doi:10.

1093/heapol/czh052
HEALTH POLICY AND PLANNING; 19(6): 371379

Health Policy and Planning 19(6),

Oxford University Press, 2004; all rights reserved.

Accountability and health systems: toward conceptual clarity

and policy relevance
DERICK W BRINKERHOFF
Research Triangle Institute, Washington, DC, USA

Key words: accountability, health systems, performance improvement

Introduction
Around the world governments face pressures to provide
health services effectively, efficiently and equitably. Reform
and strengthening efforts in industrialized and
developing/transitioning countries have adopted similar
approaches to getting health systems to perform better:
downsizing, privatization, competition in service delivery,
performance measurement and indicators, and citizen
participation (see, for example, McPake and Mills 2000). All
these approaches converge in emphasizing accountability as
a core element in implementing health reform and improving system performance.
The current concern with accountability and health systems
reflects several factors. First is dissatisfaction with health
system performance in both industrialized and
developing/transitioning countries. Discontent has focused
on costs, quality assurance, service availability/access, equitable distribution of services, abuses of power, financial
mismanagement and corruption, and lack of responsiveness.
Secondly, accountability has taken on a high degree of
importance because the size and scope of health care bureaucracies in both the public and private sectors accord health
system actors significant power to affect peoples lives and
well-being. Further, health care constitutes a major
budgetary expenditure in all countries, and proper accounting for the use of these funds is a high priority.
All health systems contain accountability relationships of
different types. Health ministries, insurance agencies, public
and private providers, legislatures, finance ministries, regulatory agencies and service facility boards are all connected
to each other in networks of control, oversight, cooperation
and reporting. However, the accountability interests of these

actors vary. For example, legislatures have quite a different

accountability focus from that of health regulatory agencies.
The former are interested in clear accounting for the use of
taxpayer resources as well as demonstrating responsiveness
to their constituencies. The latter are primarily interested in
whether providers meet procedural and quality standards.
Health ministries combine a wide variety of accountability
concerns. If the ministrys mandate includes paying
providers, there is usually a unit responsible for payment for
services, with an accountability focus on financial accounting
and value for money. The health ministry also has policy
responsibility and thus has accountability interests and pressures related to public health outcomes and issues.
Frequently, it is the perception of failed or insufficient
accountability that furnishes the impetus for change. For
example, among the rationales for health sector decentralization reforms is the need to establish stronger accountability linkages among citizens, policymakers and service
providers. Hutchinson et al. (1999, p. 103) note this dynamic
in Ugandas reform; prior to the creation of decentralized
health committees, . . . citizens unhappy with the performance of health workers or priority setting by local politicians
had few mechanisms for redressing their grievances or
improving services.
Uganda is just one example of how accountability is front and
centre on the stage of current health system improvements
and policy prescriptions. However, as a guide to the specifics
of what to do to improve health systems, simply calling for
more accountability is less than helpful. On the surface, the
notions of checks and restraints on power and discretion, of
increased oversight and scrutiny, or of closer connections
between service users and providers seem straightforward.
However, for accountability to inform policy and

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Improved accountability is often called for as an element in improving health system performance. At first
glance, the notion of better accountability seems straightforward, but it contains a high degree of complexity. If accountability is to be more than an empty buzzword, conceptual and analytical clarity is required. This
article elaborates a definition of accountability in terms of answerability and sanctions, and distinguishes
three types of accountability: financial, performance and political/democratic. An analytic framework for
mapping accountability is proposed that identifies linkages among health sector actors and assesses capacity
to demand and supply information and exercise oversight and sanctions. The article describes three accountability purposes: reducing abuse, assuring compliance with procedures and standards, and improving
performance/learning. Using an accountability lens can: (1) help to generate a system-wide perspective on
health sector reform, (2) identify connections among individual improvement interventions, and (3) reveal
gaps requiring policy attention. These results can enhance system performance, improve service delivery
and contribute to sound policymaking.

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Derick W Brinkerhoff

programmes effectively, further conceptual work needs to be

done. Calls for more accountability are often efforts by interested actors to change the focus and purpose of accountability, rather than simply to do more of the same (Romzek
2000, p. 35). Accountability risks becoming another
buzzword in a long line of ineffectual quick fixes, or, worse,
a one-size-fits-all bludgeon that encourages excess and overregulation.

Defining accountability
Despite its popularity, accountability is often ill-defined. For
example, Mulgan (2000, p. 555) calls accountability a
complex and chameleon-like term. As Schedler (1999, p. 13)
notes, accountability represents an underexplored concept
whose meaning remains evasive [sic], whose boundaries are
fuzzy, and whose internal structure is confusing. General
definitions of accountability include the obligation of individuals or agencies to provide information about, and/or
justification for, their actions to other actors, along with the
imposition of sanctions for failure to comply and/or to engage
in appropriate action.
Answerability and sanctions
The essence of accountability is answerability; being accountable means having the obligation to answer questions regarding decisions and/or actions (see Schedler 1999). Two types
of accountability questions can be asked. The first type asks
simply to be informed; this can include budget information
and/or narrative description of activities or outputs. This type
of question characterizes basic monitoring and implies a oneway transmission of information from the accountable
actor(s) to the overseeing actor(s). The second type of
question moves beyond reporting of facts and figures, and
asks for explanations and justifications (reasons); that is, it
inquires not just about what was done but why. Justification
questions incorporate information transmission, but go
beyond to dialogue between the accountable and the overseeing actors. This dialogue can take place in a range of
venues, from internal to a particular agency (for example,
medical personnel answering to their hierarchical superiors),
between agencies (for example, facilities reporting to health
insurance funds), to more public arenas (for example, parliamentary hearings where health ministers answer to legislators, or community meetings where local health officials
answer to residents). The justification aspect of answerability
links to the World Health Organizations notion of

The availability and application of sanctions for illegal or

inappropriate actions and behaviour uncovered through
answerability constitute the other defining element of
accountability. The ability of the overseeing actor(s) to
impose punishment on the accountable actor(s) for failures
and transgressions gives teeth to accountability. Answerability without sanctions is generally considered to be weak
accountability. Most health policy sanctions are based upon
regulatory power, for example in the United States,
Medicares authority to levy fines on hospitals that improperly code patient discharges. The courts intervene with legal
sanctions to enforce accountability between provider and
patient, and patient and payer, but this relates to a different
level of accountability from the health system overall.
Other examples of regulatory frameworks that are intended
to create incentives and increase accountability include: (1)
licensing and accreditation of physicians, nurses, other
categories of health care providers, and facilities (for
example, Salmon et al. 2003); (2) health care financing and
payment schemes that link funding to the amount and quality
of services provided (see Maceira 1998; Gauri 2001); and (3)
quality assurance policies that establish standards and benchmarks, practice guidelines and compliance mechanisms to
improve quality of care, service utilization and client satisfaction (for example, Hermida and Robalino 2002). Accountability is achieved through the application of the laws,
standards and procedures these frameworks put in place,
which shape the incentives for various actors to comply.
Legal and regulatory sanctions are at the core of enforcing
accountability, but sanctions can be thought of more broadly.
They include, for example, professional codes of conduct,
which do not have the status of law. It should be noted that
some of the regulatory frameworks noted above include
normative elements similar to codes of conduct. Licensing
and accreditation, linked to human resource development,
often incorporate professional socialization to the norms and
values related to patient care and commitment to service.
Quality assurance emphasizes a set of core values, not simply
the achievement of service provision targets at a given level
of quality (see Silimperi et al. 2002). These kinds of incentives are intended to reward good behaviour and action and
deter bad behaviour and action, without necessarily involving recourse to regulatory enforcement.
Another category of such incentives relates to the use of
market mechanisms for performance accountability; these
underlie reforms to separate service provision from payment,
and to introduce privatization of, and competition among,
service providers. Health systems reform in many countries
seeks to establish these types of incentives often through
contracting (see Maceira 1998; England 2000). For example,
if public health clinics, under a capitated health services
contract system, are required to compete for clients on the

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This article focuses on accountability as it relates to health

systems and policy in developing/transitioning countries. The
analysis reviews and synthesizes the literature on the topic,
noting areas of convergence and of ongoing debate. The
article addresses the definition and clarification of accountability, examining how the term can be more precisely
defined and made more operationally relevant. It then offers
an analytic framework for accountability and health service
delivery systems that highlights the following questions.
What are the various purposes and targets for accountability?
What are the linkages among accountability actors, and what
is their capacity to exercise accountability?

stewardship in its contribution to government responsiveness and good governance (see Saltman and FerroussierDavis 2000; Travis et al. 2002). Further, such dialogue can
build citizen trust by signalling that government actors are
interested in citizens views and well-being (see Gilson 2003).

Accountability and health systems

basis of publicly available information on quality and
performance, accountability is enforced through the ability
of clients to switch from low quality/performing clinics to
high quality/performing ones. The ability of health clinic
users to hold clinics accountable by exercising their exit
option creates incentives for responsiveness and service
quality improvement (see, for example, Paul 1992). Of
course, as discussed further below, information asymmetry
poses a classic barrier in that clients may not have sufficient
information to judge quality and performance, and thus may
not demand the right kind of health care (Gauri 2001). This
can dampen the effectiveness of exit for accountability.

Sanctions without enforcement significantly diminish

accountability. Lack of enforcement and/or selective enforcement undermine citizens confidence that government
agencies are accountable and responsive, and contribute to
the creation of a culture of impunity that can lead public
officials to engage in corrupt practices. Enforcement
mechanisms are critical, from broad legal and regulatory
frameworks to internal facility monitoring systems. As
discussed below, institutional capacity is also important; the
best regulatory frameworks and enforcement mechanisms
will remain ineffective if there is not sufficient capacity
among the institutions with accountability roles (see, for
example, Standing and Bloom 2003). In health sector reform,
capacity-building efforts are directed at health ministries,
insurance funds, and accreditation and licensing boards. At
the facility level, hospital and clinic management systems
improvement can address accountability enforcement; and at
the local level, community empowerment initiatives often
target capacity to exercise oversight and to provide feedback
to service providers (for example, Cornwall et al. 2000).
A lively debate regarding enforcement concerns the extent
to which service delivery markets can be created such that
accountability is automatically enforced when poor quality
providers are eliminated as purchasers select higher quality,
more entrepreneurial providers.1 To deal with information
and expertise asymmetries, insurance fund agencies often
serve as the agents of individual citizens in negotiating with
providers. Through the terms of contracting arrangements,
funding agencies are able to require participating providers
to meet service and quality standards, and to report on costs

as well as a variety of other indicators, thus joining answerability and sanctions. Armed with this database, the agencies
can enforce both financial and performance accountability
through the negotiation of contract provisions and fees.
Accountability for what?
Defining accountability more precisely also relates to specifying accountability for what? Three general categories
emerge from answering this question. The first addresses the
most commonly understood notion of accountability, financial accountability. The literature in this area deals with
compliance with laws, rules and regulations regarding financial control and management. The second type of accountability is for performance. The literature here is arguably the
largest, encompassing public sector management reform,
performance measurement and evaluation, and service
delivery improvement.2 The third category focuses on
political/democratic accountability. Literature here ranges
from theoretical and philosophical treatises on the relationship between the state and the citizen, to discussions of
governance, increased citizen participation, equity issues,
transparency and openness, responsiveness and trustbuilding.
Financial accountability
Financial accountability concerns tracking and reporting on
allocation, disbursement and utilization of financial
resources, using the tools of auditing, budgeting and accounting. The operational basis for financial accountability begins
with internal agency financial systems that follow uniform
accounting rules and standards. Beyond individual agency
boundaries, finance ministries, and in some situations
planning ministries, exercise oversight and control functions
regarding line ministries and other executing agencies. Since
many executing agencies contract with the private sector or
with non-governmental organizations (NGOs), these oversight and control functions extend to cover public procurement and contracting. For example as noted above, insurance
fund agencies play a key role in financial accountability in
health systems that pay providers for predetermined
packages of basic services. As purchasers of services, these
agencies are able to use their clout to exercise sanctions for
financial accountability through contracting arrangements.
Provider payment systems can be important mechanisms for
enforcing increased financial accountability and cost control
among participating private providers (see Bovbjerg and
Marsteller 1998; Maceira 1998).
Legislatures pass the budget law that becomes the basis for
health ministry spending targets, for which they are held
accountable within the rules governing budget execution.
Accountability sanctions available to legislatures include
reductions in ministry funding, holding hearings on ministry
spending, and/or launching audit investigations. Obviously, a
critical issue for the viable functioning of financial accountability is the institutional capacity of the various public and
private entities involved. Health policymakers, for instance,
need the ability to track and compare drug prices across
various types of facilities to identify price variation that is not

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A related set of softer sanctions concerns public exposure

or negative publicity. This creates incentives to avoid damage
to the accountable actors reputation or status. For example,
investigative panels, the media and civil society watchdog
organizations use these sanctions to hold government
officials accountable for upholding ethical and human rights
standards. Self-policing among health care providers is
another example of the application of this type of sanction,
where professional codes of conduct are used as the standard
(see, for example, Cruess and Cruess 2000). However, in
many countries, the medical profession is a powerful actor
that tends more toward self-protection than self-policing.
The soft sanction of self-policing is insufficient for improved
accountability in the absence of transparency, informed
health service users and regulatory enforcement (Brugha and
Zwi 1998).

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Derick W Brinkerhoff

attributable to local cost factors. They also need the capacity

to detect and sanction malfeasance and corruption, for
example, procurement fraud, overbilling, falsified staffing
levels and so on (for example, Di Tella and Savedoff 2001).
At the facility level, for example, hospital managers need to
be able to account for the disposition of the funds they
receive from various sources, and to enforce compliance
from their staff.
Performance accountability

Political/democratic accountability
In essence, political/democratic accountability has to do with
ensuring that government delivers on electoral promises,
fulfils the public trust, aggregates and represents citizens
interests, and responds to ongoing and emerging societal
needs and concerns. As a result, effective political/democratic accountability enhances the legitimacy of government
in the eyes of citizens. The political process and elections are
the main avenues for this type of accountability. In many
countries, both developing and developed, health care issues
often figure prominently in political campaigns. Building
health facilities or providing affordable drugs can be attractive options for politicians in generating electoral support.
Elected officials and legislatures, then, are key to
political/democratic accountability, and through their oversight of ministers and other agency heads they link to the
health bureaucracy at various levels, depending upon the
extent of decentralization. As previously noted, a central
concern here is the highly political nature of health system
performance, particularly concerning the issue of equity. An
important government responsibility is to remedy health care
market failures both through regulation and resource allocation, which involves inherent tensions between economic

Political/democratic accountability also relates to building

trust among citizens that government acts in accordance with
agreed-upon standards of probity, ethics, integrity and
professional responsibility (Gilson 2003). These standards
reflect national values and culture, and bring ethical, moral
and on occasion religious issues into the accountability
equation at both agency and facility levels. For example, in
some countries, caring for the sick is a religious duty, and in
response health care providers feel an obligation to deliver
services. What this means for political/democratic accountability is that health systems whose providers reflect such
values can contribute to increased levels of citizen trust, not
simply in health care providers, but also in the states interest
in their welfare (see Tendler and Freedheim 1994).

Analyzing accountability and health systems

Applying the above classification of types of accountability
to health services delivery will develop a clearer picture of
what accountability issues emerge, and of where gaps,
contradictions and conflicts may lie. These issues can then be
assessed in terms of three purposes of accountability.3 The
first purpose is to control the misuse and abuse of public
resources and/or authority.4 This relates directly to financial
accountability. The second is to provide assurance that
resources are used and authority is exercised according to
appropriate and legal procedures, professional standards and
societal values. This purpose applies to all three types of
accountability. The third is to support and promote improved
service delivery and management through feedback and
learning; the focus here is primarily on performance accountability. These three purposes overlap to some extent, but in
some cases pursuit of one can lead to conflicts with another.
Perhaps the most recognized tension is between accountability for control, with its focus on uncovering malfeasance
and allocating blame, and accountability for improvement,
which emphasizes discretion, embracing error as a source of
learning, and positive incentives.
There are numerous challenges to achieving these accountability purposes in the health sector, as noted by a variety of
observers. Among these are the following. First, health
services are characterized by strong asymmetries among
service providers, users and oversight bodies in terms of
information, expertise and access to services. Regarding
information, central oversight bodies can experience difficulties in monitoring provider performance since providers
often control the necessary information (see, for example,
Millar and McKevitt 2000). Concerning expertise, for
example, service users may be ignorant of treatments and
medicines that could harm them, and thus need some form
of protection (Shaw 1999, p. 12). Regarding access,
providers can exercise significant gatekeeper power, for

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Performance accountability refers to demonstrating and

accounting for performance in light of agreed-upon performance targets. At the health system level, the focus is on the
services, outputs and results of public agencies and
programmes, not on individual service encounters between
patients and providers. Health system performance accountability is linked to financial accountability in that the financial resources to be accounted for are intended to produce
goods, services and benefits for citizens, but it is distinct in
that financial accountabilitys emphasis is largely on
procedural compliance whereas performance accountability
concentrates on results. For example, provider payment
schemes that maximize efficiency, quality of care, equity and
consumer satisfaction demand strong financial and management information systems that can produce both financial
and performance information. Performance accountability is
connected to political/democratic accountability in that
among the criteria for performance are responsiveness to
citizens and achievement of service delivery targets that meet
their needs and demands. As Saltman and von Otter (1995)
point out, however, there can be conflicting pressures
between the pursuit of efficient health system performance
and democratic principles of equitable service provision,
which in many countries has politicized the search for
accountability.

and social decision criteria (Saltman and van Otter 1995;

Bovbjerg and Marsteller 1998). In developing countries,
these tensions are exacerbated by a lack of resources and
capacity; even if government provides fiscal subsidies, facilities and caregivers are frequently maldistributed, poorly
equipped, and in rural areas, scarce or nonexistent (see
Bloom 2000).

Accountability and health systems

example, determining who receives what care, despite official
procedures. Health service users, especially the poor, are in
a weak position to confront this power.
Secondly, there are often divergences between public and
private interests and incentives, which can constrain efforts
to increase accountability (see Bennett et al. 1997). For
example, Shaw (1999) notes differences between public and
private sector providers in terms of the extent to which they
receive and face incentives to act upon service user feedback.
The difficulties of creating performance incentives for public
sector providers insulated from client accountability are well
recognized (see, for example, Goetz and Gaventa 2001), as
are the challenges facing incentives design for the private
sector (see Bennett et al. 1997; Brugha and Zwi 1998).

Thirdly, institutional capacity gaps often constrain or undermine efforts to increase accountability for all three purposes.

The inability of health facilities to track and report on

budgets, collection of fees, pharmaceutical purchases and
supply inventories, vehicles and equipment, and so on, limits
possibilities for accountability for control and assurance
purposes. It results in waste in the health system and can
create fertile ground for corruption. Further, weak capacity
to exercise oversight of facility and practitioner performance
hampers efforts at accountability for the purpose of performance improvement. This capacity gap is aggravated by the
difficulty in isolating the contributions of various health
system actors to achieving performance goals. Many
developing/transitioning countries that have moved away
from predominantly public provision of health care toward
private sector models have weak regulatory capacity, making
it difficult to exercise quality assurance (see Standing and
Bloom 2003).
Disparities between the sanctions that exist on paper and
capacity to enforce them pose equally serious accountability
problems. Facilities that lack the ability to identify who
works there, where they are at a given time, and what they
are doing cannot take the first steps toward holding staff
accountable for performance. Insurance funds that are
unable to develop a database on costs of care that can inform
negotiations with private providers cannot use contracts as
an effective sanction for either financial or performance
accountability.
Table 1 presents illustrative health system issues associated
with the three types of accountability: financial, performance
and political/democratic. It identifies the dominant purposes
of accountability associated with these issues: controlling
abuse, assuring conformity with standards and norms, and

Table 1. Accountability types, purposes and health service delivery

Type of accountability

Illustrative health system issues

Dominant purposes of accountability

Financial

Cost accounting/budgeting for:

Personnel
Operations
Pharmaceuticals/supplies
Definition of basic benefits packages
Contract oversight
Allocation of resources needed for effective system
performance
Quality of care
Service provider behaviour
Regulation by professional bodies
Contracting out

Control and assurance are dominant.

Focus is on compliance with prescribed input
and procedural standards; cost control; resource
efficiency measures; elimination of waste, fraud
and corruption.

Performance

Political/democratic

Service delivery equity/fairness

Transparency
Responsiveness to citizens
Service user trust
Dispute resolution

Assurance and improvement/learning are

dominant.
Assurance purpose emphasizes adherence to the
legal, regulatory, and policy framework; professional
service delivery procedures, norms, and values;
and quality of care standards and audits.
Improvement/learning purpose focuses on
benchmarking, standard setting, quality
management, operations research, monitoring and
evaluation (M&E).
Control and assurance purposes are emphasized.
Control relates to citizen/voter satisfaction, use of
taxpayer funds, addressing market failure and
distribution of services (disadvantaged populations).
Assurance focuses on principal-agent dynamics for
oversight; availability and dissemination of relevant
information; adherence to quality standards,
professional norms, and societal values.

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Another divergence of public versus private interests arises

between policymakers focused on assuring some minimum
level of care available to all and individual service users with
an interest in receiving the maximum amount of care necessary to address their health need. This divergence can influence accountability enhancement in that it creates conflicting
demands for accountability. At the system level, accountability is targeted at allocative decisions and the institutional
arrangements to assure resources allocated are used appropriately. At the service provider level, the accountability
relationship is between patient and provider, and the grounds
for accountability focus on the quality of service, professional
ethics, and not the cost (see, for example, Emmanuel and
Emmanuel 1996; Fuchs 1996).

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Derick W Brinkerhoff
governance and institutional structures: for example,
national, district and local health councils; hospital boards;
medical review boards and professional certification bodies;
decentralization, and so on (see, for example, Mills 1994;
Savage et al. 1997; Gershberg 1998; NPPHCN 1998; Salmon
et al. 2003). In the health economics and financing literature,
as noted above, accountability implications can be identified
in the context of analyses of health care markets, principalagent issues arising from information asymmetries, publicprivate mix, demand-driven services and user fees,
priority-setting, and separation of payment from provision.5
Accountability also figures, sometimes implicitly, sometimes
explicitly, in the quality assurance/quality improvement
literature.6

supporting improved performance/learning. This creates a

framework for categorizing and taking stock of health system
reforms in terms of accountability.
A focus on accountability can lead to an increased understanding of health system operations, clearer identification of
the pressures and incentives facing health system actors, and
better reform design and implementation. This systemic
focus helps to identify factors that influence the success
potential of interventions intended to achieve one or another
of the three purposes. For example, tackling corruption in the
health sector is not likely to be sustainable without some
degree of political/democratic accountability, which creates
and strengthens the incentives for health policymakers to
respond to citizens needs and demands.

Mapping accountability linkages

Figure 1 offers an assessment matrix to map accountability
linkages and to examine actors interactions. The matrix
tracks the patterns of answerability and sanctions in terms of

Supply information, respond to sanctions

Health svc users/patients

MOH
Agencies of restraint
Funding agencies
Parliament
Local govt officials
NGOs
Hospital boards
Health councils
Professional associations
Unions
Health care providers
International donors

Code:
Capacity to supply information or respond to sanctions: Weak , Medium , Strong
Capacity to demand information or impose sanctions: Weak , Medium , Strong

Figure 1. Health sector actors accountability matrix

International donors

Health care providers

Unions

Professional assoc

Health councils

Hospital boards

NGOs

Local govt officials

Parliament

Funding agencies

Agencies of restraint

Health sector actors

MOH

Health svc users/

patients

Demand information, impose sanctions

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Once types and purposes of accountability have been

unpacked, a next step in integrating a focus on accountability
into health policy and systems strengthening is to develop a
clearer picture of accountability relationships and connections. This begins with enumerating a list of health system
actors, and then proceeds with mapping the linkages among
them.

However, few policy designs and strategies for health sector

reform and system strengthening use accountability as an
integral theme. Rather, they focus on one or another aspect
of health system reform, and treat accountability (if
mentioned at all) as a secondary or corollary dimension. For
example, there is a large literature on community participation in health services reform and delivery, some of which
notes that among the rationales for, and results of,
community participation is increased targeting of services on
community needs and more accountability (see, for example,
Cornwall et al. 2000). Another topic area where accountability issues are mentioned concerns health system

Accountability and health systems

which actors are in a position to demand information and
impose sanctions, and which actors are charged with
supplying information and are subject to sanctions. To
adequately capture the complexity of accountability linkages,
separate tables for answerability and sanctions would be
prepared, which would take into consideration the distinctions between these two elements of accountability and the
different implications for the design of system improvements.
For reasons of economy, Figure 1 illustrates both information
demand/supply and sanctions on a single table.
The table(s) can indicate situations where there are either
two few or too many accountability linkages. There is no
universally correct number of accountability linkages. How
many linkages are appropriate will, to an important extent,
be situation-specific, and will depend upon the quality, not
simply the number, of connections. Nonetheless, the literature and experience suggest the following:

As the code for the table indicates, these supply and demand
linkages can be rated as strong, medium or weak. The
downward arrows indicate capacity to demand information
or impose sanctions. The horizontal arrows show capacity to
supply information or respond to sanctions. Effective
accountability systems will exhibit a high number of boxes
with both downward and horizontal arrows, indicating that
demand for information is adequately met by supply. For
example, systems with a preponderance of downward arrows
without corresponding horizontal ones suggest several
possible problems: mistargeted accountability demand, inadequate response capacity, and/or disagreements over appropriate linkages.
These ratings seek to capture information on the capacity of
the various actors to fulfil their accountability roles, the
pattern of accountability relationships, and the relative
strength or weakness of the accountability chains that
connect them. For example, health ministries may have a
legal mandate for budgetary oversight of public health facilities expenditure and collection of user fees, but in many
countries their ability to exercise that accountability function
is substantially limited (Russell et al. 1999). Regulators are
often another set of actors with weak capacity (Standing and
Bloom 2003). For a particular country, the tables should be
customized by including the specific array of actors in each
of the categories, and/or by tracing the linkages for different

types of accountability, for example financial versus service

delivery performance.
Building on the matrix/matrices, next steps would include
identification of problems/issues related to answerability and
sanctions, and of which types of accountability (financial,
service delivery performance, political/democratic) are
involved. Such analysis would inform appraisal of actors
capacity to fulfil accountability roles, help to pinpoint gaps,
and feed into setting purposes and targets. When undertaken
as a team effort, the mapping exercise could also serve to
support the process dimension of achieving change targets. It
could forge consensus among reform team members, as well
as point to who else needs to be involved. Strategy implementation will depend upon tapping the shared interests of
various actors to build coalitions, commitment and mutual
understanding (see Gilson 1997; Gilson et al. 1999; Brinkerhoff and Crosby 2002). Clarifying actors connections, capacities and interests is a key input for developing strategies to
strengthen accountability.

Conclusions
Increasing accountability is a key element in a wide variety
of policies and reforms, from government-wide anti-corruption campaigns, to national-level health system reform
programmes, to decentralized health service delivery at the
local level, and community-based health funds. One of the
main reasons why this range is so broad relates to the interconnections among the various types and purposes of
accountability (see Table 1). Financial accountability quickly
leads to performance issues, and these two combined have
implications
for
political/democratic
accountability.
Accountability to curb abuse underlies accountability for
purposes of adhering to standards and of improving performance.
The accountability landscape is filled with a broad array of
actors with multiple connections; in some cases these actors
are both accountable to one set of actors while simultaneously exercising accountability with regard to another set
(see Figure 1). These connections create layered webs of
accountability with varying degrees of autonomy and sources
of control/oversight. For example, public providers, health
ministries, finance ministries, parliamentary health committees, insurance fund agencies and hospital boards are often
linked. This leads to intervention strategy issues, such as the
advantages or disadvantages of strengthening different nodes
in the web. For instance, efforts to increase the power and
autonomy of hospital boards to exercise expanded oversight
may not be effective if the health minister is not subject to
political accountability and can dismiss board members who
displease him/her with impunity. The configuration of
accountability actors and their capacities also highlights the
difficult issue of the gap between the ideal and the possible.
As countries move toward market-driven health systems, the
critical weaknesses in regulatory capacity, technical oversight, application of sanctions and availability of information
to service users can often undermine the hoped-for accountability improvements.

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Too few linkages can open the door to corruption, lack of

responsiveness, poor quality services, and evasion of
responsibility on the part of health service providers.
Too many linkages, particularly if they are distant or attenuated connections, can limit the effectiveness of accountability. When many actors, along with their differing
interests, are involved, health service provision risks not
being sufficiently accountable to anyone.
Linkages that are predominantly internal to the public
health bureaucracy and that connect upwards within the
hierarchy orient actors to the priorities and needs of
bureaucratic superiors rather than being accountable to
service users, particularly the poor.

377

378

Derick W Brinkerhoff

The analytic framework presented here represents an initial

effort to consider accountability from a systemic perspective,
with the intent to respond to calls for attention to how best
to regulate, supervise and monitor both public and private
sector providers and how best to encourage them to act in
the broader public interest (Mills 1998, p. 511). However, the
practical utility of the proposed framework in identifying,
measuring and improving accountability in health systems
remains to be demonstrated. Determination of what value it
adds must necessarily await field applications.

Endnotes

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Acknowledgements
Support for this research, conducted while the author was at Abt
Associates, is acknowledged from the U.S. Agency for International
Development, through the Partners for Health Reform Project,
Phase II (PHRplus). The views expressed are solely those of the
author and should not be attributed to USAID. The author thanks
Sara Bennett, Lucy Gilson, Charlotte Leighton, Mark McEuen,
Mary Paterson and Nancy Pielemeier for helpful comments.

Biography
Derick W Brinkerhoff is RTI Senior Fellow in International Public
Management at the Research Triangle Institute. He is a specialist in
policy analysis and implementation, strategic management and
public administration. He has worked extensively on administrative
and health systems reform in developing countries, concentrating on
decentralization, corruption, evidence-based policymaking and
public-private partnerships. Dr Brinkerhoff has published widely,
including six books and numerous articles and book chapters. He
holds a doctorate in social policy and administration from Harvard
University and a masters in public administration from the
University of California, Riverside. Prior to joining RTI, he was a
Principal Social Scientist with Abt Associates Inc. for 10 years, and
previously spent a decade on the faculty of the University of
Maryland at the International Development Management Center.
Correspondence: Derick W Brinkerhoff, Research Triangle Institute, 1615 M Street NW, Suite 740, Washington DC 20036, USA.
Email: dbrinkerhoff@rti.org

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