The Importance Of Public Accountability

Introduction

Public accountability has re-emerged as a top priority for health systems all over the world. Public accountability refers to

‘the spectrum of approaches, mechanisms and practices used by the stakeholders concerned with public services to ensure a desired level and type of performance’ (Paul

1991). Although there is a range of possible definitions of accountability, the essence is of answerability between sets of actors in relation to specific activities or interventions. Answerability can be enforced with either positive or negative sanctions, or internalized ethics such as codes of conduct (Standing 2004).

Direct engagement of the public, citizens or communities in accountability systems can be through ‘exit’ or

They also point to the importance of issues of legitimacy, representation and health system– community relations in community accountability. Overall, community accountability arguably moves beyond community participation in requiring the health system to be responsive to the issues raised through participation. In this context, ‘responsiveness’ can be defined as changes made to the health system on the basis of ideas or concerns raised by, or with, community members through formally introduced deci-sion-making mechanisms.

The potential intrinsic and instrumental benefits from strengthening community accountability in health delivery have led to significant resources being used by governments and non-governmental organizations to introduce and improve mechanisms. Some of these initiatives are linked to peripheral health facilities, which are important sources of care for low-income populations (Loewenson et al. 2004). Mechanisms introduced include patient/citizen rights charters, suggestion boxes, health and development committees, health clubs and

The search terms are shown in Table 1. We considered descriptive and evaluation papers focusing on urban or rural primary health care facilities (e.g., health centres, health posts, dispensaries, community pharmacies), where the authors described at least one measure to enhance community account-ability that was linked with those facilities. We excluded papers published before 1990, in languages other than English, and where the setting was the hospital/district level. An initial PubMed search was conducted in 2006, and cross-checked and updated in late 2009. The papers identified were supplemented by hand searches of the following websites: World Bank, World Health Organization, Partnerships for Health Reform, id21 and TARSC (Training and Research Support