Onions, elephants and lenses; reflections on the accountability for health equity workshop

By Ligia Paina, FHS Researcher

What happens when you bring 80+ social activists, anthropologists, health systems researchers and policy makers together for a three day workshop and ask them to further the collective understanding of accountability and its role in health equity?

I am going to leave that question for the team from the Institute of Development Studies that hosted the workshop, but here I wanted to share some reflections on what was a fascinating event.

Accountability takes on a different meaning depending on the context in which it is described, the actors from whose perspective it is articulated, the language that one uses to define it, and many other spoken and unspoken dimensions, such as politics and power. Defining it becomes even more difficult when you bring in different disciplines and experiences in one workshop. As a result, metaphors were abound. We talked about applying lenses, peeling away at densely packed onions and acknowledging elephants that had made their way into the room.

The anthropologists reminded us of the importance of language in how we define and speak about accountability; that context and history matter and that our perspectives are shaped by many factors, which drive us to have certain assumptions that we may or may not explicitly acknowledge. The social activist shared humbling stories of what building accountability means in practice. How, in specific contexts, a persistent effort is required to cut across multiple sectors, engage multiple actors, and manage formal and informal power dynamics. This often takes place in contexts in which communities are recovering from war or in which the voice of the community is weak and may fail to allow open dialogue and let the voices of those most vulnerable be heard. The health system researchers acknowledged the challenges related to how we define success in accountability interventions. They highlighted that often they can only implement a focused set of interventions for a short period of time, and, how, overall, this could unintentionally reinforce health system fragmentation. To add a further level of complexity, each of these actors had their own lines of accountability – to donors, to constituents – that colored how they engaged with the concepts related to accountability for health equity.

The Future Health Systems team of which I was part of, contributed to various aspects of the workshop. Dr. Shaila Mahmoud from ICDDR,B spoke about the community scorecard pilot that her team is developing, and the lessons to be learned from implementing it in both urban and rural areas in Bangladesh. Dr. Suzanne Kiwanuka asked difficult questions around multiple sources of accountability in a community and unintended consequences of institutionalizing social accountability, which could contribute to distortions in the health system. Dr. Elizabeth Ekirappa-Kiracho led a discussion around opportunities for how to support accountability better – including building the capacity of leaders to manage power dynamics and supporting a balanced set of incentives for embedding accountability structures. Prof. Sara Bennett and Dr. Daniela Rodriguez led a dialogue around the politics of evidence and considerations around whose knowledge counts and the role of knowledge translation. Finally, Prof. David Peters challenged us, in the final plenary of the workshop to both identify and challenge our assumptions, particularly around the role of accountability in ensuring fairness and addressing social determinants of health, leaving us to ponder about the role of researchers in this debate.

This blog does not attempt to do justice to the deep, nuanced discussions we had over the course of the workshop. Nor can it be claimed that these discussions have steered us towards clear solutions. In fact, how to foster sustainable accountability for health equity that can be institutionalized and ready for scale-up is such a huge challenge that the answer may not become apparent to any of us in the near future.

So what did I take away from the workshop? Something about an elephant peeling an onion whilst looking through a variety of lenses…

Or back in the real world, one lesson would be that as researchers we should collectively strive to discuss and develop meaningful formal and informal accountability relationships. The workshop and the examples of work that were presented, suggested that by implementing a ‘learning-by-doing’ approach and co-creating the intervention, it is possible to will begin to open spaces for dialogue, as well as make us all more comfortable with challenging and engaging with power. This is something we will continue to strive to do across all of our FHS projects in the future.

We should continue to rethink and test our assumptions of how to best do so equitably, by understanding each contexts unique accountability eco-system. We also need to agree how to best measure and understand success and the unintended consequences of these endeavors. Finally operationalizing and unlocking institutionalization, sustainability, and intersectionality in accountability relations will go some way into facilitating greater health equity. I look forward to seeing where the conversation goes.