Local health governance in Tajikistan: accountability and power relations at the district level

Abstract

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.

How does power shape district health management team responsiveness to public feedback in low- and middle-income countries: an interpretive synthesis

“…, 2020 ). Finally, in Tajikistan, NGO-supported community-based organizations (CBOs) at the village level had little leverage to demand feedback from the DHMT as they were directly linked to NGOs rather than the state mechanisms ( Jacobs and Baez Camargo, 2020 ).…”

“…DHMTs also operated in contexts of resource scarcity illustrated by unpredictable and inadequate disbursements of funds from national or regional levels ( Van Belle and Mayhew, 2016 ; Nyikuri et al. , 2017 ; Jacobs and Baez Camargo, 2020 ), understaffing and low supplies of commodities for the primary health-care (PHC) facilities they supervised ( Tuba et al. , 2010 ; Jacobs and Baez Camargo, 2020 ).…”

“…, 2017 ; Jacobs and Baez Camargo, 2020 ), understaffing and low supplies of commodities for the primary health-care (PHC) facilities they supervised ( Tuba et al. , 2010 ; Jacobs and Baez Camargo, 2020 ). NGOs operating at the district level sometimes filled a few of these resource gaps ( Tuba et al.…”

“…, 2019 ; Razavi et al. , 2019 ; Jacobs and Baez Camargo, 2020 ; Mukinda et al. , 2020 ; Parashar et al.…”

RoMoMatteR: Empowering Roma Girls’ Mattering through Reproductive Justice

“…In this process, communities must have undisputed leadership, because it is rightfully theirs [ 37 ]. Lastly, overcoming the inequities suffered by Roma girls requires processes of accountability that empower communities to achieve effective results [ 59 ]. This requires evaluation processes that respect democratic rights and freedoms.…”