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The crowded space of local accountability for maternal newborn and child health: a case study of the South African health system

机译：地方对产妇新生儿和儿童健康负责的拥挤空间：南非卫生系统的案例研究

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Global and national accountability for maternal, newborn and child health (MNCH) is increasingly invoked as central to addressing preventable mortality and morbidity. Strategies of accountability for MNCH include policy and budget tracking, maternal and perinatal death surveillance, performance targets and various forms of social accountability. However, little is known about how the growing number of accountability strategies for MNCH is received by frontline actors, and how they are integrated into the overall functioning of local health systems. We conducted a case study of mechanisms of local accountability for MNCH in South Africa, involving a document review of national policies, programme reports, and other literature directly or indirectly related to MNCH, and in-depth research in one district. The latter included observations of accountability practices (e.g. through routine meetings) and in-depth interviews with 37 purposely selected health managers and frontline health workers involved in MNCH. Data collection and analysis were guided by a framework that defined accountability as answerability and action (both individual and collective), addressing performance, financial and public accountability, and involving both formal and informal processes. Nineteen individual accountability mechanisms were identified, 10 directly and 9 indirectly related to MNCH, most of which addressed performance accountability. Frontline managers and providers at local level are targeted by a web of multiple, formal accountability mechanisms, which are sometimes synergistic but often duplicative, together giving rise to local contexts of ‘accountability overloads’. These result in a tendency towards bureaucratic compliance, demotivation, reduced efficiency and effectiveness, and limited space for innovation. The functioning of formal accountability mechanisms is shaped by local cultures and relationships, creating an accountability ecosystem involving multiple actors and roles. There is a need to streamline formal accountability mechanisms and consider the kinds of actions that build positive cultures of local accountability.
机译：孕产妇，新生儿和儿童健康（MNCH）的全球和国家责任日益成为解决可预防的死亡率和发病率的关键。 MNCH的责任追究策略包括政策和预算跟踪，孕产妇和围产期死亡监测，绩效目标以及各种形式的社会责任追究。但是，对于一线参与者如何接受越来越多的MNCH问责战略以及如何将其整合到本地卫生系统的整体功能方面，人们所知甚少。我们对南非的MNCH的地方责任机制进行了案例研究，涉及对国家政策，计划报告和其他与MNCH直接或间接相关的文献进行文件审查，并在一个地区进行深入研究。后者包括对问责制做法的观察（例如，通过例行会议）以及对与MNCH有关的37位经过精心挑选的卫生经理和一线卫生工作者的深入访谈。数据收集和分析以一个框架为指导，该框架将问责制定义为问责制和行动（个人和集体），涉及绩效，财务和公共问责制，并涉及正式和非正式程序。确定了19个个人问责机制，其中10个与MNCH直接相关，9个与MNCH间接相关，其中大多数解决了绩效问责制。地方一级的一线管理人员和提供者的目标是多个正式的问责机制网络，这些机制有时是协同作用的，但往往是重复的，一起导致“问责制超负荷”的本地环境。这些导致趋向于官僚主义的顺从性，消极的动机，降低的效率和效力以及有限的创新空间。正式的问责机制的功能受当地文化和关系的影响，创建了一个由多个参与者和角色组成的问责生态系统。有必要简化正式的问责机制，并考虑建立积极的地方问责文化的各种行动。

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