Perceptions and Experiences of Frontline Health Managers and Providers on Accountability in a South African Health District

Abstract Objective This study explored and described accountability as perceived and experienced by frontline health managers and providers of maternal, newborn and child health (MNCH) services in a South African health district.Methods This was a qualitative study involving in-depth interviews with a purposive sample of 58 frontline health managers and providers in the district office and in two sub-districts, examining the meanings of accountability and related lived experiences.Results Accountability was described by respondents as both an organisational mechanism of answerability and responsibility and an intrinsic professional virtue. Accountability relationships were understood to be multidirectional - upwards and downwards in hierarchies, outwards to patients and communities, and inwards to the “self”. The practice of accountability was challenged in organisational environments where impunity and unfair punishment existed alongside each other, where political connections constrained the ability to sanction and by climates of fear and blame. Accountability was enabled by open management styles, teamwork, good relationships between primary health care, hospital services and communities, investment in knowledge and skills development and responsive support systems. The interplay of these enablers and constraints varied across the facilities and sub-districts studied.Conclusions and Recommendations Providers and managers have well-established ideas about, and a language of, accountability. The lived reality of accountability by frontline managers and providers varies and is shaped by micro-configurations of enablers and constraints in local accountability ecosystems. Fairness, open leadership styles, teamwork and collaboration between primary health care and hospitals and community participation were seen as promoting accountability, enabling collective responsibility and a culture of learning rather than blame.