The document discusses various aspects of accountability in health systems, focusing on the interplay between states, markets, and social organizations. It highlights the challenges faced by indigenous populations in accessing health services, despite existing legal frameworks, and emphasizes the importance of citizen-led accountability movements. Key issues raised include stakeholder contestation, the nature of health service offerings, and the effectiveness of social accountability processes in ensuring equitable access to health services.

1. Health Systems and Accountability
Gerry Bloom and Alex Shankland
MAVC/GPSA/TAI Research Workshop on
‘The Quest for Citizen-led Accountability – Looking into the State’
Institute of Development Studies, Sussex
30 April 2015

2. Overview
• Understanding Accountability in Health Systems
• Accountability in Decentralised and Marketised Health Systems
• Regulatory Strategies in Health Markets
• Accountability and Universal Health Coverage
• Indigenous Peoples’ Health and Social Accountability

3. Accountability in health systems: partnerships between states,
markets and social organisations
• Health systems involve a wide variety of services aimed at different
problems
•Safety and public goods (epidemics, sanitation, dangerous practices)
• Information asymmetry, power and knowledge (creation of institutions such
as organised professions, or hierarchical management to mitigate impact and
assure safety and effectiveness)
• Finance, insurance and equity of access (public finance of services)
People feel strongly about these issues, which have a big impact on their
sense of safety and well-being and can be implicated in government
legitimacy (UK NHS, China SARS and health system reform, South Africa and
HIV/AIDS, Nigeria and counterfeit drugs).
The framing of issues and popular perceptions strongly influence what issues
are seen to be important. There is stakeholder contestation to influence
regulatory and political agendas.

4. Accountability in Decentralised and Marketised Health Systems:
• Rapid spread of market-like activities in most low and middle-income
countries linked to changes in development model
• In many countries the legal framework has been unchanged for years
• Enforcement capacity is weak
• A substantial proportion of activities take place outside the regulatory
system

5. Regulatory strategies in health markets
• Administrative and bureaucratic controls: licensing and accrediting
providers, registration of drugs and so forth
• Market supply oriented Self-regulation, contracts, incentives and
subsidies including performance-related pay
• Consumer or citizen oriented: education, right to information, rights,
legal redress (balanced scorecards, MFA and village action in China,
Health Watch in Bangladesh)
• Collaboration oriented: co-production of services and regulation,
partnerships for transparency and accountability (sub-standard drugs,
adherence to ART)
Importance of politics, power and social norms
Bloom, G., Henson, S. and Peters, D. Innovation in regulation of rapidly changing health markets.
Globalization and Health 10:53

6. Accountability and Universal Health Coverage
• Rights-based movements for universal health access have been strengthened
by alliances between progressive actors within the state and non-state actors
leading bottom-up mobilisations (“sandwich strategy”)
• Brazil case: movimento sanitarista successfully institutionalised via social
accountability spaces, generating pressure on local governments to deliver
• This kind of mobilisation can be very successful in pushing to end exclusion
from access to services and holding states and service providers accountable
for non-delivery
But what happens when you have achieved universal coverage of basic
services? Moving from rights to entitlements, disease specific advocacy creates
problems of resource allocation and opens space for accountability to become
lobbying; mediating between different interest groups requires a shift from from
rights-claiming to deliberation
What about accountability for decisions on the nature of the health services
offered? Key issue for marginalised groups such as indigenous peoples…

7. Indigenous peoples have missed
the health MDGs by a significant
margin, leaving them “behind
everyone, everywhere”
(Stephens et al. 2005)
Disparities between national
average infant mortality rate (IMR)
in seven countries and IMR for
selected indigenous populations
in those countries
Source: Stephens et al. (2006)
“Disappearing, displaced, and
undervalued: a call to action for
Indigenous health worldwide” The
Lancet Vol 367

8. Challenges for universal access: indigenous health in Brazil
Policy processes
Physical accessibilityEpidemiological specificity
Attitudes and behaviour

9. Accountability politics in Brazil’s Indigenous Health Subsystem
• Brazil has a strong legal framework for social
accountability in health, and specific provisions for
indigenous participation in the accountability structures of
the Indigenous Health Subsystem, established in 1999
after vigorous social movement campaigns
• The Subsystem performed very poorly over its first
decade, with problems of corruption and mismanagement
contributing to the fact that in 2008 the indigenous IMR
remained 3 times higher than the national average
despite per capita spending 5 times higher
• Indigenous movement organisations participated
actively in official social accountability structures, but calls
for changes to the health care model went unheeded
• Indigenous protests became increasingly unruly in
2008-10 until the government agreed to create a new
Special Secretariat of Indigenous Health in the MoH
• However, problems of top-down management and over-
standardised services have worsened, and indigenous
frustration is building up once again.

10. Some issues for discussion
• Who should identify priority issues for government action? How can we
differentiate between interest group politics and community accountability?
• How can we construct partnerships that aren’t simply going to be
captured by powerful actors?
• To what extent are certain aspects of health and safety understood as
signposts of government legitimacy? How can we differentiate between
actions targeted at these issues from more bread and butter issues of
accountability?
• How do strategies for influencing and interacting with the state differ
depending on the type of health services?
• How can social accountability processes move from a focus on “using
and choosing” health services to “making and shaping” health policies?