Accountability from Below

EXPLORING ACCOUNTABILITY FOR HEALTH RIGHTS, EDITORIAL, Vol 27/2, 2025, pp. 1-7  PDF

Paul Hunt and Anuj Kapilashrami 

We are indebted to everyone who, through this collection of papers and viewpoints, is sharing their experiences and research on human rights accountability in Gaza, Tigray, Kurdistan, Uganda, Bangladesh, Nepal, South Africa, Taiwan, Maharashtra (India), Aotearoa New Zealand, New York City (United States), and globally. Some of these contributions describe intolerable suffering, the inspirational professionalism of health and human rights workers, and the indispensable dedication of allies. Most of them expose, to one degree or another, the failure of state-centered accountability and a determination to reimagine and construct people-centered accountability.

Global health is characterized by regime complexity, fragmentation, and overlapping norms. As Rosalind Turkie and Pramiti Parwani write in their contribution, human rights responsibilities are dispersed and lines of accountability are blurred across multiple and diverse stakeholders. We are grateful to those contributors who examine these challenging issues, including how to conceptualize accountability in modernity.

In this editorial, we begin with a human rights paradox and the contemporary human rights landscape within which we locate health and accountability. We then signal some of the issues that emerge from the special section’s collection of experience, insights, and ideas. We close with a practical, specific, institutional proposal, as well as an agenda for future research.

A paradox and the contemporary human rights landscape

Human rights are meant to control the conduct of states. But states ratify human rights treaties. They pass national human rights laws. They implement these treaties and national laws. States adjudicate human rights disputes through their courts. In short, the state-centered human rights sphere is deeply paradoxical. Human rights are meant to regulate the conduct of states, but states control human rights.[1]

Given this human rights paradox, we envisage the contemporary human rights landscape as a state-centered human rights sphere (e.g., states and corporations); a people-centered human rights sphere (e.g., communities, peoples, and social movements); and a space where both spheres relate to each other—that is, a “relational space.”

Relatively speaking, the state-centered human rights sphere is dominant and the people-centered human rights sphere is subordinate, but emergent and growing.

The relational space between the two spheres includes international human rights bodies, national human rights institutions, professionalized civil society organizations, and philanthropic organizations, which, to one degree or another, are independent from the state and corporations.

Both spheres, and the relational space lying between them, are very important and need more attention. However, a crucial way of responding to the problematic human rights paradox is by empowering the people-centered sphere. This special section gives particular (but not exclusive) attention to advancing accountability in the people-centered human rights sphere. We call this people-centered accountability or accountability from below.[2]

Emerging issues

One the most striking issues to emerge from the contributions has two interrelated dimensions: the patronizing disposition of unaccountable power and the yawning accountability gap.[3] This undemocratic disposition of power, and accountability gap, extend to subnational, national, and global levels in health.

Most contributors recognize that power and accountability are inextricably connected. Depending on their experiences, some contributors pose searching questions, while others venture some answers. Drawing from their experience in New York City, Marie-Fatima Hyacinthe, Jessica Peñaranda, and Alice Miller, for example, ask “How do we facilitate accountability when people and institutions with power abuse those who are systematically denied power?” They conclude that “conversations about accountability are conversations about power inequities.” On the other hand, drawing from the experience of community-based accountability in Maharashtra, Dhanajay Kakade suggests how meaningful accountability within public health demands the interaction of “three interdependent yet distinct forms of power—mandate power, solidarity power, and knowledge power.” Kakade reports that these intersecting powers, exercised by communities, together generate “a change cycle.”

A second issue, solidarity, comes in multiple forms. Bilal Irfan, Kaden Venugopal, Michelle Anne Cohen, et al., for example, present three “grassroots movements” recently prominent in Gaza: Doctors Against Genocide, Healthcare Workers Watch, and the Freedom Flotilla Coalition. These initiatives represent coalitions of health care workers, civil society, and parliamentarians who exemplify “translocal networks translating global norms into localized, insurgent institutional practices, thereby expanding who enforces human rights and how.” The authors discuss the politics of coalition-building, recognize the inevitable tensions, and chart a way forward. They advise that “[people-centered accountability] requires adopting movement-level codes of conduct that safeguard the dignity of those most at risk.”

Coalitions of health workers and others recur. Dawit Kassa, Zazie Huml, and Bram Wispelwey describe the recent war in Tigray, which dismantled one of Ethiopia’s strongest regional health systems, leaving it in ruins. Health professionals in Tigray are constructing “an alternative, victim-led architecture of accountability.” At the forefront of this effort is the Tigray Medical Association (TMA), a professional body that has “transformed into a rights-based coalition.” Also, a coalition of TMA, civil society organizations, women’s associations, and legal advocates has established a transitional justice working group that has received some support from civil society organizations in Canada and Ireland. These partnerships highlight “the emergence of a fragile transnational solidarity.” As the contributors put it, “Tigrayan health professionals are working to advance accountability from below through grassroots, survivor-led efforts that seek justice through collective organization, legal innovation, and moral authority.”

Goran Zangana, Shokh Mohammad, Baxan Jamal, et al., remind us that in fragile and conflict-affected settings, traditional accountability structures are often weak or absent. The Kurdistan Region of Iraq offers a stark illustration: electoral delays, parliamentary paralysis, and widespread corruption have eroded public trust and oversight. The contributors explain that within this vacuum “grassroots citizen committees have emerged as crucial actors in advancing the right to health and fostering people-centered accountability.” Local citizens have stepped in to monitor, document, and identify breaches of the right to health. “Citizen-led health committees in the Kurdistan Region exemplify how grassroots initiatives carry the potential for sustaining accountability where formal structures fail.”

In their contribution, Grady Arnott, Beatrice Odallo, Teddy Nakubulwa, et al., examine rights-based approaches to access sexual and reproductive health services, primarily at the local level, drawing from case studies in Uganda, Bangladesh, and Nepal. Collaboration, participation, accountability, and solidarity are features of the three case studies, and here we mention one of them. A consortium established a human rights-based accountability initiative in Rohingya refugee camps in Bangladesh (2022–2025), integrating legal, social, and participatory accountability mechanisms, with leadership from Rohingya women and community leaders at its core. Accountability for access to services was operationalized through four interconnected components, one of which was “community solidarity networks that provided peer support and feedback relating to [sexual and reproductive health and rights], gender, and human rights realities.”

A third recurrent issue is that when addressing accountability, the focus on states and courts is necessary, but not sufficient. Contributors devote attention to holding states accountable, but they also look beyond the statist horizon. Gamze Erdem Türkelli and Rossella De Falco, for example, focus on how to hold accountable multi-stakeholder partnerships. While some authors discuss the role of the judiciary in South Africa (Lindani Mhlanga and Tamanda Kamwendo) and Taiwan (Tsung-Ling Lee and Chien-Liang Lee), several contributions (such as Kakade), look beyond the role of the courts. In short, when it comes to accountability and global health, consideration of states and courts is important, but not enough if we aspire to effective accountability.

Another theme is independence. Some, but not all, forms of accountability depend on independence. But what does independence mean? In her contribution, Alicia Ely Yamin explains that autonomy (freedom from political influence) and decision-making authority (which depends on normative and institutional legitimacy) are equally relevant to the independence of an oversight mechanism at the global level. In their viewpoint, Tania Agosti, Andrea Baldwin, Susana Fried, et al., consider how to respect the independence of an accountability mechanism while ensuring that the mechanism upholds essential features of international human rights, which are subject to the principle of non-retrogression. This conundrum is an echo of the Roman aphorism “Who guards the guards?” The authors argue that civil society should scrutinize the work of United Nations Independent Experts, and they urge the Office of the United Nations High Commissioner for Human Rights to promote good practices among independent accountability mechanisms and to call out any deviations from established human rights standards.

A fifth issue is the close relationship between advocacy, activism, and accountability. All three are interrelated and important, but they are not the same. While advocacy focuses more on shifting attitudes and aims to garner greater support for ideas or collective interests, activism involves more direct action that may involve challenging ideas, underlying structures, and social norms and values.[4]

Consider sit-ins, consumer boycotts, and shareholder activism against the privatization of health services. Advocates and activists may demonstrate and hold posters that declare “PEOPLE NOT PROFITS.” Their objective may be accountability. They may even call for accountability. Demonstrations, posters, and calls for accountability are important tools and tactics for advocacy and activism, but they are different from accountability.

What is accountability? In our call for papers, we adopted a working definition of accountability and encouraged contributors to critique it. This entailed a narrative definition plus some constituent features of accountability. The narrative definition, which emphasizes a relational understanding of power, views accountability as

the formal and informal processes, norms, and structures, particularly in a democratic system[,] that [demand] power holders account for their decisions and actions and remedy any failures in delivering their duties.[5]

As for the constituent features of accountability, we identify monitoring (e.g., data collection and interviews); review (e.g., assessing what is happening against human rights commitments and standards); and remedial action (e.g., taking necessary steps when monitoring and review reveal that human rights commitments and standards are not being kept).[6] This complementary combination of narrative and constituent features provides our working definition of human rights accountability.

Several contributors discuss the conceptualization of accountability. For example, Thana de Campos-Rudinsky and Daniel Wainstock propose “a people-centered, decolonial approach to global health governance” that reconceptualizes accountability as a moral virtue and operationalizes it through the structural principle of subsidiarity. In his contribution, Mulu Beyene Kidanemariam explores the maternal death surveillance and response (MDSR), which is a form of maternal death review. He argues that MDSR should be reconceptualized as a human rights accountability mechanism “without reducing it to blame.”

In their paper, Lee and Lee reject the understanding of accountability as “an episodic event.” They argue that accountability relies on multiple interactions between a range of institutions—courts, parliaments, executives, civil society organizations, the public, the media, and human rights commissions—over time. For this reason, they call for “temporal accountability”—that is, “an institutional design that builds time-bound obligations for review, disclosure, and corrective action into the accountability cycle.”

In her viewpoint, Emma Rawson-Te Patu emphasizes that different worldviews conceptualize accountability differently. As she puts it, “Western models of accountability tend to be individualistic and revolve around legal responsibility, compensation, and punishment. In contrast, Indigenous worldviews tend to emphasize the interconnectedness of all beings, the importance of historical context, and the restoration and prioritization of relationships underpinned by lore, rather than law.”

“In this ongoing process,” she writes, “accountability demands not only reparations for the past but also a shared commitment to a future built on equity, mutual respect, and genuine partnership.” She concludes that there are lessons “from this conception of accountability that resonates with the worldviews of many Indigenous peoples globally,” and she offers Indigenous values as guiding principles.

Clearly, more discussion is needed on the meaning of human rights accountability in law, governance, and local contexts. However, if we wait for widespread agreement on what human rights accountability means, we are likely to be waiting a long time. Perhaps the way forward is not a one-size-fits-all definition but a broad consensus on key principles and vision. In any event, the discussion should be informed by thoughtful, inventive praxis because the undemocratic disposition of unaccountable power, and the accountability gap, are too serious to wait. This takes us to the next paragraphs.

A new accountability proposal at the global level

Some contributors raise the possibility of establishing new human rights accountability arrangements in health. In their discussion about multi-stakeholder partnerships, Türkelli and De Falco suggest that “a solution might be to devise an external, independent body that effectively holds them and their constitutive members accountable.” Kidanemariam observes that another human rights approach “is to establish national, regional or global independent, transparent, non-statist bodies charged with responsibility for identifying, analyzing and publicizing the structural injustice exposed by [maternal death surveillance and response].” Irfan et al. remark that movements have turned to public hearings, civil society juries, and people’s tribunals to gather testimony, apply international standards, and determine when acts and omissions are breaches of human rights and humanitarian law. Although such tribunals “lack coercive power, they have shaped public understandings of atrocity and informed subsequent legal processes.”

Yamin provides a remarkable reflection on the United Nations Secretary-General’s Independent Accountability Panel on Women’s, Children’s and Adolescents’ Health (IAP). She served on the IAP throughout its short life between 2016 and 2020. Yamin observes that the story of United Nations efforts to create “an independent mechanism to foster greater accountability across global health is one of high hopes, missed opportunities, and, ultimately, planned project failure.” She argues that “the deeply neoliberal and colonial architecture of global governance for health constrains possibilities for transformative accountability.”

Most useful for present purposes, Yamin writes:

I … share four lessons as to why meaningful accountability has been so elusive in global health and how future efforts might benefit from these insights. These lessons relate to the need for (1) normative grounding; (2) institutional legitimacy; (3) genuine independence; and (4) conceptual clarity with respect to the meaning of accountability.

We keep Yamin’s lessons in mind as we briefly outline a new accountability proposal. Of course, if the proposal proceeds, we look forward to a closer examination of her insights.

We encourage communities, peoples, and social movements to devise effective accountability arrangements in health at the subnational and national levels. We hope that some of the diverse contributions—from the Middle East, Africa, Oceania, South Asia, and North America—will inspire and provide guidance. While subnational and national accountability arrangements will have to reflect their own unique historical and contemporary context, some arrangements may have features that are transferable from one context to another. In the following paragraphs, however, we confine our remarks to the global level.

If the health community is serious about accountability at the global level, we cannot depend on states and their international agencies.[7] The state-centered approach is not working. Allies in the relational space have a major role to play, but they cannot do the job by themselves. Instead, we must look to the people-centered human rights sphere—communities, peoples, and social movements—where human and collective rights belong. We propose a global health coalition of robustly independent organizations and networks that are closely aligned with these constituencies.

The global health coalition should establish a human rights accountability panel or platform. The coalition’s organizations, and their constituencies of communities, peoples, and social movements, would ask the panel to consider carefully selected and defined global health issues. The panel would hold specific human rights duty bearers to account, such as a state, corporation, or multi-stakeholder initiative.

Sitting in public, the panel would provide a platform for those affected to tell their stories and tender evidence. Duty bearers, such as states and corporations, would be invited to address the panel. The panel would give particular attention to inequitable structures, their origins, and the most deprived. Human rights violations would be found, or not. The panel’s findings would be as short and accessible as possible. Its follow-up recommendations would include grassroots activism and advocacy, such as boycotts where appropriate.

Of course, this people-centered approach gives rise to numerous questions. The panel’s findings would not be binding, for example, but neither are the decisions of international human rights bodies. The panel would elevate the voices, perspectives, and values of communities, peoples, and social movements. Importantly, it would take account of contemporary international human and peoples’ rights, as well as the epistemologies of the global health coalition and its constituencies.

Our proposal builds on numerous precedents. There are examples of public hearings, citizen forums, and peoples’ tribunals. The People’s Health Movement and its assemblies have extensive experience from which we can benefit.[8] Peoples’ Tribunals and International Law, edited by Andrew Byrnes and Gabrielle Simm, is an encouraging resource.[9]

In summary, the panel’s legitimacy would rest on the global health coalition and its constituencies of communities, peoples, and social movements. As Irfan et al. put it in their paper, “legitimacy comes from the people they serve, not from the podiums they reach.” Building on existing practice, the panel would be a standing (i.e., permanent) body subject to review after three years. Panel membership would be chosen by the global health coalition and its constituencies; membership would vary with the topics under scrutiny and include those with lived experience. The panel’s methods and standards would be grounded in human and peoples’ rights, respectful of diverse worldviews, and informed by data and other evidence. Subject to the preceding sentence, the panel would find states, corporations, multi-stakeholder partnerships, and other duty bearers responsible for violations of human and peoples’ rights (or not). The panel’s short and accessible findings would be publicized as widely as possible.

The panel would be located in the people-centered human rights sphere and supported by suitable allies from the relational space. Aware that the proposal reflects a particular worldview, we simply place it on the table for discussion and emphasize the imperative of epistemic justice. By advancing accountability from below, the proposal aims to address the patronizing disposition of unaccountable power, as well as the wide accountability gap at the global level.

If there is sufficient support, we wish to advance this proposal in 2026. What is your view? Do you favor a global health coalition, closely aligned with communities, peoples, and social movements, which establishes a permanent panel that addresses the human rights accountability gap in global health? The coalition and panel will need time to take shape, develop, and flourish. Should we make a start? Please let us know what you think.

Conclusion

Whether or not the proposal attracts sufficient support, there is much more work to be done to broaden the scope of accountability research across multiple domains. The scope of the research should encompass empirical, conceptual, and praxis. This includes a deeper exploration of the design and processes that govern accountability mechanisms (how they are working), as well as the overarching sociopolitical and institutional contexts, and underlying conditions, in which they operate, especially as they relate to socially excluded and marginalized groups.

A second aspect is attending to what Anuj Kapilashrami, Neil Quinn, and Abhijit Das refer to as the “black hole” in accountability scholarship and practice. It is crucial to extend inquiries into “the corporate-state nexus and the multi-level governance in which contemporary (health) systems and states operate.”[10]

A third aspect is about acknowledging and correcting power imbalances within both community dynamics and state-citizen relationships. Furthermore, decolonizing the praxis of accountability necessitates transcending mere reform within existing colonial frameworks. Instead, we must fundamentally reimagine accountability—and indeed, the world order—through the lens of decolonial principles, including sovereignty, relational epistemologies, and justice.

There are several important ways to approach this work, such as:

• Investigating how colonial legacies continue to shape contemporary judicial and non-judicial forms of accountability.
• Exploring alternative epistemologies and practices of accountability rooted in Indigenous, local, and marginalized (minoritized) perspectives—i.e., challenging Western-centric perspectives.
• Assessing the role of restorative justice in decolonial contexts, with an emphasis on healing, reparations, and recognition of communities affected by colonial injustices.
• Understanding how global power relations affect local accountability efforts, alongside investigating how decolonial strategies can promote genuine local sovereignty and self-determination.

This agenda not only calls for robust research and dialogue but also strives for transformative accountability that genuinely reflects the needs and voices of marginalized communities.

We close by acknowledging the irrepressibility of communities, peoples, social movements, and professional associations in the struggle for accountability from below. Despite huge challenges and powerful opposition, there are encouraging developments and a positive spirit, especially among the global majority. As Irfan et al. put it:

If state-centered systems remain unable or unwilling to deliver, accountability from below will proceed—counting the dead with accuracy, confirming human rights violations and violators, preserving the names and methods of those who cared, and insisting that the right to health is a claim on power exercisable by the people themselves.

Paul Hunt, MA, MJUR, PhDs (Hon), is emeritus professor at Essex University, United Kingdom, and adjunct professor at Waikato University, Aotearoa, New Zealand.

Anuj Kapilashrami, MA, MSc, PhD, is professor and director, Centre for Global Health and Intersectional Equity Research, University of Essex, United Kingdom.

Please address correspondence to Paul Hunt. Email: phmhunt@essex.ac.uk.

Competing interests: None declared.

Copyright © 2025 Hunt and Kapilashrami. This is an open access article distributed under the terms of the Creative Commons Attribution-Noncommercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original author and source are credited.

References

[1] P. Hunt, “Empowering Human Rights for Revolutionary Change,” Human Rights Quarterly 48/2 (2026), forthcoming.

[2] B. Rajagopal, International Law from Below: Development, Social Movements, and Third World Resistance (Cambridge University Press, 2003); O. De Schutter and B. Rajagopal (eds), Property Rights from Below: Commodification of Land and the Counter-Movement (Routledge, 2019).

[3] J. Jones, The Patronising Disposition of Unaccountable Power (UK Home Office, 2017).

[4] A. Kapilashrami, N. Quinn, and A. Das, Advancing Health Rights and Tackling Inequalities: Interrogating Community Development and Participatory Praxis (Policy Press, 2025), p. 84.

[5] Ibid., p. 122 (citing Brinkerhoff 2004; Boydell et al. 2018).

[6] C. Williams and P. Hunt, “Neglecting Human Rights: Accountability, Data and Sustainable Development Goal 3,” International Journal of Human Rights 21/8 (2017).

[7] P. Hunt, “Health Rights and Accountability,” correspondence in The Lancet 406/10510 (September 27, 2025).

[8] People’s Health Tribunal, https://peopleshealthhearing.org/project/peoples-health-hearing/pht2023/verdict/.

[9] A. Byrnes and G. Simm (eds), People’s Tribunals and International Law (Cambridge University Press, 2018).

[10] Kapilshrami et al. (see note 4), p. 137.