title: The impact of human immunodeficiency virus (HIV) service scale-up on mechanisms of accountability in Zambian primary health centres: a case-based health systems analysis.
abstract: BACKGROUND
  Questions about the impact of large donor-funded HIV interventions on low- and middle-income countries' health systems have been the subject of a number of expert commentaries, but comparatively few empirical research studies. Aimed at addressing a particular evidence gap vis-à-vis the influence of HIV service scale-up on micro-level health systems, this article examines the impact of HIV scale-up on mechanisms of accountability in Zambian primary health facilities.
  
  
  METHODS
  Guided by the Mechanisms of Effect framework and Brinkerhoff's work on accountability, we conducted an in-depth multi-case study to examine how HIV services influenced mechanisms of administrative and social accountability in four Zambian primary health centres. Sites were selected for established (over 3 yrs) antiretroviral therapy (ART) services and urban, peri-urban and rural characteristics. Case data included provider interviews (60); patient interviews (180); direct observation of facility operations (2 wks/centre) and key informant interviews (14).
  
  
  RESULTS
  Resource-intensive investment in HIV services contributed to some early gains in administrative answerability within the four ART departments, helping to establish the material capabilities necessary to deliver and monitor service delivery. Simultaneous investment in external supervision and professional development helped to promote transparency around individual and team performance and also strengthened positive work norms in the ART departments. In the wider health centres, however, mechanisms of administrative accountability remained weak, hindered by poor data collection and under capacitated leadership. Substantive gains in social accountability were also elusive as HIV scale-up did little to address deeply rooted information and power asymmetries in the wider facilities.
  
  
  CONCLUSIONS
  Short terms gains in primary-level service accountability may arise from investment in health system hardware. However, sustained improvements in service quality and responsiveness arising from genuine improvements in social and administrative accountability require greater understanding of, and investment in changing, the power relations, work norms, leadership and disciplinary mechanisms that shape these micro-level health systems.
authors.affiliation: Schools of Public Health and Medicine, University of Alabama, Birmingham, USA. globalstopp@gmail.com.|Centre for Infectious Disease Research in Zambia, PO Box 30338, Lusaka, Zambia. globalstopp@gmail.com.|Nossal Institute for Global Health, University of Melbourne, Level 4, 161 Barry Street, Alan Gilbert Building, Carlton, 3010, VIC, Australia. globalstopp@gmail.com.
authors.forename: Stephanie M
authors.initials: SM
authors.lastname: Topp
authors.affiliation: Nossal Institute for Global Health, University of Melbourne, Level 4, 161 Barry Street, Alan Gilbert Building, Carlton, 3010, VIC, Australia. jim.black@unimelb.edu.au.
authors.forename: Jim
authors.initials: J
authors.lastname: Black
authors.affiliation: Nossal Institute for Global Health, University of Melbourne, Level 4, 161 Barry Street, Alan Gilbert Building, Carlton, 3010, VIC, Australia. martham@unimelb.edu.au.
authors.forename: Martha
authors.initials: M
authors.lastname: Morrow
authors.affiliation: University of Lusaka, Plot No 37413, Mass Media, Lusaka, 101010, Zambia. jchipukuma@gmail.com.
authors.forename: Julien M
authors.initials: JM
authors.lastname: Chipukuma
authors.affiliation: Public Health and Health Policy Unit, ITM-Antwerp, Sint-Rochusstraat 2, 2000, Antwerpen, Belgium. wvdamme@itg.be.|School of Public Health, University of the Western Cape, Robert Sobukwe Road, Bellville, 7535, Republic of South Africa. wvdamme@itg.be.
authors.forename: Wim
authors.initials: W
authors.lastname: Van Damme
mesh_terms: D003151:Community Health Centers / Q000191:economics*; D006078:Government Programs; D015658:HIV Infections / Q000191:economics; D006295:Health Resources / Q000191:economics; D006801:Humans; D007407:Interviews as Topic; D008483:Medical Assistance; D019370:Observation; D019982:Organizational Case Studies; D011320:Primary Health Care / Q000592:standards*; D058996:Quality Improvement; D012424:Rural Population; D012941:Social Responsibility; D013597:Systems Analysis; D015024:Zambia