19, as a global public health emergency, resulted in calls for urgent action which have unsurprisingly displaced some of the energy and aspiration for systemic transformation processes. A combination of accountability approaches and mechanisms have their own legitimacy in fostering health systems change, demanding collaboration between those that move both fast and slow, top-down and bottom-up.

CONCLUSION

We argue that social accountability, much like all efforts to strengthen health systems, is "everybody's business" and that we must understand better the historical processes that have shaped the field of practice over time to move forward. These differences of perspective, knowledge-base and positioning vis-a-vis interventions or longer-term political commitment should not drive a conflict of legitimacy but instead be named, subsequently enabling the development of a shared code of conduct that applies to the breadth of actors involved in social accountability work. If we are concerned about the state of/status of social accountability within the context of "building back better" we must approach collaboration with a willingness to create dialogue across distinct disciplinary, technical and politically-informed ways of working.