There is a worrying divergence between the way that sexual and reproductive health and rights problems and solutions are framed in advocacy at the global level and the complex reality that people experience in health services on the ground. An analysis of approaches to accountability used in advocacy at these different levels highlights the different assumptions at play as to how change happens. This paper makes the case for a reinvigorated approach to accountability that begins with the dynamics of power at the frontlines, where people encounter health providers and institutions. Conventional approaches to accountability avoid grappling with these dynamics, and as a result, many accountability efforts do not lead to transformative change. Implementation science and systems science are promising sources for fresh approaches, beginning with the understanding of health systems as complex adaptive systems embedded in the broader political dynamics of their societies. By drawing insights from disciplines such as political economy, ethnography, and organizational change management - and applying them creatively to the experience of people in health systems - the workings of power can begin to be uncovered and tackled, sharpening accountability towards those whose health and rights are at stake and generating meaningful change.
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