Strengthening accountability to improve health outcomes

Published on 10 September 2020

​​​​​​​This learning session, held on the 10th September, provided participants with practical tools to understand and tackle accountability to improve health outcomes. It illustrated the use of these tools through several examples to demonstrate what can be done to encourage better accountability. Different contexts (How fragile? How decentralised? What programmatic aims?) lend themselves to different ways of improving accountability – options include working with regulatory bodies, supporting parliamentarians, bolstering decentralised functions, and challenging the status quo of government/CSO relationships. It was delivered as part of the Health Systems Strengthening Learning Journey, which aims to support FCDO’s (formerly DFID’s) understanding, capacity and influence in strengthening health systems to improve the health and well-being amongst the poorest and marginalised in low- and middle-income countries. This session involved a combination of content delivery with trainee participation and interaction.​​​​

Why this session now?

Governance and accountability can seem like abstract notions – but in fact they are at the heart of implementation. If something that is supposed to happen does not happen, there is generally a problem with governance and accountability. COVID-19 has laid bare the practical importance of these concepts. Whose fault is a weak K4D Health Systems Strengthening Learning Journey Session response? What is the role of professional organisations and trade unions? How does the pandemic affect government/CSO transactions in fragile situations?

More generally, why does accountability warrant a specific mention in one of the SDGs? Why do the SDG 16 logos refer to violence, the rule of law, corruption, and the importance of transparent institutions?
Previous Learning Journey sessions have explored political economy analysis (understanding the wider context as a necessary step in thinking through the influences on what makes change happen) and improving quality of care (identifying mechanisms to make change happen). This Governance session – with its spotlight on Accountability – logically follows because it will focus on how to identify weaknesses in Accountability and a range of ways to improve accountability as a necessary part of the route to better health outcomes.

Learning objectives

  1. To explain what accountability in the health sector is, and provide relevant, useable tools and frameworks
  2. To illustrate the tools and frameworks with health-related examples
  3. To illustrate accountability and its challenges in FCAS
  4. To demonstrate the value of a dialogue between governance and health professionals.

Supporting Resources


  1. Health governance: concepts, experiences and programming options

Brinkerhoff D and Bossert T | 2008 | USAID Health Systems 20/20 project.

This is a classic which has stood the test of time. The Tables act as useful checklists and the article includes the “Health Governance Framework” (otherwise known as the Accountability Triangle), Figure 1 on page 7, which we will refer to extensively in the session.

  1. In Brief: Evidence on the role of social accountability in advancing women, children and adolescents’ health

Hurd S et al | 2020 | Global Health Visions.

An up-to-date reference with extensive links to relevant examples.


How motivation can fix public systems
Gopalka, Abhishek | | 2019 | TED Talk

If you’d like to watch a TED Talk this provides food for thought, even if you end up shouting at your screen that it’s not that simple.

Macro evaluation of DFID’s policy frame for empowerment and accountability
Holland J and Schatz F | 2016  

A long academic read, but well worth browsing. The section Key takeaways for DFID practitioners (Table 6.1 page 90) is recommended, as is the discussion of the “Accountability Trap” (section 2 from page 22) in which local accountability-bolstering activities are not sustained or effective because they are not linked in a strategic way to the higher levels of the institutions which need to change.

Three World Bank Reports have featured extensive discussions of accountability: the 2004 Report did much to raise interest in Accountability in global health circles and extensively used the Accountability Triangle:

Making services work for poor people
World Bank Report 2004

Conflict, security and development
World Bank Report 2011

Governance and the law
World Bank Report 2017

WHO’s Country Assessment Framework and index of country examples can be found at:

Session providers

Session 3 will be delivered by Dr Catriona Waddington, Global Practice Leader for Health/Health Economist, Mott MacDonald and Dr Steve Commins, Associate Director, Global Public Affairs, Luskin School of Public Affairs, UCLA and facilitated by Dr Shehla Zaidi, Associate Professor of Health Policy, Aga Khan University.


More information on the K4D Health Systems Strengthening Learning Journey can be found here.


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