A review and analysis of accountability in global health funding, research collaborations and training: towards conceptual clarity and better practice.

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.

The Integration of Primary Care and Public Health in Medical Students' Training Based on Social Accountability and Community-Engaged Medical Education.

Objectives: Primary care and public health comprise the bedrock of health systems, but their divergence has produced two groups of practitioners either focused on individual health or population health. We explored how primary care and public health were integrated in medical students' training in Zamboanga Peninsula, Philippines. Methods: Our qualitative study reviewed community health plans in two municipalities and thematically analyzed the perspectives of medical students, faculty, alumni, and community stakeholders through focus group discussions and in-depth interviews. Results: Integration began by operationalizing a curriculum requiring medical students to serve rural communities during most of their training-a departure from the conventional, hospital-based medical education in the Philippines. The medical students' community immersion provided opportunities for integrating primary care and public health activities that influenced their personal orientations and the health situation in communities. Integration continued after training as alumni found themselves serving as primary care and public health practitioners in the region. Conclusion: Social accountability and community-engaged medical education provided the foundation for medical students to integrate primary care and public health in practice to respond to local needs.

Cocreation in Health Workforce Planning to Shape the Future of the Health Care System in the Philippines.

BACKGROUND: The Philippines passed landmark legislation in 2019 on universal health coverage, including reforms in the development of its health workforce, an essential building block of responsive health care systems. HEALTH WORKFORCE PLANNING COCREATION PROCESS: We based our planning process on a model of cocreation defined as sharing power and decision making to solve problems collaboratively and build consensus around action. Through cocreation with policy makers, researchers, and other stakeholders, we performed projection studies on 10 selected health professions and estimated the need for primary care at national and subnational levels, which was the most extensive health workforce projection carried out by the Philippine Department of Health to date. We determined health workforce requirements based on target densities recommended by the World Health Organization and a health needs approach that considered epidemiological and sociodemographic factors. In consultation with stakeholders, we interpreted our analysis to guide recommendations to address issues related to health workforce quantity, skill mix, and distribution. These included a broad range of proposals, including task shifting, expanding scholarships and deployment, reforming health professionals' education, and pursuing a whole-of-society approach, which together informed the National Human Resources for Health Master Plan. CONCLUSIONS: Our cocreation model offers lessons for policy makers, program managers, and researchers in low- and middle-income countries who deal with health workforce challenges. Cocreation led to relationship building between policy makers and researchers who jointly performed the research and identified solutions through open communication and agile coordination. To shape future health care systems that are responsive both during normal times and during crises, cocreation would be essential for evidence-informed policy development and policy-relevant research.

Who should decide for local health services? A mixed methods study of preferences for decision-making in the decentralized Philippine health system.

BACKGROUND: The Philippines decentralized government health services through devolution to local governments in 1992. Over the years, opinions varied on the impact of devolved governance to decision-making for local health services. The objective of this study was to analyze decision-makers' perspectives on who should be making decisions for local health services and on their preferred structure of health service governance should they be able to change the situation. METHODS: We employed a mixed methods approach that included an online survey in one region and in-depth interviews with purposively-selected decision-makers in the Philippine health system. Study participants were asked about their perspectives on decision-making in the functions of planning, health financing, resource management, human resources for health, health service delivery, and data management and monitoring. Analysis of survey results through visualization of data on charts was complemented by the themes that emerged from the qualitative analysis of in-depth interviews based on the Framework Method. RESULTS: We received 24 online survey responses and interviewed 27 other decision-makers. Survey respondents expressed a preference to shift decision-making away from the local politician in favor of the local health officer in five functions. Most survey participants also preferred re-centralization. Analysis of the interviews suggested that the preferences expressed were likely driven by an expectation that re-centralization would provide a solution to the perceived politicization in decision-making and the reliance of local governments on central support. CONCLUSIONS: Rather than re-centralize the health system, one policy option for consideration for the Philippines would be to maintain devolution but with a revitalized role for the central level to maintain oversight over local governments and regulate their decision-making for the functions. Decentralization, whether in the Philippines or elsewhere, must not only transfer decision-making responsibility to local levels but also ensure that those granted with the decision space could perform decision-making with adequate capacities and could grasp the importance of health services.

Optimising decentralisation for the health sector by exploring the synergy of decision space, capacity and accountability: insights from the Philippines.

BACKGROUND: Several studies on decentralisation have used the 'decision space' approach to assess the breadth of space made available to decision-makers at lower levels of the health system. However, in order to better understand how decentralisation becomes effective for the health sector, analysis should go beyond assessing decision space and include the dimensions of capacity and accountability. Building on Bossert's earlier work on the synergy of these dimensions, we analysed decision-making in the Philippines where governmental health services have been devolved to local governments since 1992. METHODS: Using a qualitative research design, we interviewed 27 key decision-makers at different levels of the Philippine health system and representing various local settings. We explored their perspectives on decision space, capacities and accountability in the health sector functions of planning, financing and budget allocation, programme implementation and service delivery, management of facilities, equipment and supplies, health workforce management, and data monitoring and utilisation. Analysis followed the Framework Method. RESULTS: Across all functions, decision space for local decision-makers was assessed to be moderate or narrow despite 25 years of devolution. To improve decision-making in these functions, adjustments in local capacities should include, at the individual level, skills for strategic planning, management, priority-setting, evidence-informed policy-making and innovation in service delivery. At institutional levels, these desired capacities should include having a multi-stakeholder approach, generating revenues from local sources, partnering with the private sector and facilitating cooperation between local health facilities. On the other hand, adjustments in accountability should focus on the various mechanisms that can be enforced by the central level, not only to build the desired capacities and augment the inadequacies at local levels, but also to incentivise success and regulate failure by the local governments in performing the functions transferred to them. CONCLUSION: To optimise decentralisation for the health sector, widening decision spaces for local decision-makers must be accompanied by the corresponding adjustments in capacities and accountability for promoting good decision-making at lower levels in the decentralised functions. Analysing the health system through the lens of this synergy is useful for exploring concrete policy adjustments in the Philippines as well as in other settings.

What conditions enable decentralization to improve the health system? Qualitative analysis of perspectives on decision space after 25 years of devolution in the Philippines.

BACKGROUND: Decentralization is promoted as a strategy to improve health system performance by bringing decision-making closer to service delivery. Some studies have investigated if decentralization actually improves the health system. However, few have explored the conditions that enable it to be effective. To determine these conditions, we have analyzed the perspectives of decision-makers in the Philippines where devolution, one form of decentralization, was introduced 25 years ago. METHODS: Drawing from the "decision space" approach, we interviewed 27 decision-makers with an average of 23.6 years of working across different levels of the Philippine government health sector and representing various local settings. Qualitative analysis followed the "Framework Method." Conditions that either enable or hinder the effectiveness of decentralization were identified by exploring decision-making in five health sector functions. RESULTS: These conditions include: for planning, having a multi-stakeholder approach and monitoring implementation; for financing and budget allocation, capacities to raise revenues at local levels and pooling of funds at central level; for resource management, having a central level capable of augmenting resource needs at local levels and a good working relationship between the local health officer and the elected local official; for program implementation and service delivery, promoting innovation at local levels while maintaining fidelity to national objectives; and for monitoring and data management, a central level capable of ensuring that data collection from local levels is performed in a timely and accurate manner. CONCLUSIONS: The Philippine experience suggests that decentralization is a long and complex journey and not an automatic solution for enhancing service delivery. The role of the central decision-maker (e.g. Ministry of Health) remains important to assist local levels unable to perform their functions well. It is policy-relevant to analyze the conditions that make decentralization work and the optimal combination of decentralized and centralized functions that enhance the health system.

Soil-Transmitted Helminthiasis and Schistosomiasis in Children of Poor Families in Leyte, Philippines: Lessons for Disease Prevention and Control.

Objective: Neglected tropical diseases (NTDs) continue to be a public health problem in the Philippines. We assessed the association of soil-transmitted helminthiasis (STH) and schistosomiasis with selected health-related and socioeconomic variables in four villages in Leyte, Philippines. Methods: Stool specimens from 418 adults and 533 of their children from 209 families were examined through the Kato-Katz technique. Results: STH and schistosomiasis were present in 64.6% and 12.5%, respectively, of study participants. Analysis through the generalized linear mixed model revealed a number of associations between infection in parents and their children. Findings indicate that years of disease prevention and control efforts in these areas have been unable to bring down prevalence in children and their parents. Eliminating NTDs as public health problems will require a systems thinking approach beyond implementation of vertical control programs alone.

Parasitological and nutritional status of school-age and preschool-age children in four villages in Southern Leyte, Philippines: Lessons for monitoring the outcome of Community-Led Total Sanitation.

While preventive chemotherapy remains to be a major strategy for the prevention and control of soil-transmitted helminthiases (STH), improvements in water, sanitation, and hygiene (WASH) comprise the long-term strategy to achieve sustained control of STH. This study examined the parasitological and nutritional status of school-age and preschool-age children in four villages in Southern Leyte, Philippines where two of the villages attained Open-Defecation-Free (ODF) status after introduction of Community-Led Total Sanitation (CLTS). A total of 341 children (89.0% of the total eligible population) submitted stool samples which were examined using the Kato-Katz technique. Results showed that 27.9% of the total stool samples examined had at least one type of STH (cumulative prevalence), while 7.9% had moderate-heavy intensity infections. Between the two villages where CLTS was introduced, Buenavista had a significantly higher cumulative prevalence of STH at 67.4% (p<0.001) and prevalence of moderate-heavy intensity STH at 23.5% (p=0.000), while Caubang had a significantly lower cumulative prevalence at 4.9% and prevalence of moderate-heavy intensity at 1.8%. On the other hand, the non-CLTS villages of Bitoon and Saub had similar rates for cumulative prevalence (16.7% and 16.8%, respectively; p=0.984) and prevalence of moderate-heavy intensity STH (2.0% and 3.1%, respectively; p=1.000). The findings may be explained by factors that include possible reversion to open defecation, non-utilization of sanitary facilities, and mass drug administration (MDA) coverage, although further studies that can accurately assess the impact of CLTS are recommended. While this study was descriptive, the data indicate no clear pattern among the parasitological and nutritional parameters, as well as the presence of CLTS in the village, suggesting the need to monitor the ODF status of villages on a regular basis even after the end of CLTS activities to ensure the sustainability of the CLTS approach. In order to achieve effective control of STH, deeper collaboration between the WASH and STH sectors are recommended where partners can work together in the area of monitoring and evaluation that may include improved parasitological and nutritional status in high-risk groups, as well as sustainable behavior change as outcome indicators.

Soil-transmitted helminthiases in secondary school students in selected sites in two provinces in the Philippines: policy implications.

The latest World Health Organization (WHO) strategic plan for eliminating soil-transmitted helminthiases (STHs) as a public health problem in children puts the emphasis on school-age children. On the other hand, the Philippine national helminth control program excludes secondary school students in mass deworming for STH. This study determined the prevalence and intensity of STH in a sample of 633 students (14-15 years old) in selected secondary schools in two Philippine provinces. Stool specimens were processed following the Kato-Katz technique and examined for the presence of helminth ova. Overall cumulative prevalence of STH was 31.3%, while prevalence of moderate-heavy-intensity infections was 7.7%, well beyond the WHO target of ≤1% for reducing morbidity in school-age children. Recommendations were made to update the Philippine helminth control program and to re-examine the WHO strategic plan so that helminth prevention and control strategies may also be emphasized for secondary school students especially in high-prevalence areas.