What does accountability for health equity mean in southern Africa?

11 December 2017

In July 2017, I attended the Institute of Development Studies (IDS) conference ‘Unpicking Power and Politics for Transformative Change: Towards Accountability for Health Equity’. The conference examined the practices and politics shaping accountability in health systems from local to global levels. As a southern African, I have some reflections on some of the conversations that took place at the event.

Cynthia Ngwalo-Lungu presents at the Accountability for Health Equity Conference

Accountability for health equity is essentially about citizens being able to hold governments to account to deliver health for all. It is about inclusivity and ensuring better health for the less privileged, marginalised and vulnerable people. 

The state of health accountability and inequity in the Region

It is commonly known that within Southern Africa public sector financing for health is meagre and below the 15 per cent committed to in the Abuja declaration. People in need struggle to access healthcare. In some countries people walk up to 30 km to get to the nearest health centre, only to find that it does not have the basic resources to function. 

In countries where the health system has largely been privatised it can be virtually impossible for poor communities to afford healthcare. This situation is worsened when there is abuse of resources, a lack of transparency in health management, a lack of public information on health budgets and expenditures and when budget and policy processes are centralised in a top down approach that allows for little or no citizen participation in decision-making. 

The reality of accountability 

In response, the region has seen a rapid development of social accountability initiatives that trigger active citizenship, where communities actively participate in health decision-making and hold governments to account on how resources are mobilised and used. The Centre for Civil Society Capacity Building, a Mozambican organisation, recounted how  social accountability initiatives have been used to not only improve transparency and accountability in health but have also to a certain extent influenced the development of national formal health accountability mechanisms in which citizens influence decision making and provide feedback using scorecards. 

While these efforts have achieved varying positive outcomes, they often tackle ‘low hanging fruit’, addressing local challenges like health worker attitudes or cleanliness within the vicinity of health facilities, thereby bringing about change in local practice. While these changes are commendable, they are often tied to project timelines, are localised and often do not trigger national level changes. 

Community level initiatives have struggled to address more systemic challenges, such as access to information, budget setting or expenditure tracking and bottlenecks in procuring and supplying medicines. Many argued at the conference that this is because social accountability efforts have failed to respond to higher level constraints affecting the ability of local service providers to respond to community feedback. 

Much more broadly, social accountability initiatives have in some cases failed to recognise the complex power dynamics that are typical of health systems. Social accountability efforts ought to engage with power if they are to bring about equity and social justice, otherwise, there is the risk that initiatives will simply replicate existing social hierarchies. 

Creating accountability for the long-term

Another factor affecting these social accountability initiatives is sustainability and ability to outlive short-term project timelines. There is a need to cultivate an active citizenship that raises voice to point out accountability concerns without relying on external drivers. Given the weaknesses in general environments to support this, we need to recognise and explore the role of formal structures for accountability in health, notwithstanding their pitfalls. This implies critically considering the extent to which the community voice can be integrated with local level formal accountability structures without being compromised or ‘swallowed’ by them. 

In the Northern part of Malawi, for example, the Catholic Commission for Justice and Peace has cultivated an active citizenship that engages within the formal mechanisms in health, as a form of structured and sustainable citizen engagement with the health system.

Social accountability initiatives should respond to particular contexts. For example, in the case of politically charged states within southern Africa, communities and civil society pushing for health rights and social justice are often tackling a wide range of issues that may confront power and carry unintended political connotations. 

Traditional social accountability tools and approaches which work in democratic and participatory environments may not be useful in politically charged contexts where  social accountability proponents become human rights defenders who need a unique set of skills to pursue issues without risking their own lives and security. Such environments call for unique capacities, language, strategies and mechanisms to achieve results without exacerbating conflict. 

Protecting the public interest when the private sector are involved 

While many of these initiatives appear to focus on public sector services, there are other non-state and private for profit actors involved in the delivery of healthcare. Across the region health has attracted markets and business operators resulting in a range of providers including public -private –partnerships (PPPs). How do we ensure that in the face of a growing private sector, public interests continue to take centre stage as a means to achieving equity in health? What mechanisms can be used to hold these private actors to account on social goals and health needs, when their preoccupation is with profit margins and ‘fair returns’? 

Lessons from the negative effects of pluralistic health markets in other countries, such as Mongolia, can be used by the region to inform the development and implementation of sound regulation of the ‘business of health’ and to ensure that PPP’s and health financing schemes including health insurance are developed and implemented in an accountable manner and in line with equity goals. 

These are significant challenges, but there are also opportunities to strengthen accountability through innovation. Despite low internet access and high telecommunication charges in some parts of the region, information technology is spreading. Throughout the region, technology is fast becoming a powerful tool in pushing for social economic rights- with the click of a button communities can voice public health concerns or access critical health sector information. With these tools, the means to accountability for transformative change may indeed lie in people’s hands!


Cynthia Ngwalo-Lungu is a Development Specialist with over 10 years’ experience in health, sexual rights and diversity, governance, HIV and AIDS, gender and child rights. She holds a Masters Degree in Business Administration from The University of Wales, United Kingdom and a Bachelor’s Degree in Humanities for The University of Malawi, Chancellor College. She is currently the Programme Manager for Equitable Access to Health within the Economic and Social Justice Cluster at The Open Society Initiative  for Southern Africa (OSISA).

This blog reproduces with permission and minor amendments an editorial by the author in the EQUINET Newsletter – December 2017


Photo credit: Institute of Development Studies, 2017

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