4 Ways to Boost Accountability for Better Health Services in Asia

A rural health worker in Bangladesh using a tablet to register a household and tracking services they have received.
A rural health worker in Bangladesh using a tablet to register a household and tracking services they have received.

By Kirthi Ramesh

Addressing accountability opens the doors for wider governance reforms for stronger health systems in Asia and the Pacific.

Many years ago, I accompanied the mobile ambulance of a local NGO in a remote rural area in India. After a 4-hour ride through a dense bamboo forest, we arrived in a community where a young woman was suffering from severe post-labor pain and bleeding. Without transportation there was no way she could get to a place for treatment and the next health facility was miles away. We took her with us, and hours later she was treated at a hospital run by the NGO. If it was not for the goodwill of the organization, the girl would probably not have survived.

Elsewhere, women may have access to family planning, skilled birth attendance or antenatal care, but that does not necessarily mean that they know which services they are entitled to, and what quality they can expect. I remember a woman who was fully covered by a social health insurance package that covered catastrophic expenditure, but when she arrived at the hospital she was informed about additional payments for a gynecological surgery.

Accountability requires decision-makers and health service providers to provide information and justify their decisions and actions with regard to their mandated duties. The (often silent) assumption is that combined with voice and enforcement mechanisms, this will in turn improve health services. Patients should get clear information about their rights and access to channels to report problems and demand official responses, ideally in form of improved services or sanctions for non-compliance. Receiving feedback from patients and monitoring service providers and governments help reduce failures in coverage, low quality of care, and misuse of funds.

The adoption of the Sustainable Development Goals (SDGs) presents a renewed opportunity to hold governments and service providers to account for their health commitments. At the recent Inter-Country Conference on Measurement and Accountability held in Dhaka, Bangladesh, participants discussed how to strengthen accountability for better and more equitable health care and for achieving the SDGs. I gathered four ways we can engage in to boost accountability:

  1. Information and transparency are important prerequisites. The data revolution makes information on the performance of health systems more available to governments, service providers and citizens, but we need aligned investments to enhance data quality and availability, and work toward integrating fragmented health information systems. Leveraging the data revolution for accountability also means reaching a wider public, and ensuring external verification to avoid performance exaggeration. We must enable governments to produce data that is relevant and actionable, and ensure there are means to make complex data comprehensible for those who will be using it.
  2. While information is crucial, it is not enough. A variety of accountability mechanisms need to be in place to hold governments and service providers accountable, and—going a step further—sanctioning them for non-compliance. Demand-side or citizen-led social accountability mechanisms such as citizen report cards or community oversight committees allow monitoring government or service provider performance but also ensure that patients have a possibility to give feedback about the quality of services delivered. Complementing supply-side or state-led accountability mechanisms that facilitate voice and incentivize governments and service providers to be responsive are also necessary. These can include legislative frameworks such as Information Acts but also strengthening existing checks and balances including institutions such as anti-corruption offices or regulatory agencies involved in setting and monitoring quality standards through licensing and accreditation of health care providers.
  3. Investments in digital mHealth and eHealth solutions enhance transparency and accountability. They are cost effective tools that allow for timely data collection and processing, reaching hard-to-reach populations, facilitating data visualization and dissemination and enabling citizen voice. Bangladesh is currently piloting a variety of ICT solutions such as using mobile phones to channel complaints of patients, data dashboards to visualize complex data for monitoring and decision-making, and GIS mapping of geographic health inequalities across constituencies.
  4. Innovative financing mechanisms like results-based lending—when carefully designed—can strengthen accountability. By making disbursements contingent on governments reporting progress on their health commitments, governments and service providers can be incentivized and resourced to be more responsive to meeting health targets and addressing patient’s needs.

I left the conference excited about the possibilities of leveraging the digital and data revolutions to hold health care systems to account. We cannot, however, expect technology to do our work for us. Accountability requires us to take a closer look at health and non-health actors, institutions and rules. Besides addressing the capacity and resource requirements we need to understand the incentives that will encourage decision-makers and service providers to be more responsive to citizens’ health needs. We must also consider the enabling environment and the kind of data that citizens should have to hold decision-makers and service providers accountable. Addressing accountability thus opens the doors for wider governance reforms for stronger health systems.