Human development and accountability

Accountability is about ensuring that governments and service providers are answerable to their citizens and deliver on their commitments (political, financial or service delivery). To allow this, citizens must have a voice, and governments and service providers must have the ability and motivation to respond. This requires effective redress mechanisms when duties and commitments are not met. Accountability relationships can occur at and between various levels – local, national and international, and be both vertical and horizontal. Transparency and accountability of services, organisations and institutions help improve their quality, responsiveness and answerability (O’Meally, 2013).

Accountability between citizens and public service providers can be understood as involving two pathways: short and long. Short route accountability links citizens directly with service providers, while long route accountability delegates citizens’ authority to political representatives, who govern bureaucracies and service providers (Fox, 2014). ‘Tactical accountability’ approaches aim to improve society’s voice and access to information, while ‘strategic accountability’ approaches use multi-pronged practices which also encourage enabling environments and government responsiveness reforms (Fox, 2014). Strategic approaches show more evidence of impact, while tactical approaches have only very limited evidence of effectiveness (Fox, 2014).

Context plays an important role in shaping accountability. Relevant contextual factors include inequalities in society, the ability of elites and states to respond to demands, and the nature of the political settlement and informal politics (O’Meally, 2013). It is important for accountability actors to consider formal and informal politics and power relationships, and to focus on increasing responsiveness and effectiveness, not just on increasing demand (O’Meally, 2013). Strategic accountability packages need to be built on strong contextual analysis and, where possible, be locally led and owned (Fox 2014).

Fox, J. (2014). Social accountability: What does the evidence really say? (Draft paper for GPSA). Washington, DC: World Bank.
This paper re-evaluates the body of evidence on impacts of social accountability initiatives. It suggests that there is more positive evidence for multi-pronged, strategic initiatives that encourage enabling environments and state capacity to respond. These have more impact than tactical interventions, which only promote citizen voice and access to information.
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O’Meally, S. C. (2013). Mapping context for social accountability: A resource paper. Washington, DC: World Bank. Social Development Department.
This paper finds that context shapes the form and effectiveness of social accountability in unpredictable and complex ways. The main messages are:
– Think ‘politically’ in designing and implementing social accountability, as formal and informal politics and power dynamics have strong effects.
– Build synergies between social and political forms of accountability, and work across the supply and demand divide.
– Build on what is already there, embed social accountability in ‘organic’ pressures for pro-accountability change, and ‘work with the grain’.
– Take a multipronged approach to accountability reform, and address issues of poverty, inequality, and exclusion more systematically in social accountability programming. Address the global dimensions of accountability failures.
– Adopt longer time horizons and an adaptable learning-by-doing approach.
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A systematic review suggests that there is no rigorous evidence on what works to improve accountability in healthcare (Berlan & Shiffman, 2012). Healthcare providers in low- and middle-income countries demonstrate limited accountability to consumers. This may have adverse effects on the quality of healthcare they provide and ultimately on health outcomes (Berlan & Shiffman, 2012).

Berlan, D., & Shiffman, J. (2012). Holding health providers in developing countries accountable to consumers: a synthesis of relevant scholarship. Health Policy and Planning, 27(4), 271-280.
What works in developing health care provider accountability? This is a systematic review of research on health provision in low-, middle- and high-income countries. The evidence base on what works is extremely weak. However, the research suggests four mechanisms that may improve provider responsiveness: 1) creating official community participation mechanisms in the context of health service decentralisation; 2) enhancing the quality of health information that consumers receive; 3) establishing community groups that empower consumers to take action; and 4) including NGOs in efforts to expand access to care.
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Sexual and Reproductive Health

The literature suggests that accountability for SRHR is considered to be important in holding policymakers to internationally agreed goals, transforming services and meeting family planning needs (Boydell & Keesbury, 2014). There is almost no evidence on programme impact or effectiveness of accountability interventions for SRHR (Boydell & Keesbury, 2014).

Accountability addressing SRHR problems and solutions at the global level is very different to the complex reality that people experience in frontline health services. Approaches to accountability need to begin with the dynamics of power in the health services on the ground (Freedman & Schaaf, 2013).

Freedman, L. P., & Schaaf, M. (2013). Act global, but think local: accountability at the frontlines. Reproductive Health Matters21(42), 103-112.
How do women and men experience SRHR accountability with local level health service providers? This paper makes the case for a changed approach to accountability that begins with the dynamics of power at the frontlines, where people encounter health providers and institutions. Conventional approaches to accountability do not usually engage with power dynamics and the institutional incentives of policymakers and service providers. The authors suggest that approaches drawn from implementation science and systems science are better suited to understanding the political dynamics of health systems. An understanding of power and politics improves accountability towards health service users.
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Boydell, V. & Keesbury, J. (2014). Social Accountability: What are the Lessons for Improving Family Planning and Reproductive Health Programs? A Review of the Literature (Evidence Project Working Paper). Washington, DC: Population Council.
This systematic review first presents the state of the evidence on accountability in the broader health sector. It then focuses on the family planning and reproductive health fields. In these fields, activities are often broader than social accountability (which tends to focus on the community or service delivery level), focusing instead on tracking the fulfilment of global and national policy and financial commitments. Some programmes are also applying the principles of social accountability to the delivery of rights-based, voluntary, high-quality FP/RH services.
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There is little information on accountability in education, but lessons from the health and WASH sectors might be applicable to education. Although the evidence is weak, it is known that participation helps make services responsive to users and ensures that they are used effectively. Schools function best when they respond to local needs and priorities, and local governance and accountability structures directly contribute to quality of schooling (Pradhan et al, 2011). Accountability to communities has an impact on keeping more children in school, and in improving their learning and ultimately their job prospects (Pradhan et al, 2011).

Pradhan, M., Suryadarma, D., Beatty, A., Wong, M., Alishjabana, A., & Gaduh, A. (2011). Improving educational quality through enhancing community participation: results from a randomized field experiment in Indonesia. Washington, D.C: World Bank.
To address deficiencies in service provision, is it effective to make schools accountable for performance? This study evaluates the effect of four randomised interventions aimed at strengthening school committees, and subsequently improving learning outcomes, in public primary schools in Indonesia. It concludes that measures that foster outside ties between the school committee and other parties, particularly the village council, are more effective than reinforcing existing school committee structures or providing grants and training interventions. This suggests that local governance contributes to improved learning.
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Improved water accountability improves sanitation and hygiene, leading to improved health. There is a considerable body of literature on water services and governance, although less on water accountability specifically. The literature emphasises the role of community, both individuals and organisations, in managing water services accountably. Sanitation in particular requires locally appropriate technologies and solutions. Progress on sanitation is restricted by a lack of commitment from governments, which may change over time as sanitation became a human right in 2010.

Nicol, A., Mehta, L., & Allouche, J. (2012). Introduction: ‘Some for all rather than more for some’? Contested pathways and politics since the 1990 New Delhi Statement. IDS Bulletin, 43(2), 1-9.
This introduction provides a historical look at the development of the water and sanitation international discourse since 1990. It challenges the wider global water and sanitation community to rethink approaches and emphases, shifting from targets and technocratic terms to politics, sustainability and local knowledge. Water management has a complex political, social, economic and ecological landscape, which affects access, sustainability and control. There is an ongoing debate about whether water is an economic good or a right. The paper also challenges the perception of communities’ ability and willingness to lead management of WASH delivery.
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