Sparking, supporting and steering change: grounding an accountability framework with viewpoints from Nigerian routine immunization and primary health care government officials.

Existing accountability efforts in Nigeria primarily serve as retrospective policing. To enable accountability to guide change prospectively and preemptively, we drew from a literature review to develop a framework that highlights mutually reinforcing dimensions of accountability in health systems along three counterbalancing axes. The axis of power sparks change by wielding 'sticks' that curb the potential abuse of power, but also by offering 'carrots' that motivate constructive agency. The axis of ability supports change by enabling service delivery actors with formal rules that appropriately expand their authority to act, but also the informal norms and inputs for improved performance. Last, the axis of justice orients the strategic direction of change, balancing political representation, community ownership and social equity, so that accountability measures are progressive, rather than being captured by self-interests. We consulted Nigerian government officials to understand their viewpoints on accountability and mapped their responses to our evolving framework. All government officials (n = 36) participating in three zonal workshops on routine immunization filled out questionnaires that listed the top three opportunities and challenges to strengthening accountability. Thematically coded responses highlighted dimensions of accountability within the axes of ability and power: clarifying formal roles and responsibilities; transparency, data and monitoring systems; availability of skilled health personnel that are motivated and supervised; addressing informal norms and behaviours; and availability of inputs regarding funding and supplies. Other dimensions of accountability were mentioned but were not as critical from their viewpoints: managerial discretion; sanctions and enforcements; political influence and community engagement. Strikingly, almost no respondents mentioned social equity as being an important aspect of accountability, although a few mentioned broad development concerns that reflected community perspectives. Reframing accountability as a means of sparking, supporting and steering change can highlight different dimensions of health systems that need reform, particularly depending on the positionality of the viewpoints consulted.

Evaluation of the integrated disease surveillance and response system for infectious diseases control in northern Ghana.

BACKGROUND: Well-functioning surveillance systems are crucial for effective disease control programs. The Integrated Disease Surveillance and Response (IDSR) strategy was developed and adopted in 1998 for Africa as a comprehensive public health approach and subsequently, Ghana adopted the IDSR technical guidelines in 2002. Since 2012, the IDSR data is reported through the new District Health Information Management System II (DHIMS2) network. The objective was to evaluate the Integrated Disease Surveillance and Response (IDSR) system in northern Ghana. METHODS: This was an observational study using mixed methods. Weekly and monthly IDSR data on selected infectious diseases were downloaded and analyzed for 2011, 2012 and 2013 (the years before, of and after DHIMS2 implementation) from the DHIMS2 databank for the Upper East Region (UER) and for two districts of UER. In addition, key informant interviews were conducted among local and regional health officers on the functioning of the IDSR. RESULTS: Clinically diagnosed malaria was the most prevalent disease in UER, with an annual incidence rate close to 1. Around 500 suspected HIV/AIDS cases were reported each year. The highest incidence of cholera and meningitis was reported in 2012 (257 and 392 cases respectively). Three suspected cases of polio and one suspected case of guinea worm were reported in 2013. None of the polio and guinea worm cases and only a fraction of the reported cases of the other diseases were confirmed. A major observation was the large and inconclusive difference in reported cases when comparing weekly and monthly reports. This can be explained by the different reporting practice for the sub-systems. Other challenges were low priority for surveillance, ill-equipped laboratories, rare supervision and missing feedback. CONCLUSIONS: The DHIMS2 has improved the availability of IDSR reports, but the quality of data reported is not sufficient. Particularly the inconsistencies between weekly and monthly data need to be addressed. Moreover, support for and communication within the IDSR system is inadequate and calls for attention.