Table 1 summarizes the characteristics of key informants from the two sub-districts and the district office. Of a total of 58 participants, 36 (62%) were female, 43 (74%) were managers (senior and mid), and 3 (5%) were chairpersons of the hospital boards representing the community. Thirty (51.7%) respondents were nurses and 9 (15.5%) doctors; their experiences vary from less than one year to over 10 years at the time of this study.
In the following sections, we provide a detailed description of what the respondents understood or perceived as accountability, what they experienced as the barriers and enablers of accountability, and their recommendations for improving accountability.
Frontline health managers and providers in the district had well-formulated views and definitions of accountability, with words such as being “responsible”, “answerable” and “transparent” frequently invoked (Figure 1). Formal, bureaucratic versions of accountability existed alongside ideas of accountability as a professional virtue and a product of intrinsic motivation (referred to by one respondent as “passion”).
a. Accountability as being responsible
Accountability was most often referred to as being responsible for any decision taken, and “act or omission” in the line of duty.
A hospital Chief Executive Officer (CEO), as the main “accounting officer” of the institution, indicated his awareness of his ultimate responsibility for all actions taken in the hospital.
“For all the good things I am accountable and even for all the bad things and also for omissions of which our officials might have been involved in…” [Hospital CEO].
A senior nursing manager understood accountability as assigning responsibility to “subordinates” in a management line, while retaining accountability.
“Accountability according to my understanding… is assigning responsibility to your immediate subordinates, but as the accounting person you don’t assign accountability, accountability remains with you” [Nursing Manager].
An information officer described accountability as taking responsibility for doing one’s work without mistakes.
“everything that you are doing you are ... we are responsible for it; you must make sure that there’s no mistake there… accountability means you must take full responsibility” [Information Manager].
Accountability was also referred to as a process of assigning responsibility to other system actors in cases of wrongdoing or negative outcomes.
“Whose fault is it that someone got malnourished or died or anything like that?” [Dietician].
Such wrongdoing could invite sanction:
“…the Minister said where we are going there will be time if anything is really happening in the hospital, [an] investigation done [which] finds that there is something like negligence, so and so will be accountable; and when you are accountable, people they will even lose maybe a salary…” [Manager]
b. Accountability as being answerable
Accountability was also perceived, alongside responsibility, as being able to answer or explain, referring to the obligation to justify any decision or action taken that resulted in the observed outcome for the patient or for the system.
“To be accountable is to be able to answer, to be answerable, to be able to answer for the actions that you have taken, to be able to give the reasons why you did what you did and the way you did it. So that to me that is accountability” [Operational Manager].
Accountability required facing the community requesting explanations, including in difficult situations when mistakes had been made.
“…to be accountable, you have to avail yourself to the community and inform the community about the situation even if it’s a bad situation” [Hospital Board Chairperson].
c. Accountability as complying to norms and targets
Accountability was also perceived as compliance with norms, guidelines, policies, or performance targets.
“Accountability means that you agree to abide by the protocols, the prescripts, the guidelines and whatever that you do, it is [judged] against what the protocols or guidelines are saying…” [Manager].
d. Accountability as a virtue
The narratives of respondents also made frequent reference to accountability as an internal process relating to personal values, intrinsic motivation and professional commitment.
“To me, it’s a sense of duty, accountability means a sense of duty, sense of urgency, effectiveness, sense of accountability itself and sense of responsibility as well. To me, all that forms part of accountability” [District Programme Manager].
As a moral value or virtue, accountability transcends professional knowledge and experience to embrace “knowledge with passion”, and collective commitment to the provision of quality care, as expressed in one sub-district.
“…one of the key things helping this sub-district is to have people with passion in those wards … like here in maternity ward Sister [name], paed’s ward Sister [name], the operational manager; to have people with a passion at the same time experience, because they’ve been here for a long time. They have the experience, they have knowledge. If you have the knowledge it’s good. But if you have knowledge and passion then you make a difference… ” [Allied Health Manager].
Accountability is being sensitive to patient needs:
“You need to stand up and go to the waiting area and check; that also makes people more comfortable. If they know that she [nurse] has seen me, she knows about me, every time she comes out, she says I have noticed you, see you now, now, it makes people comfortable, they can relax, they know they will be helped” [PHC Manager].
Finally, as a virtue, accountability is perceived as a response to trust that the community placed in the health system.
“I’m accountable to the patient that I’m giving the service to. Because I’m accountable to her, that I know that when she left her home to come here, she trusts us and she is putting all her trust to me, so I must do justice to her, I’m accountable to her” [Operational Manager].
The multiple directions of accountability
When asked to whom they were accountable, respondents typically saw themselves as being accountable simultaneously to other health system actors, upwards and downwards in a hierarchy, horizontally to peers, and outwards to patients and communities.
“Firstly, I’m accountable to the patient that I’m giving the service to. And also, I always tell myself I’m accountable to the colleagues that I’m supervising because whatever good and bad things that they are doing it will reflect back to me[…] And all in all, I’m accountable to the Department because they put me here as they’ve trusted me that I’m going to represent them in a good way” [Operational Manager].
For some, accountability encompassed a reciprocal relationship of “giving hope” and responsiveness to staff downwards in a hierarchy:
“Administration-wise… apart from accounting to the District Manager, the head of the department and the MEC for Health, at the end of the day I account to the community […], as well as the staff, meaning here I must give hope to the staff because you see, there are lots of challenges and internal issues that need to be attended to, your shortage of staff, your lack of equipment, your shortage of skills, your need for training...” [Hospital CEO].
Accountability was expressed as a relationship, both to immediate line managers and patients and to a wider system and “citizens”.
“Workwise, I account to the District Manager in terms of meeting all the objectives that I have to meet according to the key performance… I am [also] accountable to the citizens of the country for one reason - they are the funders of the whole government project” [District Programme Manager].
Community representatives on Hospital Boards described a complex mix of accountability relationships involving communities, political principals (the Member of the Executive Council (MEC) - the Provincial Health Minister) and trade unions.
“My accountability, or our accountability, as board members I think, is in two ways. We account to the community, that’s a very critical role. And the second one, we also account to the MEC and you would understand that because the MEC is directly elected by the community” [Hospital Board Chairperson].
“…the unions and also the community members, there is no way that you can disregard what they say” [Hospital Board Chairperson].
Finally, linked to the narratives of accountability as a professional virtue, frontline managers and providers often described a relationship of accountability to the self.
“First, I’m accountable to myself … because you know every time you save a life…I don’t say it’s happiness, it’s something like it’s a fulfilment, you go back home and you say I saved a life […] I think the first one is to myself, [then] to the community, to the management” [Medical Officer].
Enablers and barriers of accountability
a. Leadership and management styles and practices
Respondents identified hands-on, accessible leadership styles as key to accountability. One hospital CEO described his “open door policy” as follows:
“…having this open-door policy I speak even with the cleaner down there, I am not saying no, no I won’t speak to you I will only speak to your supervisor or whoever just to be in contact with everyone…. when you are in touch with your people you know they can come to you at any time, phone you, talk to them, go to where they work, look at the area where they are working, you will understand the situation” [Hospital CEO].
Variation in the involvement and closeness of the leadership to staff within the district was described by another frontline provider as follows:
“The leadership is very important. For example, in Hospital A, I worked also in that hospital, the leaders are there somewhere, and you, you are your side. It is very different from Hospital B, the leaders are very involved starting by the CEO, you could see that every time he’s got an occasion he attends the meetings; Dr [clinical manager], once I take the phone and say, “mommy I am in difficult situation” she will arrive. You see that the leadership is very involved” [Medical Officer].
Leadership styles and practices were most evident in the manner in which “adverse events” such as maternal deaths were responded to at district and higher levels. While these events were infrequent, the attention brought to them, and the way responsibility was assigned and sanctions applied, was watched carefully by frontline actors, setting a wider tone for perceptions of accountability at sub-district and facility levels. Respondents described instances of both unfair, harsh punishment and impunity in response to adverse events.
“In this office yes... others were suspended for something that they did not do” [District Programme Manager].
“…but when it comes to sanctions, why these ones are punished this way, I can say it’s a punishment, why those ones are not punished, you know this discrepancy…” [Medical Officer].
Politically connected players could escape sanction:
“…politics is mixed with the administration… so, that compromises accountability a lot; if people are doing wrong it’s difficult to reprimand them; because if you go to your external structure, that person is the secretary or the chairperson in your political branch” [District Programme Manager].
Practices of impunity created the conditions for malpractice suits, while unfair punishment engendered a climate of fear of reporting:
“…When they are suing the hospital, they are not suing you as an individual. That’s where accountability is coming in because people are thinking that if something happens it’s fine the government will resolve it for me, and they can continue doing the very same things” [Manager].
“Most of the time, people, they think that maybe when you report, the punishment is coming…” [Manager].
b. Strengthening provider motivation and skills
Paying attention to the motivation of providers and a people-centred approach was seen as a key enabler of accountability by a senior clinician in the district.
“The things in health are run by people; a machine can help but it’s the people who are delivering the service… If we have the right people with the right training, the right updating [of knowledge] and everything, also with the right motivation that they are really attended to in proper way as human beings, then for me it’s almost impossible not to reach the point” [DCST member].
Provider motivation could be strengthened in several ways, including responsiveness to needs, acknowledgement of good performance and respectful interactions:
“Motivation is a very wide word. I don’t want to say we’ll give you more salary, we’ll give you a house. Motivation sometimes is to attend the people’s needs, to have the proper equipment, to work in proper conditions, and to tell them “thank you, you are doing well” when you are doing well; And when they are not doing well to call their attention in a respectful way. Motivation is not necessarily about spending money or to give more [material] things; motivation for a human being can be simple” [DCST member].
Of these, acknowledgement of good performance and achievement was particularly valued.
“… I spoke to him [HOD] and asked […] I would like you before you leave to go and say something nice to my nursing staff. He asked me why, I said you know since I’ve been here, we never had any maternal death, and those guys need at least to hear from you a “thank you”. He came and spent some minutes with them, he thanked them and it was very good” [Medical Officer].
Alongside strengthening their motivation, improving accountability required equipping providers with the right knowledge and skills.
“So, I think knowledge is power…If we are given money to improve accountability, I think step number one will be to give people the information, knowledge. Because once people have knowledge on that particular programme or on that particular work that they are doing, they will be able to account better and even the superiors or the accounting officer would be able to hold them accountable because they’d be having knowledge” [Allied Health Manager].
Respondents expressed as demotivating the problematic (but common) human resource practice of being placed in an acting or interim position of authority. One expressed it as a feeling of “being used”.
“She is acting as an operational manager but you don’t want to put it formally so you just want her to conduct the roles of the operational manager while she is still anyone else. It is not easy for her to work effectively because she feels like you are just using her, …and the minute she doesn’t feel well about it she won’t perform” [Operational Manager].
c. Communication and teamwork
Respondents identified effective communication and collaborative team between levels of care as an important element in strengthening collective responsibility and a “no-blaming” environment.
“Because previously we were having that thing that PHC would point at the hospital, we, when we have done wrong, we will point it back to the PHC, and we have been pointing it back because they are not in our meetings; now we are together” [Operational Manager].
Conversely, the lack of communication was experienced as a barrier to accountability that affected quality of care and created a culture of blaming and shifting of responsibility, as these two quotes from one facility illustrate.
“I have to be honest… I identified that there is no link, there is no communication in terms of the hospital as well as the PHC” [Hospital CEO].
“There is a culture of blaming within the hospital that brings the feeling of embarrassment; there is also a behaviour of policing behind your back, like people watching you report on any mistake” [Medical Officer].
Finally, unity and teamwork among key managers in hospitals (the “Big Five”) was important in consolidating accountability within the organisation.
“I think the key people are the “Big Five” at the hospital level; the CEO, the nursing service manager, the corporate manager, then finance and the clinical manager […] even though I’m a nursing service manager, but when I go to a unit, I will make a doctor account the same way the clinical manager will make a nurse account for his/her action. So probably the teamwork between the Big Five is important to ensure that people are accountable” [District Programme Manager].
d. Engaging communities and trade unions
Open days and community dialogues were raised as facilitators of accountability.
“We normally conduct community dialogues, where different stakeholders come together […], an example regarding the late booking of the antenatal care; people are voicing out what can be done and they are voicing out why people are not booking early for the antenatal care. Then after the dialogue, we sit down and plan for the activities that can improve the situation together with the community” [District Programme Manager].
The role and influence of trade union structures was also a recurring theme in interviews. Respondents expressed various views on trade unions as a ‘voice’ in the accountability ecosystem, with a complex set of mandates.
“…organised labour formation, that for me is very key because it also contributes to the wellbeing of the entire operations within a hospital setup” [Hospital Board Chairperson].
Trade unions were also described as powerful, but problematic players.
“No, their voices are not for pushing for improvement. Their voices are more for getting people angry; If they use that effort, you would see a different place, if they use that effort to try to improve and try to motivate and try to get people to do the right thing” [PHC Manager].