Table 1 The programme theory of the Ghana study [66]

• Public accountability is actualised when actors are answerable to the public and remedial action is undertaken

• Public accountability requires both answerability and enforceability. The capability of the District Health Management team, the sexual and reproductive health NGOs and of partnerships and to inform, evaluate and report in an open manner is grounded in compliance and persuasion. Persuasion is founded on trust and reciprocity, grounded in actors’ perceptions of shared values and norms, goals and of future gain

• Enforceability is grounded in the capability of the public to demand accountability on the one hand, and in meta-governance, i.e. the function exercised by state actor(s) of regulating, supervising and sanctioning, on the public’s behalf, on the other hand. Enforceability is required to ensure answerability, especially to the public

• The accountability practices of health actors are embedded in vertical, horizontal and partnership governance arrangements, which are insufficient in themselves to ensure public accountability. Accountability practices in vertical governance arrangements are strong, if they are grounded in effective hierarchical power. The number of actors in the local health system, the social fabric and the local power structure are important local context conditions that influence the relative strength of public accountability practices

• Public accountability requires a public demanding accountability and/or a meta-governor that monitors and enforces when necessary the actors to be accountable. The meta-governor requires adequate resources, decision space and the capacity to play its role effectively

• Public accountability practices operate along four dimensions of accountability (social, political, organisational and provider dimensions). To be publicly accountable, each actor needs to put in place a specific configuration of public accountability practices, based on the public it claims to serve, its organisational profile and culture, and the governance arrangements in which it is engaged. Multi-level governance arrangements weaken public accountability when there is confusion over roles and responsibilities between actors