The missing factor in equity?

Participation and accountability in health systems

Von Rene Loewenson

In a time of scarce resources and in a context of significant new threats, such as high HIV/AIDS related illness and poverty, ensuring that health systems meet priority health needs demands choices: Choices on how national resources are to be shared and the weighting given to health, choices within health systems on where and how to spend public resources, choices on how to motivate and direct private health spending and choices on how household contributions will be balanced against state contributions. Three social dimensions of equity need greater policy and programme attention, if vertical equity and pro-poor policies are to be achieved: Social networking influences the ability of people and households to make and act on their choices, levels of participation influence their interaction with public services while the system of governance influence the way societal resources are distributed to support those choices.

The increasing gap between current knowledge and practice has generated tension within health systems. Health professionals have expressed dissatisfaction over services and conditions that do not provide adequate resources to reflect their professional capacities. Many communities have expressed dissatisfaction with the gap between what they know to be possible (and what they see some communities accessing in preventive and curative health) and their own health services. Perhaps the most recent and visible appearance of this is in the terrible inequality between north and south in access to therapies for AIDS. It has also however been present for a much longer time in relation to access to known therapies for many preventable diseases, or more importantly to the water supply, sanitation or other inputs needed to prevent them.

The solution to this problem lies in part in the development of cheaper and more cost effective technologies. But there is a bottom line to „low cost“ and it usually exceeds the 5 US-Dollar per capita that some populations of the region access for health, even while others access significantly more. It must therefore also lie in the manner in which different social groups are able to direct resources towards their health needs and to access existing technical options.

It is commonly stated that people are the centre of health systems and services. People play many roles, as producers of health inputs and providers of goods and services for health; as consumers of health and health care inputs; as contributors to the financing of health systems, and as citizens in defining and guiding the implementation of the norms, standards and policies that shape health systems. Despite the centrality of this role, we live in a world where the majority of people are de jure citizens but continue to be excluded from participation in social, political and economic life, whether through economic deprivation, or through centralisation of political power or bureaucratic authority.

This exclusion intensifies when people lose access to health services. Used to strong state driven policies and systems, when health systems declined in countries of the region, many of t he poorest people turned to self-help and became spectators of a collapsing national asset. As noted in the recent Health Review Commission in Zimbabwe, "The system is characterised by apprehension and uncertainty about its future among the general public and health workers." (1999).

What are the dimensions of social and health systems that enable social groups to influence policy and direct resources towards their health needs? This paper proposes that for vertical equity, health systems need to pay attention to three major dimensions: social networking, participation across all aspects of health systems and measures for enhancing informed stakeholder involvement in and accountability of governance in health.

Social networks

It has been evident for some time that social factors such as female education are critical for health outcomes, but there is a growing body of evidence that social exclusion and isolation is itself unhealthy In contrast social norms and networks appear to improve household welfare and to enhance the efficiency of society by facilitating co-ordinated public action. Equitable forms of health financing, for example, are based on risk pooling and solidarity, which at community level depend on social networks. A World Bank study in Tanzania found for example that membership in groups and networks was a key contributor to household social welfare even after taking account of the size of the household, male schooling, female schooling, household assets, market access and after controlling for other human, natural, physical capital variables. Village level networking or participation in groups had a stronger relationship with household wellbeing than female education or market access. Organisational and associational infrastructure appeared to be an important vehicle for improvements in household wellbeing. Conversely one dimension of poverty and deprivation is social isolation.


„Community Involvement in Health“ (CIH) or „participation“ has been recognised as a critical dimension of health systems for many decades. The 1976 Alma Ata declaration made participation a central feature of primary health care. The 1987 WHO Harare declaration endorsed direct public involvement in health systems and the reorientation of political and health systems to support such participation.

Despite longstanding policy support and experience, the term „participation“ appears to have many meanings, to be poorly operationalised and often ambiguously used in health systems. For vertical equity, those forms of participation that promote health knowledge, health seeking behaviours, inclusion of community preferences in health systems and enhance responsiveness of health systems in low income communities would need to be promoted. In doing this ambiguities in the use of „participation“ would need to be addressed.


The wider definition of participation leads into the third dimension, which is the nature of governance systems in health. This refers to the relationship between the state and citizens, whether the latter is organised as private sector or through civil society. It incorporates how different social groups articulate their interests, the way political, economic and administrative authority is exercised; how social groups exercise their rights and obligations and how power is exercised in managing the economic and social resources for health. Of importance to equity it concerns both the measures that citizens use to articulate and insert their interests in policy, the measures that the state uses to protect national interests and public goods within a diverse range of social interests and the systems through which these policy measures are negotiated and applied.

These elements of governance are clearly changing. In many countries, state driven welfare systems and government sponsored associations going down to grassroots level were used to build trust and legitimacy around policies and programmes that were essentially developed at central level. As liberalisation policies have widened the roles, responsibilities and burdens of social actors outside the state, it has also led to a refocus on the relationship between state and non-state actors in shaping and implementing public policy. This is a response to many real pressures, including citizen dissatisfaction with erosion of basic public health rights and standards and with quality of care increased citizen access to information and education a growing diversity of contributions to and channels of service delivery increased direct burdens of care on citizens due to AIDS, rising costs of care and declining service coverage a growing demand from citizens to hold bearers of public office responsible for their performance and the results of their decisions.

*Rene Loewenson is programme manager of the Regional network for Equity in Health in Southern Africa (EQUINET). Contact:, Her input (Powerpoint slides) at the MMS Symposium is part of the Symposium’s internet documentation.

Rene Loewenson’s contribution to this reader is a short extract of a paper examining the features of social and governance systems that support vertical equity in health and their current application within health systems. The paper which draws from published literature, findings of action research work in Zimbabwe and experiences shared and conclusions from an EQUINET/TARSC/WHO/IDRC southern African regional meeting on public participation in Health systems held in May 2000 (EQUINET/TARSC 2000) proposes measures and mechanisms that need to be included or strengthened within health systems in order to enhance the relationship between citizen and state towards enhancing vertical equity. The complete paper “Participation and accountability in health systems: The missing factor in equity?“ (Equinet Discussion Paper 1) can be downloaded from: (27 p., pdf) or ordered at EQUINET.