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A multi-sectoral approach is essential for ensuring social accountability and a Health in All Policies approach.

A multi-sectoral approach (MSA) is an integrated, collaborative process whereby different actors come together to address complex challenges and interrelated goals that relate to PHC, such as universal health coverage (UHC) and the Sustainable Development Goals (SDGs).123 It is a broad term that is variably referred to as “joined-up working”, a “cross-sectoral approach” or an “integrated approach” and encompasses:

  • A whole-of-government (WoG) approach to health, in which ‘public service agencies work across portfolio boundaries to develop integrated policies and programmes towards the achievement of shared or complementary, interdependent goals.3
  • A whole-of-society (WoS) approach to health, which ‘represents a broader approach, moving beyond public authorities and engaging all relevant stakeholders, including individuals, families and communities, intergovernmental organizations, religious institutions, civil society, academia, the media, voluntary associations and [...] the private sector and industry’.3

MSA requires the deliberate involvement of a range of stakeholder groups and sectors, including governmental bodies, the community, civil society, the private sector, payers, provider associations, and nongovernmental organizations. Deliberate involvement means that each stakeholder group and sector is committed to building relationships and networks that enable them to leverage their unique knowledge, expertise, reach, and resources to address shared goals that relate to PHC.12345

PHCPI is a partnership dedicated to transforming the global state of primary health care, beginning with better measurement. While the content in this report represents the position of the partnership as a whole, it does not necessarily reflect the official policy or position of any individual partner organization.

Before taking action, countries should first determine whether multi-sectoral approach is an appropriate area of focus and where to target improvement efforts. Read on to learn how to use country data to:

  • Make informed decisions about where to spend time and resources 
  • Track progress and communicate these updates to constituents or funders 
  • Gain new insights into long-standing trends or surprising gaps

Countries can measure their performance using the Vital Signs Profile (VSP). The VSP is a first-of-its-kind tool that helps stakeholders quickly diagnose the main strengths and weaknesses of primary health care in their country in a rigorous, standardized way. The second-generation Vital Signs Profile measures the essential elements of PHC across three main pillars: Capacity, Performance, and Impact. Multi-sectoral approach is measured in the Governance domain of the VSP (Capacity Pillar).

If a country does not have a VSP, it can begin to focus improvement efforts using the subsections below, which address:

Key indications

If your country does not have a VSP, the indications below may help you to start to identify whether multi-sectoral approach is a relevant area for improvement:

  • Evidence of and capacity for multi-sectoral collaboration
    • Do the following stakeholder groups and sectors within and outside the government engage with the Ministry of Health on issues related to PHC?
      • Other state ministries
      • The private sector
      • Civil society organisations
      • Line departments / government departments at the state level
      • The public/citizens, including vulnerable and marginalized communities
      • Provider associations
      • Academia678
    • Are their roles clearly defined?9
    • Are they supported by clear and transparent decision-making processes (i.e. agreement on how they make decisions)9
    • Are they supported/guided by a multi-sectoral governance framework, such as health in all policies ( HiAP “An approach to public policies across sectors that systematically takes into account the implications for health and health systems of decisions, seeks collaborations, and avoids harmful health impacts in order to improve population health and health equity. A Health in All Policies approach is founded on health-related rights and obligations. It emphasizes the effect of public policies on health determinants and aims to improve the accountability of policy-makers for the effects on health of all levels of policymaking.” )?1011
    • Are MoH staff trained and capacitated to plan and facilitate multi-sectoral collaboration? For example, do they receive training in HiAP “An approach to public policies across sectors that systematically takes into account the implications for health and health systems of decisions, seeks collaborations, and avoids harmful health impacts in order to improve population health and health equity. A Health in All Policies approach is founded on health-related rights and obligations. It emphasizes the effect of public policies on health determinants and aims to improve the accountability of policy-makers for the effects on health of all levels of policymaking.” ?12
    • Have any associated financial costs of multi-sectoral engagements been identified and appropriately budgeted for?12
  • Mechanisms for social participation and multi-sectoral engagement
    • Are initiatives supported by institutionalised mechanisms for social participation and multi-sectoral engagement?679 Examples include:
      • Stakeholder forums
      • Consultations
      • Elections
      • Appointed representatives
      • Legal remedies
      • Choice mechanisms
      • Advisory committees, ad hoc or otherwise
      • Partnerships
      • Surveys
      • Joint budgets, joint workforce, etc.
      • More radically democratic innovations, such as participatory budgeting and citizens’ juries13
    • Are these mechanisms systematic?9 Do they also possess the following characteristics?612
      • Two-way communication
      • Regular, proactive engagement
      • Fair and appropriate consideration given to a range of views
      • Feedback that feeds into decision-making processes
      • Social participation including actions to:
        • Raise awareness of health rights in disadvantaged groups
        • Give voice to the vulnerable to influence policies that affect them
        • Promote responsiveness and the rule of law
  • Inclusion of multi-sectoral voices in health policies and plans
    • What is the extent of stakeholders’ involvement in policy formation, health planning, and monitoring and evaluation processes? Minimal, moderate, or significant?9
    • Do governments publicly disclose the status of PHC implementation and results? Including the extent to which they addressed diverse stakeholder priorities and interests?689121415
Key outcomes and impact

Countries that improve multi-sectoral approach may achieve the following benefits or outcomes:

  • Health in All Policies ( HiAP “An approach to public policies across sectors that systematically takes into account the implications for health and health systems of decisions, seeks collaborations, and avoids harmful health impacts in order to improve population health and health equity. A Health in All Policies approach is founded on health-related rights and obligations. It emphasizes the effect of public policies on health determinants and aims to improve the accountability of policy-makers for the effects on health of all levels of policymaking.” ): integration across government entities whose work intersects and interacts with PHC is an important means of ensuring a HiAP “An approach to public policies across sectors that systematically takes into account the implications for health and health systems of decisions, seeks collaborations, and avoids harmful health impacts in order to improve population health and health equity. A Health in All Policies approach is founded on health-related rights and obligations. It emphasizes the effect of public policies on health determinants and aims to improve the accountability of policy-makers for the effects on health of all levels of policymaking.” approach. HiAP “An approach to public policies across sectors that systematically takes into account the implications for health and health systems of decisions, seeks collaborations, and avoids harmful health impacts in order to improve population health and health equity. A Health in All Policies approach is founded on health-related rights and obligations. It emphasizes the effect of public policies on health determinants and aims to improve the accountability of policy-makers for the effects on health of all levels of policymaking.” requires collaboration and buy-in from multiple stakeholder groups and sectors, as well as considerable time and investment. Thus, a multisectoral approach can help to build the capacity (i.e networks, relationships, shared resources) needed for HiAP “An approach to public policies across sectors that systematically takes into account the implications for health and health systems of decisions, seeks collaborations, and avoids harmful health impacts in order to improve population health and health equity. A Health in All Policies approach is founded on health-related rights and obligations. It emphasizes the effect of public policies on health determinants and aims to improve the accountability of policy-makers for the effects on health of all levels of policymaking.” .9161718
  • Responsiveness, transparency, and accountability: It also helps to ensure that governments, implementing partners, and corporations are held accountable for the content of policies and delivery of health services by the populations they serve. For example, creating resources and communication channels to invite community feedback can help to ensure transparency and strengthen the accountability of the government to the community and the public.91920
  • Efficiency Efficiency refers to the ability of a health system to attain its desired objectives with the available resources, while minimising waste and maximising capacities to deliver care to those who need it. and effectiveness: A multi-sectoral approach can help governments and different stakeholder groups and sectors to use scarce resources to their best advantage. It can also help different stakeholder groups and sectors to use their knowledge and expertise more effectively and thus, design solutions and realise outcomes that could not be achieved in isolation.12345
  • Resilience “The ability of a system, community, or society exposed to hazards to resist, absorb, accommodate to, and recover from the effects of a hazard in a timely and efficient manner, including through the preservation and restoration of its essential basic structures and functions through risk management.” : Sharing knowledge, expertise, and resources across sectors and stakeholder groups can also increase a government’s capacity to prevent, prepare for, and respond to public health issues and emergencies. It can also support the development of more coherent and sustainable policies and activities at a lower cost.4511
  • Health equity: Intersectoral and multisectoral action can lead to the development of health, income, and social policies that foster greater equity21

PHCPI is a partnership dedicated to transforming the global state of primary health care, beginning with better measurement. While the content in this report represents the position of the partnership as a whole, it does not necessarily reflect the official policy or position of any individual partner organization.

Explore this page for a curated list of actions to improve your country's multi-sectoral approach, which embark on:

  • An explanation of why the action is important for a multi-sectoral approach
  • Descriptions of activities or interventions countries can implement to improve their multi-sectoral approach
  • Descriptions of the key drivers in the health system that should be improved to maximise the success or impact of actions
  • Relevant case studies, tools, or resources that showcase what other countries around the world are doing to their multi-sectoral approaches as well as select tools and resources

Key actions:

PHCPI is a partnership dedicated to transforming the global state of primary health care, beginning with better measurement. While the content in this report represents the position of the partnership as a whole, it does not necessarily reflect the official policy or position of any individual partner organization.

Understanding and identifying the drivers of health systems performance--referred to here as “related elements”--is an integral part of improvement efforts. We define related elements as the factors in a health system that have the potential to impact, whether positive or negative, a multi-sectoral approach. Explore this section to learn about the different elements in a health system that should be improved or prioritized to maximize the success of actions described in the “take action” section. 

While there are many complex factors in a health system that can impact a multi-sectoral approach, some of the major drivers are listed below. To aid in the prioritization process, we group the ‘related elements’ into:

Upstream elements

We define “upstream elements” as the factors in a health system that have the potential to make the biggest impact, whether positive or negative, on a multi-sectoral approach.

Policy & leadership

Strong PHC policies and leadership help to establish the systems, laws, and context that build an environment for multisectoral action and citizen-led accountability at multiple levels.55 For social accountability programs to be effective, civil society needs to have institutional structures, including policies and quality management, to ensure that their feedback regarding problems with the health system and services can be rectified through proper channels. More information is available in the Policy & Leadership module.

Adjustment to population health needs

Participatory priority-setting mechanisms, a component of Adjustment to Population Health Needs, are one method of engaging relevant stakeholders, ensuring social accountability, and promoting multi-sectoral approaches in decision-making. More information is available in the Adjustment to Population Health Needs module.

Information & technology

Accessible and well-designed surveillance, information, and communication systems enable transparency of data and open feedback loops and communication channels between actors, just as insufficient information and technology systems can impede these capabilities. These avenues of data can also be used to hold providers and health systems accountable to their populations. More information is available in the Information & Technology module.
 

Population health management

Aspects of both local priority setting and community engagement are mutually reinforcing mechanisms for having a multi-sectoral approach. Priority setting The process of making decisions about how best to allocate limited resources to improve population health. at the local level can help identify existing and emerging social concerns to be elevated back to the national level. Similarly, community engagement mechanisms ensure the participation of communities in social accountability and planning activities. This includes holding governments and services accountable to the needs of communities. More information is available in the Population Health Management module. 

Management of services

Mechanisms of performance measurement and management complement multi-sectoral social accountability by providing a critical data source for holding an array of providers and systems accountable to the populations they serve, helping to overcome the potential for mismanagement of services. More information is available in the Management of Services module. 

PHCPI is a partnership dedicated to transforming the global state of primary health care, beginning with better measurement. While the content in this report represents the position of the partnership as a whole, it does not necessarily reflect the official policy or position of any individual partner organization.

Countries seeking to improve their multi-sectoral approach can pursue a wide array of potential improvement pathways. The short case studies below highlight promising and innovative approaches that countries around the world have taken to improve. 

PHCPI-authored cases were developed via an examination of the existing literature. Some also feature key learnings from in-country experts. 

East Asia & the Pacific
Europe & Central Asia
Latin America & the Caribbean
Middle East & North Africa
North America
South Asia
Sub-Saharan Africa

PHCPI is a partnership dedicated to transforming the global state of primary health care, beginning with better measurement. While the content in this report represents the position of the partnership as a whole, it does not necessarily reflect the official policy or position of any individual partner organization.

Building consensus on what a strong multi-sectoral approach looks like and key strategies to fix gaps is an important step in the improvement process.

Below, we define some of the characteristics of a strong multi-sectoral approach in greater detail:

  • Implementation of any multi- and intersectoral initiative will require commitment and support at the leadership level. This will include establishing a clear and coherent policy agenda for MSA. In doing so, it is critical that contextual factors are taken into account as each country’s health system will face unique challenges depending on its political and socioeconomic context. The implementation of any integrated approach should aim to adapt to the political, administrative and broader societal structures present in any given country.4 Successful, adapted implementation will also rely on understanding who the facilitators are, the working culture in which they operate, and ensuring that a system is not only open to new mechanisms and policies but encourages the spirit of innovation and accompanying risk that comes with implementing a new, integrated approach.43 To that end, the WHO has recommended that more qualitative data be collected on the implementation of new policies in order to better understand the level at which policies and approaches can be transferable from one culture or community to another.43 Some factors to take into consideration to ensure MSAs are adapted to the local context include:

    • Level of political support for multi-sectoral & intersectoral action
    • Financial and human resources available to support implementation efforts
    • Ability of a country’s health system to collaborate with other sectors
    • Pre-existing cross-sectoral relationships
    • Level of engagement from civil society 
    • Public pressure and/or level of support from media

    For example, even if MSA has yet to be fully integrated into a country’s health system, governments can capitalize on pre-existing relationships or informal structures within the health system that are already working to address gaps in the health system. These relationships and informal mechanisms can be leveraged to gain insight into how to build better, more effective partnerships moving forward. Pre-existing relationships can also be particularly useful as trust, respect and mutual interest are typically already established. Additionally, understanding constraints on cross-governmental workings within a context can help leaders create structures to better support MSA. For example, in decentralized contexts where challenges are present in decision-making, a bottom-up approach can be utilized to increase accountability throughout different levels of the government and policymaking process. While these factors - as well as the others listed above - should be considered at the country level to help ensure that multi-sectoral action is adapted to each diverse local context, it is important for countries to share learnings from successful multi- and intersectoral initiatives as they can help inspire other countries to engage in a way that is best suited to their own context.

  • It is vital that MSAs are both holistic and integrated in order to leverage them most effectively. In a time where countries are encouraged to work towards Sustainable Development Goals (SDGs), the capability and appetite to improve upon MSAs is enhanced as these SDGs are extremely interrelated and interdependent. Two ways to achieve more holistic MSAs include the utilization of a whole-of-government (WoG) and/or a whole-of-society (WoS) approach to health:

    • A whole-of-government (WoG) approach to health, in which ‘public service agencies work across portfolio boundaries to develop integrated policies and programmes towards the achievement of shared or complementary, interdependent goals.3
    • A whole-of-society (WoS) approach to health, which ‘represents a broader approach, moving beyond public authorities and engaging all relevant stakeholders,  including individuals, families and communities, intergovernmental organizations, religious institutions, civil society, academia, the media, voluntary associations and [...] the private sector and industry’.3

    The benefit of applying these approaches is 1) that they reinforce the widely helpful body of knowledge that health relies on sectors outside of health care and is highly influenced by the Social Determinants of Health (SDH) and 2) in order to address the SDH and their associated challenges, countries must stray from ‘departmentalism’ in order to breakdown work silos and increase policy coherence.3 These approaches serve as a way to bring together different stakeholders in order to address complex and nuanced challenges and work towards goals that are present across multiple sectors.3However, challenges remain and a collation of learnings from efforts to increase Health in All Policies ( HiAP “An approach to public policies across sectors that systematically takes into account the implications for health and health systems of decisions, seeks collaborations, and avoids harmful health impacts in order to improve population health and health equity. A Health in All Policies approach is founded on health-related rights and obligations. It emphasizes the effect of public policies on health determinants and aims to improve the accountability of policy-makers for the effects on health of all levels of policymaking.” ) in 41 countries including the following:3

    • A lack of sufficient governance and leadership mechanisms during implementation
    • The need for dedicated HiAP “An approach to public policies across sectors that systematically takes into account the implications for health and health systems of decisions, seeks collaborations, and avoids harmful health impacts in order to improve population health and health equity. A Health in All Policies approach is founded on health-related rights and obligations. It emphasizes the effect of public policies on health determinants and aims to improve the accountability of policy-makers for the effects on health of all levels of policymaking.” resources 
    • There is no one-size-fits-all approach to HiAP “An approach to public policies across sectors that systematically takes into account the implications for health and health systems of decisions, seeks collaborations, and avoids harmful health impacts in order to improve population health and health equity. A Health in All Policies approach is founded on health-related rights and obligations. It emphasizes the effect of public policies on health determinants and aims to improve the accountability of policy-makers for the effects on health of all levels of policymaking.”
    • Recognition that health policymakers and other actors within the health sector often lack the necessary skills to work and collaborate with non-health sectors (i.e. diplomacy skills, negotiation skills etc.)
    • There is a real need to increase the literature available on the implementation of MSAs:
      • Implementation mechanisms are underinvestigated
      • There is an inability to generalize research
      • Difficulty in measuring outcomes, impacts and power dynamics of MSAs
      • Of the literature that does exist, the focus is on high and middle-income countries

    One of the major ways to overcome challenges related to the implementation of MSAs is to increase communication between actors and ensure all parties are guiding their work with a shared, common understanding of goals, priorities and objectives.3 This effective communication can enhance the efficiency of collaborations by increasing coordination, ensuring all actors are clear in their roles and responsibilities, uniting around shared language and continuous information sharing as well as keeping all actors consistently engaged through alignment around shared priorities.3

  • Effective MSAs will be sure to engage a wide array of groups - both within and outside the government. This list includes, but is not limited to2345:

    • Other state ministries
    • The private sector
    • Civil society organisations
    • Line departments/government departments at the state level
    • The public/citizens, including vulnerable and marginalized communities
    • Provider associations
    • Academia (WHO 2022; Baez Camargo and Jacobs 2011; Siddiqi et al. 2009)

    Engaging these diverse stakeholders will require platforms that provide the space for effective, streamlined collaboration. For example, identifying different channels and mechanisms for non-governmental groups such as citizen groups, civil society organizations and non-health actors to engage with government stakeholders will be critical to ensure MSAs are as integrated as possible. This could look like: consistent consultations with non-governmental groups as information dissemination arises, ensuring citizen groups have an equal voice and decision-making power as other government stakeholders, involvement in health care planning and policy formation, and continuous promotion of social participation and social accountability.9

  • Within the public sector, there is a large matrix of differing perspectives and viewpoints surrounding all kinds of issues – and healthcare is no exception. For MSAs to be as effective as possible, countries not only need to recognise that these diverse perspectives exist but find ways to build synergy between them and capitalise on the different viewpoints being brought to the table.4 When it comes to joined-up working, it is often not easy for individuals to put aside their personal perspectives or agendas. Finding ways to strike a balance when it comes to differing perspectives is both a challenge and a necessity for MSAs to be implemented successfully. For example, when looking at policy implementation there are often two main approaches or perspectives on how to go about it – top-down and bottom-up perspectives. While top-down perspectives to implementation focus on compliance and monitoring of policy decisions, bottom-up perspectives seek to understand why policy outcomes may differ from initial policy intentions by looking at the behaviour of individuals and groups.4 Oftentimes, the bottom-up approach is extremely helpful in raising perspectives and voices that can often get lost in a top-down or more high-level approach. Successful implementation of MSAs will incorporate both of these perspectives and pull on the strengths of each one. 

    Culture is also critically important to the successful implementation of MSAs. Many dismiss factors relating to culture - norms, values, beliefs etc. - as being ‘soft’ when in reality culture is essential to the successful implementation of MSAs, as behaviour change and how it is impacted by culture is at the heart of implementation.4 It is important that governments work to reconcile differences in organisational culture in order to develop and sustain effective MSAs. They can do so by utilising various strategies that can work to bridge these cultural differences. Some examples include:

    • Deploying or transferring individuals to other departments or shifting them within governmental levels.
    • Having collaborators participate in shared training or capacity-building exercises on various thematic issues such as cultural capacities required for MSA (i.e. ability to work across boundaries, build strategic alliances and relationships, effective negotiation, management of complex situations and the ability to capitalise on opportunities afforded by interdependence).
    • The completion of joint assessments can help raise awareness about cultural differences between groups and collaborators as well as work to promote an integrated perspective.45
    • Build two-way communication between local/community-level leaders and national/system-level leaders and ensure these communication channels protect opportunities for policymakers and those in positions of authority to not only listen but truly understand community perspectives. Building a national strategy that supports two-way communication should include41:
      • Strengthening communication between governmental stakeholders, allowing for cross-sectoral collaboration and consistency of messaging.
      • Ensuring reliable sources of information for communities, in the appropriate languages, with clear messages, and accessible via diverse channels such as audio and visual materials.
      • Developing and strengthening listening and feedback loops to address specific needs, concerns and challenges.
      • Explaining how community feedback and insights will be used and the various scenarios or changes that may arise as a result of their participation.
      • Building the capacity of community representatives, leaders, and caregivers to disseminate information and facilitate dialogue.
      • With community members, co-designing relevant, context-appropriate communication tools and approaches.
      • Reaching out to community workers for their insights on frequently asked questions or misperceptions within communities.
      • Supporting and encouraging targeted research to establish baseline information on community structures, values, beliefs, knowledge and attitudes.

    Finding ways to bridge differences in culture - both personal and organisational -  as well as differences in perspective will inherently foster a more collaborative environment for which MSAs can not only be successfully implemented but continue to sustain and thrive.

  • Effective MSAs require consistent collaboration from a diverse group of actors. However, joined-up working and consistent collaboration can be very demanding on both human and financial resources. To this end, governments should be sure to create as many incentives as possible to encourage continued collaboration. Some examples of incentives that governments and key ministers can promote include: devoting a part of their budget to collaborative working (i.e. training staff, developing necessary information and communication platforms etc.), identifying where certain sectors have extra money or financial room that can be devoted to improving health systems, developing a strong understanding of what it actually costs to support joined-up working in their context, rewarding joined-up working methods during organisational and employee performance reviews, releasing a clear policy statement advocating for the implementation of an MSA and ensuring actors are involved in the development of this policy. The release and promotion of this policy statement can then be used as a way to hold all actors and leaders accountable to their agreed-upon commitments.5


    In order for MSAs to be leveraged effectively, governments must incentivize groups to work together while also developing structures to help support this joined-up working model. For example, developing analytical tools that allow for joint assessments of policy issues is particularly helpful in providing a capacity for stakeholders to work together by establishing a sound evidence base for policymaking and long-term planning.45 In that same vein, it is important to keep in mind how different actors can work together when developing country strategies and policy frameworks for MSA so as to not create roadblocks down the line. Country strategies and frameworks should work to establish coherence and harmonisation among all donors, departments and sectors involved whenever possible.5 Governments can also help build capacity for groups to work together at the strategic and operational level by shifting staff within and across departments or by creating roles that advise on specific sectoral problems and opportunities.5

  • In practice, social accountability can include a variety of initiatives and activities. What makes an initiative “socially accountable” is that it relies on citizen engagement and voice to hold governments and service providers accountable. 

    Generally, the various forms of social accountability fall into one of three categories: democratic accountability, performance accountability, and financial accountability, each described below. Within each type, research suggests four necessary components to maximize opportunities for success (discussed in the How Do I Improve section): transparency of necessary data, top-down responsiveness, representative participation, and citizen-led oversight. 

    While citizen-driven social accountability approaches have existed for decades, integration of social accountability into health sector initiatives is relatively new. Thus, research on these initiatives has shown mixed results. Below, we distill these mixed results to highlight practices that have shown the most promise based both on results of field research and thought papers within the sector.

    DEMOCRATIC ACCOUNTABILITY

    Democratic accountability includes systems, laws, and contexts that build an enabling environment for citizen-led accountability. Traditionally, democratic accountability is thought of as comprising free and open elections and the existence of freedom of information laws36 (for more information from USAID, see this resource on vertical democratic accountability). For the purpose of strengthening PHC, we broaden this definition and consider democratic accountability to be initiatives by governments to open up space for citizen monitoring of the health system. 

    Democratic accountability initiatives often include a combination of transparency and responsiveness efforts.

    Transparency is about shedding light on rules, plans, processes and actions. It is knowing why, how, what, and how much. Transparency ensures that public officials, civil servants, managers, board members and businesspeople act visibly and understandably, and report on their activities.”44

    An example of transparency is the release or publication of the data and information needed for citizens to monitor the health system. For instance, open contracting for health procurement45 includes publishing contracting processes and payments for procurement of things like medicines, medical equipment, and medical infrastructure, to allow public oversight on how these contracts are finalized. Another example is open data initiatives46 that publish government administrative data on budgets, expenditures, and health and performance indicators. Overall, the purpose of these initiatives is to provide enough information to civil society to enable them to effectively monitor the health system.

    Responsiveness initiatives include government actions to respond to needs or requests that arise during citizen monitoring. An example of responsiveness is a supreme audit institution within the government that takes forward and investigates claims or asks by citizens.47 Supreme audit institutions provide civil society with a national-level ally that has the power to ensure that government actors at all levels of the system are budgeting and utilizing funds properly. A less formal but equally important national accountability actor in some countries is the ombudsman’s office. 

    In addition to national actors, many countries incorporate programs or institutions for responsiveness at the subnational level, such as institutionalized social audit programs and community development committees through which local governments work with civil society to jointly monitor elements of the health system. For example, in Zimbabwe, a citizen-led monitoring effort led to the creation of an interface monitoring committee made up of local government officials as well as citizens.48 Local civil society organizations that supported this program credited activities that educated citizens about their rights regarding waste management (the focus of the monitoring effort) and the early and intensive involvement of local government officials in the program as key reasons for its success.

    PERFORMANCE ACCOUNTABILITY 

    Performance accountability is defined as initiatives and actions by citizens and civil society organizations (CSOs) to hold government actors and service providers accountable for their performance through bottom-up monitoring and engagement.3649 This includes the participation of community members and mechanisms to hold administrators and policymakers accountable for the needs of the people. Performance accountability makes up the majority of social accountability initiatives and encompasses what is often considered “traditional” social accountability interventions such as citizen scorecards, citizen oversight committees, and watchdog organizations.

    An example of a performance accountability initiative is the Uttar Pradesh Health Systems Strengthening Project for India, which aims to improve the efficiency, quality, and accountability of health services delivery by strengthening the state health department's management and systems capacity.50 A key component of this initiative was to introduce and strengthen social accountability interventions in order to stimulate community action to demand better services, enhance positive health behavior, and promote social audits of service delivery and resource allocation.51 One component of this intervention includes an information and awareness campaign. A second component involves community members monitoring primary health care services, addressing concerns to village representatives, and participating in preparing a village scorecard that rates the quality of the health services they receive.

    FINANCIAL ACCOUNTABILITY 

    Financial accountability is defined as initiatives and actions by citizens and CSOs to track leakage and mismanagement of public budgets and expenditures within the health system. In practice, this process is quite similar to performance accountability with a different set of outcomes, namely monitoring of expenditure of funds for services. Like performance accountability, it includes a combination of activities that encourage participation of community members and mechanisms to hold those in the system accountable for the needs of the people. Financial accountability includes initiatives such as public expenditure tracking surveys, participatory budgeting and planning, and budget transparency initiatives.  

    In Mexico, for example, the civil society organization Fundar (Centro de Análisis e Investigación) developed an advocacy project called Health, Citizenship, and Human Rights. Within this initiative, Fundar initiated a monitoring strategy to address a series of specific budgetary issues affecting Seguro Popular, the agency tasked with providing healthcare to the country’s 52 million uninsured.52 Over time, the budget and expenditure tracking effort provided a foundation for advocacy and policy change within Seguro Popular to improve health service delivery. Fundar specifically focused on two key outcomes: introducing specific policies to ensure sustainable and consistent public reporting of the health budget to ensure that active civil society organizations could regularly track health expenditures and building their own internal capacity to act as a leader in national advocacy for equitable financing for health services. Both of these components of the project were critical to ensuring that the right information and the right actors to act on this information were in place to achieve better spending for health in Mexico. More information on this project can be found here.

    • Social accountability A measure of whether a country is held accountable to existing and emerging social concerns and priorities based on needs relevant to PHC of internal and external stakeholders.  is a measure of whether a country is held accountable to existing and emerging social concerns and priorities based on need. It also reflects the extent to which a government is fulfilling its health system stewardship function.
    • Health in All Policies ( HiAP “An approach to public policies across sectors that systematically takes into account the implications for health and health systems of decisions, seeks collaborations, and avoids harmful health impacts in order to improve population health and health equity. A Health in All Policies approach is founded on health-related rights and obligations. It emphasizes the effect of public policies on health determinants and aims to improve the accountability of policy-makers for the effects on health of all levels of policymaking.” ): this is a formal process that policymakers can follow to integrate health and health equity considerations into policies across multiple sectors.
    • Extrinsic incentives: Extrinsic motivation Extrinsic motivation refers to motivation that is incentivized by anything other than personal drive and commitment. Extrinsic motivation may be related to monetary or non-monetary individual incentives or environmental incentives. Individual monetary incentives may include salary, pensions, insurance, travel, child care, heat, retention allowances, subsidised meals, subsidised clothing, and subsidised accommodation. refers to motivation that is incentivized by anything other than personal drive and commitment. Extrinsic motivation Extrinsic motivation refers to motivation that is incentivized by anything other than personal drive and commitment. Extrinsic motivation may be related to monetary or non-monetary individual incentives or environmental incentives. Individual monetary incentives may include salary, pensions, insurance, travel, child care, heat, retention allowances, subsidised meals, subsidised clothing, and subsidised accommodation. may be related to monetary or non-monetary individual incentives or environmental incentives. Individual monetary incentives may include: salary, pensions, insurance, travel, child care, rural location, heat, retention allowances, subsidized meals, subsidized clothing, and subsidized accommodation.53
    • Intrinsic incentives: Intrinsic motivation Intrinsic motivation is a feeling of accomplishment driven by organisational goals and the impact of one’s work on patients and communities.  is the feeling of accomplishment driven by organizational goals and the impact of one’s work on patients and communities. 
    • Deliberative, evidence-informed process: A deliberative dialogue or process is a “process of collective and procedural discussion where an inclusive and representative set of stakeholders consider facts from multiple perspectives, converse with one another to think critically about options, and through reasoned argument refine and enlarge their perspectives, opinions and understandings.”
    • Social participation mechanisms provide a means for communities and civil society to participate in their government and meaningfully contribute to the design, financing, governance, and implementation of PHC. They also serve to promote collaborative learning, trust, and self-reflection between governments, communities, and civil society.612132032 Common examples of government-civil society social participation spaces include open-for-all forums, citizen panels, and health committees.20
    • Social accountability A measure of whether a country is held accountable to existing and emerging social concerns and priorities based on needs relevant to PHC of internal and external stakeholders.  mechanisms establish a platform for citizens and civil society, together with service providers and government, to identify and seek solutions to the specific problems they observe with their local health system.19 They also serve to hold governments and implementing partners accountable for existing and emerging social concerns.9
    • Participatory governance: Participatory governance works to contribute to responsive and people-centred health systems by bringing in the voice of end users of health services as well as the general population -- in essence, all those affected by health reforms (the general population, civil society, communities etc.). There are a variety of mechanisms for fostering a dialogue that not only empowers people but also helps to hold governments accountable for their commitments.54

PHCPI is a partnership dedicated to transforming the global state of primary health care, beginning with better measurement. While the content in this report represents the position of the partnership as a whole, it does not necessarily reflect the official policy or position of any individual partner organization.

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