Open Access Research article

Resources, attitudes and culture: an understanding of the factors that influence the functioning of accountability mechanisms in primary health care settings

Susan M Cleary1*, Sassy Molyneux2 and Lucy Gilson34

Author Affiliations

1 Health Economics Unit, University of Cape Town, Cape Town, South Africa

2 KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya

3 Health Policy and Systems Division, University of Cape Town, Cape Town, South Africa

4 Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK

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BMC Health Services Research 2013, 13:320  doi:10.1186/1472-6963-13-320

Published: 16 August 2013



District level health system governance is recognised as an important but challenging element of health system development in low and middle-income countries. Accountability is a more recent focus in health system debates. Accountability mechanisms are governance tools that seek to regulate answerability between the health system and the community (external accountability) and/or between different levels of the health system (bureaucratic accountability). External accountability has attracted significant attention in recent years, but bureaucratic accountability mechanisms, and the interactions between the two forms of accountability, have been relatively neglected. This is an important gap given that webs of accountability relationships exist within every health system. There is a need to strike a balance between achieving accountability upwards within the health system (for example through information reporting arrangements) while at the same time allowing for the local level innovation that could improve quality of care and patient responsiveness.


Using a descriptive literature review, this paper examines the factors that influence the functioning of accountability mechanisms and relationships within the district health system, and draws out the implications for responsiveness to patients and communities. We also seek to understand the practices that might strengthen accountability in ways that improve responsiveness – of the health system to citizens’ needs and rights, and of providers to patients.


The review highlights the ways in which bureaucratic accountability mechanisms often constrain the functioning of external accountability mechanisms. For example, meeting the expectations of relatively powerful managers further up the system may crowd out efforts to respond to citizens and patients. Organisational cultures characterized by supervision and management systems focused on compliance to centrally defined outputs and targets can constrain front line managers and providers from responding to patient and population priorities.


Findings suggest that it is important to limit the potential negative impacts on responsiveness of new bureaucratic accountability mechanisms, and identify how these or other interventions might leverage the shifts in organizational culture necessary to encourage innovation and patient-centered care.

Accountability; Governance; Primary health care; Low and middle income settings