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The Importance of Politics: Hierarchies and Accountability
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The Importance of Politics: Hierarchies and Accountability

In this video, Oluwaseun Akinyemi discusses how international agencies must start at the top for collaboration on vaccination campaigns (Step 2.11)
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OLUWASEUN AKINYEMI: Moving on to the importance of politics, hierarchies, and accountability. From this slide, we can see that UNICEF and [INAUDIBLE] like UNICEF, World Health Organization, WHO, private partners, like the Rotary and the Bill and Melinda Gates Foundation, as well as the USAID, United States Agency for International Development, and Japan International Cooperation Agency at the level of national government. Many times in many settings in many countries, they start their cooperation with the national government, who will then introduce them to the state and district government. And then that trickles down to the local government for implementation. But in some other setting, as I said earlier, management of the health system has been devolved to the states and to the district government.
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But it depends on the setting, and international agency must start from the top in order to ensure adequate and genuine collaboration and to ensure that the partnership works. Leadership and governance, this is one of the most important building blocks of the health system according to the World Health Organization system framework. Here we see a quote from an Afghani health official saying, “As per my opinion we need to have a healthy and good management system. Responsible and accountable government is very important.” I’d like you to think about the challenges in practicing the model we just described.
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What do you think are the challenges in having all the partners, all the donors coming from the national government and then being introduced to the states and the local government? What do you think could be the challenge? Do you see any sort of top down planning or top down implementation? What do you think could be the challenge for reception from the state or from the local government when we have this type of top down style or top down implementation style? I’d like you to take a moment to ponder on that.
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We’ll go straight to the edge of accountability. We’ll talk about a few points on the ideas. Social accountability, which is defined as the ongoing engagement of collective actors in civil society to hold the state to account for failures to provide public goods. In many developing countries, this is a real issue. Social accountability is poor, so governments get away with a number of [INAUDIBLE]. But in many developed countries, this is better. So I look at populations particularly concerned about polio vaccination. Are they concerned about routine immunization? Will they demand accountability from the health system? If they do, will it be successful? Why do you think this is so, or why do you think this is not so?
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I’d like to think about your own context, your country. What are the realities on the ground with respect to social accountability? Who aspires to hold the system accountable for high coverage in polio vaccination campaigns? What happens when you discover that your country, the vaccination campaign coverage is very low? Who has the power to hold the health system accountable for quality, routine immunization? What happens when we discover that routine immunization is very poor in our country? I want you to think about your own country. Are those people incentivized to hold the health system accountable in these ways? Who are the health workers accountable to within the health system and within the larger political system?
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Are these people incentivized to care about polio vaccination? What about routine immunization? Many questions, I believe, but I would like you to think about them.

Oluwaseun Akinyemi, MD, MPH, FWACP, FRSPH, PhD College of Medicine, University of Ibadan & University College Hospital, Nigeria

In the lecture we hear that, in many countries, cooperation and coordination for vaccination campaigns began with the national government, who then introduced the plans to the state and district governments. For a globally coordinated effort, international agencies must start from the top in order to ensure collaboration and buy in.

Reflect on this model of planning and management. Consider the following question and post your answers in the discussion:

  • What are some challenges in setting up a top-down hierarchical system, where all core partners and donors first work with the national government, and then introduce the program to the state and the local governments?
  • How might such a structure affect local acceptance and reception of the program?
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Planning and Managing Global Health Programmes: Promoting Quality, Accountability and Equity

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