Background: Relationships of power, responsibility and accountability between health systems actors are considered central to health governance. Despite increasing attention to the role of accountability in health governance a gap remains in understanding how local accountability relations function within the health system in Central Asia. This study addresses this gap by exploring local health governance in two districts of Tajikistan using principal-agent theory. Methods: This comparative case study uses a qualitative research methodology, relying on key informant interviews and focus group discussions with local stakeholders. Data analysis was guided by a framework that conceptualises governance as a series of principal-agent relations between state actors, citizens and health providers. Special attention is paid to voice, answerability and enforceability as crucial components of accountability. Results: The analysis has provided insight into the challenges to different components making up an effective accountability relationship, such as an unclear mandate, the lack of channels for voice or insufficient resources to carry out a mandate. The findings highlight the weak position of health providers and citizens towards state actors and development agents in the under-resourced health system and authoritarian political context. Contestation over resources among local government actors, and informal tools for answerability and enforceability were found to play an important role in shaping actual accountability relations. These accountability relationships form a complex institutional web in which agents are subject to various accountability demands. Particularly health providers find themselves to be in this role, being held accountable by state actors, citizens and development agencies. The latter were found to have established parallel principal-agent relationships with health providers without much attention to the role of local state actors, or strengthening the short accountability route from citizens to providers. Conclusion: The study has provided insight into the complexity of local governance relations and constraints to formal accountability processes. This has underlined the importance of informal accountability tools and the political-economic context in shaping principal-agent relations. The study has served to demonstrate the use and limitations of agency theory in health governance analysis, and points to the importance of entrenched positions of power in local health systems.
In many countries high levels of corruption persist in spite of the adoption of so-called anti-corruption “best practices”. In this paper we make a call to pursue a context-sensitive inquiry into the drivers of corruption in order to substantially improve the practices and effects of anti-corruption.
We discuss evidence from case studies in Africa, Central Asia and the Caucasus suggesting that high levels of corruption are associated to a significant discrepancy between formal rules and informal practices. Informal practices of co-optation, control and camouflage are used by political and business elites to safeguard regime survival via a de facto re-distribution of public resources in favour of informal networks of “insiders”.
From the perspective of citizens, corrupt acts such as bribing enjoy social acceptability especially when they are effective in solving practical problems and protecting livelihoods. The functional relevance of informal practices clarifies the factors behind the limited effectiveness of anti-corruption law-driven reforms, short-term action plans, and technical measures that focus on particular processes, procedures and institutions.
We argue for the need to ponder informality and consider how it may help us develop better anti-corruption strategies. The prevalence and entrenched nature of informal practices indicate their heuristic potential: they can tell us what we are missing in official policies, inform about resistances and can help uncover pathways to strategic, sustainable reforms.
This paper has been presented at the OECD Global Anti-Corruption & Integrity Forum 2017 in a form of a poster presentation.
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