Topp Stephanie M, Black Jim, Morrow Martha, Chipukuma Julien M, Van Damme Wim
Schools of Public Health and Medicine, University of Alabama, Birmingham, USA.
Centre for Infectious Disease Research in Zambia, PO Box 30338, Lusaka, Zambia.
BMC Health Serv Res. 2015 Feb 18;15:67. doi: 10.1186/s12913-015-0703-9.
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.
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).
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.
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.
关于大型捐助方资助的艾滋病干预措施对低收入和中等收入国家卫生系统的影响问题，已有多篇专家评论文章探讨，但实证研究相对较少。针对艾滋病服务扩大对微观层面卫生系统影响方面的特定证据空白，本文考察了艾滋病服务扩大对赞比亚初级卫生设施问责机制的影响。
以效果机制框架及布林克霍夫关于问责制的研究为指导，我们开展了一项深入的多案例研究，以考察艾滋病服务如何影响赞比亚四个初级卫生中心的行政和社会问责机制。研究地点根据已开展（超过3年）抗逆转录病毒治疗（ART）服务以及城市、城郊和农村特征进行选择。案例数据包括对提供者的访谈（60次）；对患者的访谈（180次）；对机构运营的直接观察（每个中心2周）以及关键信息提供者访谈（14次）。
对艾滋病服务的资源密集型投资在四个抗逆转录病毒治疗部门的行政问责方面取得了一些早期成效，有助于建立提供和监测服务所需的物质能力。同时对外部监督和专业发展的投资有助于提高个人和团队绩效的透明度，并强化了抗逆转录病毒治疗部门的积极工作规范。然而，在更广泛的卫生中心，行政问责机制仍然薄弱，受到数据收集不力和领导能力不足的阻碍。社会问责方面也难以取得实质性进展，因为艾滋病服务扩大对更广泛机构中根深蒂固的信息和权力不对称问题几乎没有起到作用。
对卫生系统硬件的投资可能会在初级层面服务问责方面带来短期成效。然而，要通过社会和行政问责的真正改善实现服务质量和响应能力的持续提升，需要更深入地理解并投资于改变塑造这些微观层面卫生系统的权力关系、工作规范、领导能力和纪律机制。
