Social accountability is getting popular as a strategy for addressing primary health care challenges such as poor utilization and allocation of resources, unresponsive health service delivery and ineffective and inefficient health system –. Social accountability is defined as “citizens’ efforts at ongoing meaningful collective engagement with public institutions for accountability in the provision of public goods” . In primary health care, this concept is derived from Alma Ata Declaration 1978 and sustained by Astana Declaration 2018 that individual, families and community participation in the management and implementation of health programs are the cornerstones for achieving Universal Health Coverage (UHC) . In many developing countries, social accountability in primary health care facilities is democratically represented by Health Facility Governing Committees (HFGCs). The HFGCs are community governing structures, created to be a community, civil societies and other interest groups representatives for voicing and shaping health service delivery in community interest , . In many developing countries these HFGCs are democratically elected by communities therefore HFGCs are directly accountable for their actions to communities , .
In a broader sense accountability relate to responsibility and responsiveness because it follows the principle of responding or being able to accomplish the given responsibilities . It is all about account giving or one’s obligation to justify and explain his/her conduct. There are three components of accountability namely the locus of accountability (who), the domains of accountability (What) and the procedure of accountability (How). The locus of accountability entails who is being held into account or holds others accountable, in primary health care these can be nurses, incharges, patients, communities, or community governing structures such as HFGCs , , . The domain of accountability refers to the activity or devolved functions to which the person or institution can legitimately hold responsible therefore required to justify its actions , , . These domains can be professional competency, community benefits of interest, professional ethics, financial performance and legal compliance. The last component is procedural accountability which entails mechanisms used to evaluate the accountability of a party . These can be through formal or informal evaluation of the compliance of the locus of accountability to the devolved functions or domain or response or justification by the accountable part such as HFGC to the extent they have accomplished their assigned duties , . After evaluation, the evaluator can decide to sanction or reward the part held into account.
Principal-Agency Theory can best be used to explain the relationship between the communities and HFGCs in primary health care facilities. the Principal-Agency Theory entails the act in which the principal is striving to maximize the value/output by engaging/delegating its responsibilities to the agents which are followed by the principal regularly monitoring or holding the agents or the agents held him/herself into account based on his/her performance , , , . The Principal/Agent Theory marches with the accountability definition that entails the “relationship between an actor and a forum, in which the actor has an obligation to explain and to justify his or her conduct, the forum can pose questions and pass judgment, and the actor may face consequences” . In the context of primary health care governance, communities, civil societies and other interest groups are Principal/Forum in which they have delegated their responsibilities to govern primary health care facilities to the HFGCs , , . On the other hand, HFGCs are agents/actors that are democratically elected by the Principal or forum which is communities or interest groups. Therefore, the HFGCs should formally or informally render accounts consistently to their electorates or appointees which are communities .
As suggested by Bovens three important elements need to be in place between the HFGCs (actor or agent) and Communities (forum or principal). That, in process of accomplishing their devolved functions and powers, HFGCs (agents) are obliged to inform the communities and other interest groups (principal) about their conducts. In the same vein, the communities and other interest groups (principal), should interrogate the HFGCs (agent/forums) and ask questions about several aspects and information relating to health service delivery in their communities or health facilities. Lastly, after hearing the response from the HFGCs, the Communities and civil societies represented by HFGCS may be in a position to pass judgment to the HFGCs. The judgment may be positive if the Communities and civil societies have judged that HFGCs are doing well, but also citizens may impose sanctions if they judge that HFGCs have failed to exercise their duties and authorities. Since citizens (communities and civil societies) elect and appoint members of HFGCs, the sanctions may be re-electing or not re-electing the HFGCs in the next term. Therefore, Justifying, explaining, reporting and sanctioning may all amount to accountability .
Even though the contribution of the HFGCs in overseeing the implementation of primary health care plans is appreciated by the global health community, there is limited evidence about HFGC's accountability in enforcing social accountability under fiscal decentralization , . The existing empirical shreds of evidence have been focused on exploring the mechanism used by HFGCs to hold health providers into account , , , the relationship between managerial competence, accountability and hospital board governance . Furthermore, studies have shown the linkage between citizens and elected politicians . Lodenstein et al found that the HFGCs accountability cycle in Sub-Saharan countries is less practiced and institutionalized. Of now, several lower and middle-income countries are decentralizing fiscal powers and responsibilities to HFGCs. However, how HFGCs accomplish their devolved fiscal powers and responsibilities in primary health facilities implementing DHFF is not known. This study assesses the status of the HFGCs accountability and their associated factors in primary health facilities implementing DHFF in Tanzania