title: Public accountability needs to be enforced -a case study of the governance arrangements and accountability practices in a rural health district in Ghana.
abstract: Improving public accountability is currently high on the global agenda. At the same time, the organisation of health services in low- and middle-income countries is taking place in fragmented institutional landscapes. State and non-state actors are involved in increasingly complex governance arrangements. This often leads to coordination problems, confusion of roles and responsibilities and possibly accountability gaps. This study aimed at assessing the governance arrangements and the accountability practices of key health actors at the level of a Ghanaian health district with the aim to understand how far public accountability is achieved.
  
  
  
  We adopted the case study design as it allows for in-depth analysis of the governance arrangements and accountability relations between actors, their formal policies and actual accountability practices towards the public and towards stakeholders. Data were collected at a rural health district using in-depth interviews, observation and document review. In the analysis, we used a four-step sequence: identification of the key actors and their relationships, description of the multi-level governance arrangements, identification of the actual accountability relations and practices between all actors and finally appraisal of the public accountability practices, which we define as those practices that ensure direct accountability towards the public.
  
  
  
  In this rural health district with few (international) non-governmental organisations and private sector providers, accountability linkages towards management and partners in health programmes were found to be strong. Direct accountability towards the public, however, was woefully underdeveloped. This study shows that in settings where there is a small number of actors involved in organising health care, and where the state actors are underfunded, the intense interaction can lead to a web of relations that favours collaboration between partners in health service delivery, but fails public accountability.
  
  
  
  It is clear that new formal channels need to be created by all actors involved in health service delivery to address the demand of the public for accountability. If the public does not find an adequate response to its genuine concerns, distrust between communities and service users on one hand, and providers, international non-governmental organisations and District Health Management Teams on the other is likely to increase to the detriment of all parties' interests.
authors.affiliation: Department of Public Health, Health Policy Unit, Institute of Tropical Medicine, Nationalestraat 155, B-2000, Antwerp, Belgium. svanbelle@itg.be.
authors.forename: Sara
authors.identifier: 0000-0003-2074-0359
authors.initials: S
authors.lastname: Van Belle
authors.affiliation: Politics and Policy Group, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Susannah H
authors.initials: SH
authors.lastname: Mayhew
mesh_terms: D003299:Cooperative Behavior; D003695:Delivery of Health Care / Q000458:organization & administration*; D005869:Ghana; D006076:Government; D006801:Humans; D019982:Organizational Case Studies; D017150:Public Sector / Q000458:organization & administration*; D019035:Rural Health Services / Q000458:organization & administration*; D012941:Social Responsibility
keywords: Accountability; Ghana; Governance; Health districts; NGO