Sparking, supporting and steering change: grounding an accountability framework with viewpoints from Nigerian routine immunization and primary health care government officials
Sparking, supporting and steering change: grounding an accountability framework with viewpoints from Nigerian routine immunization and primary health care government officials
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DOI：
10.1093/heapol/czw057
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发表时间：
2016-11-01
影响因子：
3.2
通讯作者：
Wonodi, Chizoba
中科院分区：
文献类型：
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作者：
George, Asha S.;Erchick, Daniel J.;Wonodi, Chizoba
尼日利亚现有的问责工作主要是追溯性警务。为了使问责制能够前瞻性和先发制人地指导变革，我们根据文献综述制定了一个框架，该框架强调卫生系统问责制沿着三个平衡轴相辅相成的维度。权力轴心通过挥舞“大棒”来遏制潜在的权力滥用，同时也通过提供“胡萝卜”来激励建设性机构，从而引发变革。能力轴通过为服务提供者提供正式规则来支持变革，这些规则适当地扩大了他们的行动权力，同时也提供了非正式的规范和投入以提高绩效。最后，正义轴心引导变革的战略方向，平衡政治代表性、社区所有权和社会公平，使问责措施具有渐进性，而不是被自身利益所俘获。我们咨询了尼日利亚政府官员，了解他们对问责制的看法，并将他们的反应与我们不断发展的框架结合起来。参加三个关于常规免疫的区域研讨会的所有政府官员（n = 36）都填写了调查问卷，其中列出了加强问责制的三大机遇和挑战。按主题编码的答复强调了能力和权力轴内的问责制维度：澄清正式角色和责任；透明度、数据和监测系统；拥有受激励和监督的熟练卫生人员；解决非正式规范和行为；以及有关资金和供应的投入的可用性。问责制的其他方面也被提及，但从他们的观点来看，这些方面并不那么重要：管理自由裁量权；制裁和执法；政治影响力和社区参与。引人注目的是，几乎没有受访者提到社会公平是问责制的一个重要方面，尽管少数受访者提到了反映社区观点的广泛发展问题。将问责制重新定义为激发、支持和引导变革的一种手段，可以突出卫生系统需要改革的不同方面，特别是取决于所咨询观点的立场。
Existing accountability efforts in Nigeria primarily serve as retrospective policing. To enable accountability to guide change prospectively and preemptively, we drew from a literature review to develop a framework that highlights mutually reinforcing dimensions of accountability in health systems along three counterbalancing axes. The axis of power sparks change by wielding 'sticks' that curb the potential abuse of power, but also by offering 'carrots' that motivate constructive agency. The axis of ability supports change by enabling service delivery actors with formal rules that appropriately expand their authority to act, but also the informal norms and inputs for improved performance. Last, the axis of justice orients the strategic direction of change, balancing political representation, community ownership and social equity, so that accountability measures are progressive, rather than being captured by self-interests. We consulted Nigerian government officials to understand their viewpoints on accountability and mapped their responses to our evolving framework. All government officials (n = 36) participating in three zonal workshops on routine immunization filled out questionnaires that listed the top three opportunities and challenges to strengthening accountability. Thematically coded responses highlighted dimensions of accountability within the axes of ability and power: clarifying formal roles and responsibilities; transparency, data and monitoring systems; availability of skilled health personnel that are motivated and supervised; addressing informal norms and behaviours; and availability of inputs regarding funding and supplies. Other dimensions of accountability were mentioned but were not as critical from their viewpoints: managerial discretion; sanctions and enforcements; political influence and community engagement. Strikingly, almost no respondents mentioned social equity as being an important aspect of accountability, although a few mentioned broad development concerns that reflected community perspectives. Reframing accountability as a means of sparking, supporting and steering change can highlight different dimensions of health systems that need reform, particularly depending on the positionality of the viewpoints consulted.