Last week, between 80-90 researchers, practitioners, advocates and policymakers gathered for a three-day workshop organised by the IDS Accountability for Health Equity programme. Entitled Unpicking Power and Politics for Transformative Change: Towards Accountability for Health Equity, the event was hosted in collaboration with Unequal Voices, Future Health Systems, the Open Society Foundations, the Impact Initiative, and Health Systems Global. In this blog, Tom Barker and Karine Gatellier share their reflections from the event.
People’s ability to experience good health, including their access to health services, is often hindered by complex politics and power dynamics. This is especially the case for poor and marginalised people.
During the workshop we explored how power shapes exclusion/inclusion when it comes to health services, priority-setting, how to map accountability relations from the local to the global levels, and how to bridge research and practice in order to build more equitable and accountable health systems.
The agenda was designed to challenge participants, who came from different sectors, disciplines and domains, to learn from one another to help shape accountable institutions and processes.
We discussed the following key issues:
- Ways that intersecting forms of inequality are shaped by power relations
- Implications of the spread of health markets
- The influence of longer-term historical factors in shaping current accountability relations
- The challenge of connecting civil society-led accountability initiatives with formal oversight and audit structures
- The roles of technology and knowledge intermediaries in linking researchers, community organisations and policy actors.
Dimensions shaping accountability relations, processes and institutions
During the workshop, participants identified a number of important dimensions that shape accountability relations, processes and institutions: history, language, knowledge and evidence, technology, context, institutions, interest and ideology, and power and politics.
History
Historical struggles for justice and freedom create a sense of health rights that can support contemporary struggles for accountability, or, perhaps may no longer fit with the realities of the present and future.
Key historical moments, such as the Alma Ata Declaration (PDF), which has its 40th anniversary next year, leave an important legacy.
However, in a contemporary world where new economic powers and non-state actors have emerged, history can trap our thinking in patterns that no longer fit.
Language
It is important to understanding when and how language has constructed many different meanings of accountability. Language can be used to avoid genuine accountability, or as a creative resource for challenging accountability.
Knowledge and evidence
Factors such as ideology and political power determine whose knowledge counts. We need to create space for different forms of knowledge to help us shape strong and meaningful accountability relations. This means we must go beyond research generated by research, and also look the knowledge of communities and practitioners on the frontline.
Technology
Technology can be useful a tool but it is not on its own, a ‘magic bullet’ for accountability. In addition, we must question the accountability of actors driving technological and data innovations, and better understand that different attitudes towards and experiences of technology, including between generations, can influence its utility.
Institutions
Moving to a politics of mutual accountability requires participatory spaces, compacts and bargains that bring together rights and responsibilities, including for citizens and communities. Institutionalising accountability relations is essential for scale and sustainability, but this can be hard. It may depend on sectoral or local champions whose positions and influence can often change. Institutionalisation is more about fostering a culture of accountability within organisations and societies than about laws, structures, norms or procedures.
The importance of values
When it comes to identifying the most promising ways forward, we need to understand which relationships and processes really matter for accountability to contribute to health equity. In seeking to do identify what really matters, we also need to think about the importance of values. People do not just want health systems that prevent or treat ill health. They want to be treated fairly and with dignity.
Towards accountability for health equity
During the workshop, participants were challenged to take actions and build alliances. They proposed collaborations between networks to ensure solidarity with those who are on the front line of struggles for accountability, to facilitate the strengthening of interdisciplinary approaches, and to mobilise diverse forms of knowledge for action.
Building on the agenda discussed in the workshop, the IDS Accountability for Health Equity programme will be working with partners to:
- develop conceptual framings and generate empirical evidence on social, political, managerial and market dimensions of accountability in health systems;
- co-design methods for accountability mapping, and power and political economy analysis for health equity;
- trial and test local accountability interventions to assess their effectiveness and applicability in particular contexts; and whether they could be taken to scale;
- broker, influence, and inform changes in policy and practice to enhance health systems accountability in different contexts;
- create new opportunities to convene actors from different geographies, disciplines and sectors to facilitate exchange and mutual learning on shared challenges and effective strategies for strengthening accountability for health equity.