Table 1 The initial programme theory

A pluralistic health system harbours a web of accountability relationships between actors who combine the roles of account-holder and accountor, having both accountability entitlements and obligations.

Public accountability is actualised when actors are answerable to the public and remedial action is undertaken. Public accountability requires both answerability and enforceability in order to be actualised. The answerability or the capability of the DHMT, of INGOs and partnerships to inform, evaluate and report in an open manner requires transparency and clarity on whom they represent and deliver services to. Answerability is actualised through practices grounded in compliance and persuasion.

Enforceability is grounded in the capability of the public to demand accountability on the one hand and in meta-governance, i.e. the function, exercised by a state actor(s), of regulating, monitoring and sanctioning on the public’s behalf, on the other hand.

Accountability practices operate along four dimensions (social, political, organisational and the provider dimension). Each dimension has specific bundles of strategies, practices, relationships and outcomes. Accountability is embedded in vertical, horizontal and partnership governance arrangements.

Multi-level governance arrangements weaken public accountability when there is confusion over roles and responsibilities between governing actors.