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.

中文翻译：

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塔吉克斯坦的地方卫生治理：地区一级的问责制和权力关系。

背景技术卫生系统参与者之间的权力，责任和问责关系被认为是卫生治理的核心。尽管人们越来越关注问责制在卫生治理中的作用，但在了解中亚卫生系统中地方问责制如何发挥作用方面仍然存在差距。本研究通过使用委托人代理理论探索塔吉克斯坦两个地区的地方卫生治理来解决这一差距。方法该比较案例研究采用定性研究方法，主要依靠受访者进行关键访谈并与当地利益相关者进行焦点小组讨论。数据分析以一个框架为指导，该框架将治理概念化为国家行为者，公民和卫生提供者之间的一系列委托-代理关系。要特别注意声音，责任感和可执行性是责任制的重要组成部分。结果分析提供了对构成有效问责关系的不同组成部分的挑战的见解，例如任务不明确，缺乏沟通渠道或资源不足以执行任务。调查结果突出表明，在资源贫乏的卫生系统和专制政治背景下，卫生服务提供者和公民在国家行为者和发展主体方面的地位较弱。人们发现，地方政府行为者之间的资源争夺以及负责任和可执行性的非正式工具在塑造实际的问责关系中起着重要作用。这些问责关系形成了一个复杂的机构网络，代理商在其中受制于各种问责要求。尤其是，卫生保健提供者发现自己扮演着这种角色，受到国家行为者，公民和发展机构的追究。人们发现后者与卫生服务提供者建立了平行的委托-代理关系，而没有过多关注当地国家行为者的作用，或加强了从公民到提供者的简短问责路线。结论该研究提供了对地方治理关系的复杂性和对正式问责制的制约的见解。这突出了非正式问责工具和政治经济背景在塑造委托人与代理人关系中的重要性。该研究证明了代理理论在卫生治理分析中的使用和局限性，并指出了在地方卫生系统中根深蒂固的权力地位的重要性。