Promoting transparency and accountability with district league tables in Sierra Leone and Malawi

Highlights

• League tables are suitable for promoting transparency and accountability in health sector management

• Data quality improvement and awareness of relative performance are immediate gains

• At district levels, league tables should be changeable and replicable to cater local needs

Abstract

Objectives

This paper looks at the effects on transparency and accountability of introducing league tables in the health sector in Sierra Leone and Malawi.

Methods

Drawing on long-term action research in the two countries, we have supported development of league tables at district levels. Our practical aim of this work has been to design and develop a tool that helps districts create and change league tables as they please, based on indicators relevant for them. This has been done in a participative manner. The research covers 3 years in Sierra Leone and 2 years in Malawi.

Results

Our findings show that such tools have positive immediate effects, most notably on providing new information about relative performance, and improving data quality. They contribute to understanding of health indicators, their applicability, reliability, and relevance at various levels of the health sector. League tables are also suitable for communicating priorities, giving higher levels a way to signal what health facilities are held accountable by

Conclusion

League tables are a promising tool for advancing transparency and accountability at district levels. An implication for policy is that access to peer data is necessary to evaluate your own performance. The true benefits of league tables at district level can only be reaped when they are easily changed and replicated, becoming an integral part of routine district monitoring and evaluation.

Introduction

Transparency and accountability are widely held as key building blocks of a well-functioning health system. Global health initiatives are now almost exclusively based on the paradigm that health providers are held accountable by the public, and transparency is the key to achieve this. In 2015, leaders of the global health agencies signed a five-point call for action to strengthen health measurement and accountability [1]. Two of their main aims are to strengthen country health systems to enable the use of data “at all levels” and promote accountability by holding “transparent review of progress at facility, subnational, national, regional, and global levels” (page 1). These goals are explicitly addressing the slow development of evidence-based management rooted in local data, despite the large progress of many countries to strengthen the data collection and processing capacities.

One set of tools widely implemented to provide patient - provider transparency and support accountability is league tables, that ranks health service providers, both private and public, according to a set of service delivery indicators [2]. While the benefits of league tables include helping to make informed decisions, providing a platform for health service evaluation, and incentivizing behavioral change, these tools also have restraining factors related to data quality issues, creative reporting, and stigmatization of (apparently) poor performers [3]. Similar tools, such as scorecards [4], and the balanced scorecard [5] are also used to enhance transparency and assess countries’ health performance. Common for these efforts is that the tool is linked to a beneficiary-provider relationship, either for patients to assess prospective health service providers, or for funders to assess effects of interventions on a national scale. At the same time, the benefits of strengthening transparency and accountability also within the health system and health provider organizations have received much less attention. Where league tables have been applied as an evaluation and management tool for the health system itself, it is at national or regional levels only. The literature on the use of league tables as a management tool within the health system remains thin, and the literature on development and use of league tables for district level management is almost non-existent.

In this paper, our research objective is to directly address these gaps by looking at the effects of district league tables on transparency and accountability. Based on empirical studies in Sierra Leone and Malawi, we evaluate the introduction of league tables, and the implications within the public health services. We argue that league tables can be a powerful tool for increased performance both intra-organizationally and at district level. We further draw implications by arguing that for this to take place the tool needs to be simple and flexible, focusing on conveying relative performance rather than being an overly intricate management and strategy tool.