• Netsanet Fetene, Akshar Patel, Tibebu Benyam, Assefa Ayde, Mayur M Desai, Leslie Curry, and Erika Linnander.
• Yale Global Health Leadership Initiative, Addis Ababa, Ethiopia.
• Bmc Fam Pract. 2020 Dec 6; 21 (1): 261.

BackgroundDespite calls for improved accountability in global health systems, and a set of clear and consistent theoretical accountability frameworks, empirical descriptions of how accountability is experienced and enacted in low- and middle- income country (LMIC) settings is limited. Therefore, we sought to characterize how managers at all levels of Ethiopia's primary healthcare system experience accountability in their daily practice.MethodsWe conducted in-depth key informant interviews with 41 key stakeholders across 4 regions (Amhara, Oromia, Southern Nations Nationalities and Peoples, and Tigray) in the context of the Primary Healthcare Transformation Initiative (PTI). Consistent with the principles of grounded theory, our team used the constant comparative method to identify emergent themes related to concrete areas that could be targeted to allow an overall culture of accountability to flourish.ResultsEmergent themes were: development of a shared understanding of system-wide accountability, streamlining of managerial reporting lines, strengthening of medico-legal knowledge and systems, and development of mechanisms for bottom-up accountability.ConclusionsFindings may be valuable to policymakers seeking to create more effective national accountability frameworks; practitioners and development partners seeking to strengthen implementation of evidence-based accountability systems and practices; and researchers aiming to develop meaningful, practical measures of accountability in public health.

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