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Background:
Accountability in global health is a commonly invoked though less commonly questioned concept. Critically reflecting on the concept and how it is put into practice, this paper focuses on the who, what, how, and where of accountability, mapping its defining features and considering them with respect to real-world circumstances. Changing...
Context in source publication
Context 1
... together, the accountability mechanisms and health policy subfields identified in the discussion above provide basic elements for our conceptual map of ac- countability (Figure 1). We have approached account- ability in the context of global health cooperation as a system of relations between different actors with varying degrees of power and influence. ...
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Citations
... Accountability is a core, yet complex, function of governance [60]. The documentary and interview analysis reveal a complicated, evolving picture of the accountability structures and mechanisms in place. ...
Background
Effective governance arrangements are central to the successful functioning of health systems. While the significance of governance as a concept is acknowledged within health systems research, its interplay with health system reform initiatives remains underexplored in the literature. This study focuses on the development of new regional health structures in Ireland in the period 2018–2023, one part of a broader health system reform programme aimed at greater universalism, in order to scrutinise how aspects of governance impact on the reform process, from policy design through to implementation.
Methods
This qualitative, multi-method study draws on document analysis of official documents relevant to the reform process, as well as twelve semi-structured interviews with key informants from across the health sector. Interviews were analysed according to thematic analysis methodology. Conceiving governance as comprising five domains (Transparency, Accountability, Participation, Integrity, Capacity) the research uses the TAPIC framework for health governance as a conceptual starting point and as initial, deductive analytic categories for data analysis.
Results
The analysis reveals important lessons for policymakers across the five TAPIC domains of governance. These include deficiencies in accountability arrangements, poor transparency within the system and vis-à-vis external stakeholders and the public, and periods during which a lack of clarity in terms of roles and responsibilities for various process and key decisions related to the reform were identified. Inadequate resourcing of implementation capacity, competing policy visions and changing decision-making arrangements, among others, were found to have originated in and continuously reproduced a lack of trust between key institutional actors. The findings highlight how these challenges can be addressed through strengthening governance arrangements and processes. Importantly, the research reveals the interwoven nature of the five TAPIC dimensions of governance and the need to engage with the complexity and relationality of health system reform processes.
Conclusions
Large scale health system reform is a complex process and its governance presents distinct challenges and opportunities for stakeholders. To understand and be able to address these, and to move beyond formulaic prescriptions, critical analysis of the historical context surrounding the policy reform and the institutional relationships at its core are needed.
... Unlike IGOs governed solely by their member states, global PPPs are co-governed by public and private actors who share decision-making, typically in a board bearing legal responsibility for the organization (Rushton & Williams, 2011). Global PPPs' inclusiveness in decision-making has been lauded as an extension of democracy to the global level, but many scholars have identified challenges to PPPs' political accountability due to their hybrid status blurring the lines between public and private, as well as partners' diverging interests, values, worldviews, and power asymmetries (Brown, 2010;Bruen et al., 2014;Reich, 2018). Indeed, donor countries and the Bill and Melinda Gates Foundation largely dominate the boards of global health partnerships (Brown, 2010;Bruen et al., 2014;Storeng, 2014), which may lead to a top-down approach imposing priorities on recipient countries (Adeyi, 2021;Storeng et al., 2021). ...
... Global PPPs' inclusiveness in decision-making has been lauded as an extension of democracy to the global level, but many scholars have identified challenges to PPPs' political accountability due to their hybrid status blurring the lines between public and private, as well as partners' diverging interests, values, worldviews, and power asymmetries (Brown, 2010;Bruen et al., 2014;Reich, 2018). Indeed, donor countries and the Bill and Melinda Gates Foundation largely dominate the boards of global health partnerships (Brown, 2010;Bruen et al., 2014;Storeng, 2014), which may lead to a top-down approach imposing priorities on recipient countries (Adeyi, 2021;Storeng et al., 2021). Similarly, some worry about undue industry influence over policy-making processes within partnerships (Schä ferhoff et al., 2009). ...
... PPP's accountability relies primarily, like corporations, on measuring progress toward their strategic objectives and ensuring financial accountability (Huckel Schneider, 2019). This fosters a vertical accountability system primarily directed upwards to donors (often called "shareholders"), rather than downwards to beneficiaries, or horizontally to the partners involved (Brown, 2010;Bruen et al., 2014). ...
Global public–private partnerships (PPPs) have become prominent in efforts to address global challenges, particularly in the health field. In the scholarly literature, global PPPs have been conceptualized as arenas for voluntary public–private cooperation rather than agents of global governance. This paper challenges this approach, arguing that a sub-class of highly institutionalized partnerships have developed into transnational bureaucracies that, much like international organizations, can draw from their administrative capacities to exercise agency and gain and consolidate authority over time. To substantiate this argument, I present an in-depth analysis of five global health partnerships that played a leading role in the Access to Covid-19 Tools Accelerator (ACT-A), the initiative that sought to coordinate the global response to covid-19. Based on extensive document review and analysis of the ACT-A PPPs —Gavi, the Vaccine Alliance, The Global Fund to Fight AIDS, Tuberculosis and Malaria, The Coalition for Epidemic Preparedness Innovation, Unitaid, and The Foundation for Innovative New Diagnostics — I show how these partnerships’ leadership role during the pandemic emerged from a decade long build-up of PPP agency. These organizations gained administrative capacities that enabled them to increase their authority vis-à-vis their donors, boards, and other external actors through three interlinked strategies: (a) developing greater financial autonomy; (b) expanding their mandates (including toward pandemic preparedness and response); and (c) establishing inter-partnership cooperation and mutual representation to other forums. My analysis suggests the need for future research to consider highly institutionalized PPPs as agents of global governance and to explore empirically and theoretically the consequences of their rising authority.
... This tension was also previously identified in healthcare governance during humanitarian responses [23]. Given the diversity of independent actors involved, practising accountability is complex and multipolar [165]. We argue that improving accountability requires first addressing meaningful and equitable participation in governance. ...
The persistence of inadequate vaccination in crisis-affected settings raises concerns about decision making regarding vaccine selection, timing, location, and recipients. This review aims to describe the key features of childhood vaccination intervention design and planning in crisis-affected settings and investigate how the governance of childhood vaccination is defined, understood, and practised. We performed a scoping review of 193 peer-reviewed articles and grey literature on vaccination governance and service design and planning. We focused on 41 crises between 2010 and 2021. Following screening and data extraction, our analysis involved descriptive statistics and applying the governance analysis framework to code text excerpts, employing deductive and inductive approaches. Most documents related to active outbreaks in conflict-affected settings and to the mass delivery of polio, cholera, and measles vaccines. Information on vaccination modalities, target populations, vaccine sources, and funding was limited. We found various interpretations of governance, often implying hierarchical authority and regulation. Analysis of governance arrangements suggests a multi-actor yet fragmented governance structure, with inequitable actor participation, ineffective actor collaboration, and a lack of a shared strategic vision due to competing priorities and accountabilities. Better documentation of vaccination efforts during emergencies, including vaccination decision making, governance, and planning, is needed. We recommend empirical research within decision-making spaces.
... However, accountability has permutations far beyond a bilateral relationship especially given the current multiplicity of actors in global health that include the state, civil society networks, academia, philanthropies, multinational corporations, public-private partnerships and the media. [7][8][9] In the context of health systems, Brinkerhoff has sought conceptual clarity by discussing financial, performance and political accountability as three types of accountability whose purpose are to reduce abuse, assure compliance with procedures and standards and improve performance. 9 However, there is a gap between ideal accountability that is able to fulfil its purpose and accountability that is possible in practice 9 as global health governance is impacted by vague lines of accountability between'duty bearers' and 'claims holders. ...
... Bilateral donors like the USA, consistently the biggest source of development assistance for health, 14 15 have maintained their influential positions in shaping the global health agenda but are mainly accountable to their governments rather than the recipient countries and institutions in the Global South most affected by the projects they support and advance. In the sheer volume of financing needed to address global health challenges, new public-private partnerships, like the Global Fund to Fight AIDS, Tuberculosis and Malaria (ie, the Global Fund) 7 and Gavi, the Vaccine Alliance (ie, GAVI) 16 have emerged as important players yet with blurred lines of accountability in the global health system. Systemic corruption in global health is also a problem that severely affects the poor and most vulnerable when money meant to address their needs are diverted for private gains. ...
... The two sets of charted data were later merged and reconciled through discussion. Our data charting was organised based on the accountability processes described by Bruen et al, 7 which provided an initial typology of accountability processes (deductive qualitative approach). The list of accountability processes was iterated as other accountability processes were identified (inductive qualitative approach). ...
Introduction: Accountability is a complex idea to unpack and involves different processes in global health practice. Calls for accountability in global health would be better translated to action through a better understanding of the concept and practice of accountability in global health. We sought to analyse accountability processes in practice in global health funding, research collaborations and training.
Methods: This study is a literature review that systematically searched PubMed and Scopus for articles on formal accountability processes in global health. We charted information on processes based on accountability lines (‘who is accountable to whom’) and the outcomes the processes were intended for (‘accountability for what’). We visualised the representation of accountability in the articles by mapping the processes according to their intended outcomes and the levels where processes were implemented.
Results: We included 53 articles representing a wide range of contexts and identified 19 specific accountability processes for various outcomes in global health funding, research collaborations and training. Target setting and monitoring were the most common accountability processes. Other processes included interinstitutional networks for peer checking, litigation strategies to enforce health-related rights, special bodies that bring actors to account for commitments, self-accountability through internal organisational processes and multipolar accountability involving different types of institutional actors. Our mapping identified gaps at the institutional, interinstitutional and broader system levels where accountability processes could be enhanced.
Conclusion: To rebalance power in global health, our review has shown that analysing information on existing accountability processes regarding ‘who is accountable to whom’ and ‘accountability for what’ would be useful to characterise existing lines of accountability and create lines where there are gaps. However, we also suggest that institutional and systems processes for accountability must be accompanied by political engagement to mobilise collective action and create conditions where a culture of accountability thrives in global health.
... Governance structures of multisectoral funds can be ad-hoc and complex as they bring together many stakeholders with varying degrees of power and influence, complicating accountability [7,33]. If decision-making roles are unclear, so too is who is accountable to whom [11,34]. ...
Background
The failures of the international COVID-19 response highlighted key gaps in pandemic preparedness and response (PPR). The G20 and WHO have called for additional funding of $10.5 billion per year to adequately strengthen the global PPR architecture. In response to these calls, in 2022 the World Bank announced the launch of a new Financial Intermediary Fund (The Pandemic Fund) to catalyse this additional funding. However, there is considerable unclarity regarding the governance makeup and financial modalities of the Pandemic Fund, and divergence of opinion about whether the Fund has been successfully designed to respond to key challenges in global health financing.
Methods/Results
The article outlines eight challenges associated with global health financing instruments and development aid for health within the global health literature. These include misaligned aid allocation; accountability; multistakeholder representation and participation; country ownership; donor coherency and fragmentation; transparency; power dynamics, and; anti-corruption. Using available information about the Pandemic Fund, the article positions the Pandemic Fund against these challenges to determine in what ways the financing instrument recognizes, addresses, partially addresses, or ignores them. The assessment argues that although the Pandemic Fund has adopted a few measures to recognise and address some of the challenges, overall, the Pandemic Fund has unclear policies in response to most of the challenges while leaving many unaddressed.
Conclusion
It remains unclear how the Pandemic Fund is explicitly addressing challenges widely recognized in the global health financing literature. Moreover, there is evidence that the Pandemic Fund might be exacerbating these global financing challenges, thus raising questions about its potential efficacy, suitability, and chances of success. In response, this article offers four sets of policy recommendations for how the Pandemic Fund and the PPR financing architecture might respond more effectively to the identified challenges.
... Governance structures of multisectoral funds can be ad-hoc and complex as they bring together many stakeholders with varying degrees of power and in uence, complicating accountability [7,33]. If decisionmaking roles are unclear, so too is who is accountable to whom [11,34]. ...
Background: The failures of the international COVID-19 response highlighted key gaps in pandemic preparedness and response (PPR). The G20 and WHO have called for additional funding of $10.5 billion per year to adequately strengthen the global PPR architecture. In response to these calls, in 2022 the World Bank announced the launch of a new Financial Intermediary Fund (The Pandemic Fund) to catalyse this additional funding. However, there is considerable unclarity regarding the governance makeup and financial modalities of the Pandemic Fund, and divergence of opinion about whether the Fund has been successfully designed to respond to key challenges in global health financing.
Methods/ results: To better situate the Pandemic Fund within discussions about existing challenges in global health financing, this article presents the results of a scoping review identifying key challenges associated with international health financing instruments. A total of 73 documents were collected from which 51 were reviewed for analysis. Thematic analysis identified eight thematic groupings that emerged from the literature which were then used as policy criteria to assess the current governance and financing design of the Pandemic Fund using available information on the Fund. The eight themes in hierarchical order of frequency were: misaligned aid allocation; accountability; multistakeholder representation and participation; country ownership; donor coherency and fragmentation; transparency; power dynamics, and; anti-corruption. Assessment of the Pandemic Fund against these criteria found that although some mechanisms have been adopted to recognise and address challenges, overall, the Pandemic Fund has unclear policies in response to most of the challenges while leaving many unaddressed.
Conclusion: It remains unclear how the Pandemic Fund is explicitly addressing the eight challenges identified. Moreover, there is evidence that the Pandemic Fund might be exacerbating these global financing challenges, thus raising questions about its potential efficacy, suitability, and chances of success. In response, this article offers three sets of policy recommendations for how the Pandemic Fund and PPR financing architecture might respond more effectively to the identified challenges.
... Authorship of articles was of interest to us as a marker of who is granted authority or responsibility for reporting on a GHP. Authorship lists were interdisciplinary in thirteen articles [29,34,35,37,39,[42][43][44][45][46][47][48][49] and included Southern partners in sixteen articles [29, 34-37, 39, 41-44, Table 1 Categorization of GHPs for the purposes of this review [46][47][48][49][50][51]. Where all authors' primary geographic affiliations could be identified (n = 29 articles, 152 authors), 120 (79%) authors were affiliated with institutions located in the global North -Canada [32,35,37,39,41,44,48,52]; Europe (Switzerland, Ireland, the United Kingdom, Germany, the Netherlands) [30,31,38,40,45,50,53,54]; the United States [29,33,34,36,49,[55][56][57][58]; Australia [51] -and 32 (21%) were located in the global South (Kenya [46], Nepal [47], Rwanda [43], and Uganda [42]). ...
... Authorship lists were interdisciplinary in thirteen articles [29,34,35,37,39,[42][43][44][45][46][47][48][49] and included Southern partners in sixteen articles [29, 34-37, 39, 41-44, Table 1 Categorization of GHPs for the purposes of this review [46][47][48][49][50][51]. Where all authors' primary geographic affiliations could be identified (n = 29 articles, 152 authors), 120 (79%) authors were affiliated with institutions located in the global North -Canada [32,35,37,39,41,44,48,52]; Europe (Switzerland, Ireland, the United Kingdom, Germany, the Netherlands) [30,31,38,40,45,50,53,54]; the United States [29,33,34,36,49,[55][56][57][58]; Australia [51] -and 32 (21%) were located in the global South (Kenya [46], Nepal [47], Rwanda [43], and Uganda [42]). ...
... GHPs were often situated around a topical focus on research, capacity-building, clinical, or health services issues. Though historical and political North-South dynamics were rarely examined as influential forces in GHPs, they were frequently portrayed as complex and characterized by asymmetries in power and resources [31, 32, 34, 35, 37-40, 46-48, 50, 51], as one article stated -"relations between different actors with varying degrees of power and influence" [50]. The depth in which such asymmetries were explained also varied. ...
Background
Global health partnerships (GHPs) are situated in complex political and economic relationships and involve partners with different needs and interests (e.g., government agencies, non-governmental organizations, corporations, universities, professional associations, philanthropic organizations and communities). As part of a mixed methods study designed to develop an equity-sensitive tool to support more equity-centred North-South GHPs, this critical interpretive synthesis examined reported assessments of GHPs.
Results
We examined 30 peer-reviewed articles for power dynamics, equity and inequities, and contradictions or challenges encountered in North-South partnerships. Among articles reviewed, authors most often situated GHPs around a topical focus on research, capacity-building, clinical, or health services issues, with the ‘work’ of the partnership aiming to foster skills or respond to community needs.
The specific features of GHPs that were assessed varied widely, with consistently-reported elements including the early phases of partnering; governance issues; the day-to-day work of partnerships; the performance, impacts and benefits of GHPs; and issues of inclusion. Articles shared a general interest in partnering processes and often touched briefly on issues of equity; but they rarely accounted for the complexity of sociopolitical and historical contexts shaping issues of equity in GHPs. Further, assessments of GHPs were often reported without inclusion of voices from all partners or named beneficiaries.
GHPs were frequently portrayed as inherently beneficial for Southern partners, without attention to power dynamics and inequities (North-South, South-South). Though historical and political dynamics of the Global North and South were inconsistently examined as influential forces in GHPs, such dynamics were frequently portrayed as complex and characterized by asymmetries in power and resources. Generally, assessments of GHPs paid little attention to the macroeconomic forces in the power and resource dynamics of GHPs highlights the importance of considering the broader political. Our findings suggest that GHPs can serve to entrench both inequitable relationships and unfair distributions of power, resources, and wealth within and between countries (and partners) if inequitable power relationships are left unmitigated.
Conclusions
We argue that specific practices could enhance GHPs’ contributions to equity, both in their processes and outcomes. Enhancing partnering practices to focus on inclusion, responsiveness to North-South and South-South inequities, and recognition of GHPs as situated in a broader (and inequitable) political economy. A relational and equity-centred approach to assessing GHPs would place social justice, humility and mutual benefits as central practices—that is, regular, routine things that partners involved in partnering do intentionally to make GHPs function well. Practicing equity in GHPs requires continuous efforts to explicitly acknowledge and examine the equity implications of all aspects of partnering.
... Vertical lines of participation and accountability (i.e., principal-agent relations of member states and international organizations) coexist with horizontal checks and balances between members within the partnership, i.e., mutual accountability mechanisms. This leads to a complex system of multipolar relationships and processes (Bruen, Brugha, Kageni, & Wafula, 2014). For partnerships themselves, as institutionalized forms of networked and multilayered metagovernance, scholars have discussed and called for pluralistic approaches to legitimacy and accountability. ...
The 2030 Agenda of the United Nations comprises 17 Sustainable Development Goals (SDGs) and 169 sub-targets which serve as a global reference point for the transition to sustainability. The agenda acknowledges that different issues such as poverty, hunger, health, education, gender equality, environmental degradation, among others, are intertwined and can therefore only be addressed together. Implementing the SDGs as an ‘indivisible whole’ represents the actual litmus test for the success of the 2030 Agenda. The main challenge is accomplishing a more integrated approach to sustainable
development that encompasses new governance frameworks for enabling and managing systemic transformations. This thematic issue addresses the question whether and how the SDGs set off processes of societal transformation, for which cooperation between state and non-state actors at all political levels (global, regional, national, sub-national), in different societal spheres (politics, society, and economy), and across various sectors (energy, transportation, food, etc.) are indispensable. In this editorial, we first introduce the 2030 Agenda and the SDGs by providing an overview of the architecture of the agenda and the key challenges of the current implementation phase. In a second step, we present the eleven contributions that make up the thematic issue clustering them around three themes: integration, governance challenges, and implementation.
... Vertical lines of participation and accountability (i.e., principal-agent relations of member states and international organizations) coexist with horizontal checks and balances between members within the partnership, i.e., mutual accountability mechanisms. This leads to a complex system of multipolar relationships and processes (Bruen, Brugha, Kageni, & Wafula, 2014). For partnerships themselves, as institutionalized forms of networked and multilayered metagovernance, scholars have discussed and called for pluralistic approaches to legitimacy and accountability. ...
SDG 17 calls for the international community to “strengthen the means of implementation and revitalize the global partnership for sustainable development,” emphasizing the role of multi-stakeholder partnerships for achieving the SDGs. Policy documents are replete with statements on the necessity of ‘meaningful’ engagement, especially with civil society—without clarifying what ‘meaningful’ stands for. In this article, we develop an analytical approach to partnership as a form and norm of metagovernance. Partnership as a metanorm is about the roles and relations of different sets of actors. We suggest operationalizing the concept of partnership according to different levels of accountability and participation, allowing for a gradual enhancement of the quality of partnership in terms of ‘meaningfulness.’ We apply our analytical model to the Global Action Plan for Healthy Lives and Well‐Being for All (GAP), a fairly new initiative by health and development agencies to accelerate progress towards the health-related targets of the 2030 Agenda. By investigating the development and the early phase of implementing the GAP, we empirically assess if and how the notion of partnership envisioned in the GAP qualifies as ‘meaningful’ with respect to civil society engagement. From our empirical example, we infer lessons for attaining normative standards of ‘meaningfulness’ and highlight implications for future research on partnerships.
... included Southern partners in sixteen articles (29,(34)(35)(36)(37)39,(41)(42)(43)(44)(46)(47)(48)(49)(50)(51) (42)). ...
... GHPs were often situated around a topical focus on research, capacity-building, clinical, or health services issues. Though historical and political North-South dynamics were rarely examined as in uential forces in GHPs, they were frequently portrayed as complex and characterized by asymmetries in power and resources (31,32,34,35,(37)(38)(39)(40)(46)(47)(48)50,51), as one article stated -"relations between different actors with varying degrees of power and in uence" (50). The depth in which such asymmetries were explained also varied. ...
... GHPs were often situated around a topical focus on research, capacity-building, clinical, or health services issues. Though historical and political North-South dynamics were rarely examined as in uential forces in GHPs, they were frequently portrayed as complex and characterized by asymmetries in power and resources (31,32,34,35,(37)(38)(39)(40)(46)(47)(48)50,51), as one article stated -"relations between different actors with varying degrees of power and in uence" (50). The depth in which such asymmetries were explained also varied. ...
Global health partnerships (GHPs) are situated in complex political and economic relationships and involve partners with different needs and interests (e.g., government agencies, non-governmental organizations, corporations, universities, professional associations, philanthropic organizations and communities). As part of a mixed methods study designed to develop an equity-sensitive tool to support more equity-centred North-South GHPs, this critical interpretive synthesis examined reported assessments of GHPs. We examined 30 peer-reviewed articles for power dynamics, equity and inequities, and contradictions or challenges encountered in North-South partnerships. Among articles reviewed, authors most often situated GHPs around a topical focus on research, capacity-building, clinical, or health services issues, with the ‘work’ of the partnership aiming to foster skills or respond to community needs. The specific features of GHPs that were assessed varied widely, with consistently-reported elements including the early phases of partnering; governance issues; the day-to-day work of partnerships; the performance, impacts and benefits of GHPs; and issues of inclusion. Articles shared a general interest in partnering processes and often touched briefly on issues of equity; but they rarely accounted for the complexity of sociopolitical and historical contexts shaping issues of equity in GHPs. Further, assessments of GHPs were often reported without inclusion of voices from all partners or named beneficiaries. GHPs were frequently portrayed as inherently beneficial for Southern partners, without attention to power dynamics and inequities (North-South, South-South). Though historical and political dynamics of the Global North and South were inconsistently examined as influential forces in GHPs, such dynamics were frequently portrayed as complex and characterized by asymmetries in power and resources. Generally, assessments of GHPs paid little attention to the macroeconomic forces in the power and resource dynamics of GHPs highlights the importance of considering the broader political. Our findings suggest that GHPs can serve to entrench both inequitable relationships and unfair distributions of power, resources, and wealth within and between countries (and partners) if inequitable power relationships are left unmitigated. We argue that specific practices could enhance GHPs’ contributions to equity, both in their processes and outcomes. Enhancing partnering practices to focus on inclusion, responsiveness to North-South and South-South inequities, and recognition of GHPs as situated in a broader (and inequitable) political economy. A relational and equity-centred approach to assessing GHPs would place social justice, humility and mutual benefits as central practices —that is, regular, routine things that partners involved in partnering do intentionally to make GHPs function well. Practicing equity in GHPs requires continuous efforts to explicitly acknowledge and examine the equity implications of all aspects of partnering.
