The impact of human immunodeficiency virus (HIV) service scale-up on mechanisms of accountability in Zambian primary health centres: a case-based health systems analysis

Topp, Stephanie M., Black, Jim, Morrow, Martha, Chipukuma, Julien M., and Van Damme, Wim (2015) The impact of human immunodeficiency virus (HIV) service scale-up on mechanisms of accountability in Zambian primary health centres: a case-based health systems analysis. BMC Health Services Research, 15 (67). pp. 1-14.

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Background: 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.

Methods: 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).

Results: 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.

Conclusions: 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.

Item ID: 39586
Item Type: Article (Research - C1)
ISSN: 1472-6963
Keywords: accountability, HIV service scale-up, primary health centres, health systems
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© 2015 Topp et al.; licensee BioMed Central.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

Funders: Nossal Institute for Global Health, Australian Postgraduate Award
Date Deposited: 29 Jul 2015 01:28
FoR Codes: 16 STUDIES IN HUMAN SOCIETY > 1608 Sociology > 160801 Applied Sociology, Program Evaluation and Social Impact Assessment @ 60%
11 MEDICAL AND HEALTH SCIENCES > 1117 Public Health and Health Services > 111799 Public Health and Health Services not elsewhere classified @ 40%
SEO Codes: 92 HEALTH > 9204 Public Health (excl. Specific Population Health) > 920499 Public Health (excl. Specific Population Health) not elsewhere classified @ 50%
92 HEALTH > 9202 Health and Support Services > 920299 Health and Support Services not elsewhere classified @ 50%
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