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Raven J, Mansour W, Aikins M, Bulthuis S, Chikaphupha K, Dieleman M, Kok M, Martineau T, Ssengooba F, Wyss K, Vallières F. From PERFORM to PERFORM2Scale: lessons from scaling-up a health management strengthening intervention to support Universal Health Coverage in three African countries. Health Policy Plan 2024; 39:841-853. [PMID: 38978193 PMCID: PMC11384104 DOI: 10.1093/heapol/czae063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 05/09/2024] [Accepted: 07/05/2024] [Indexed: 07/10/2024] Open
Abstract
Strengthening management and leadership competencies among district and local health managers has emerged as a common approach for health systems strengthening and to achieve Universal Health Coverage (UHC). While the literature is rich with localized examples of initiatives that aim to strengthen the capacity of district or local health managers, particularly in sub-Saharan Africa, considerably less attention is paid to the science of 'how' to scale-up these initiatives. The aim of this paper is thus to examine the 'process' of scaling-up a management strengthening intervention (MSI) and identify new knowledge and key lessons learned that can be used to inform the scale-up process of other complex health interventions, in support of UHC. Qualitative methods were used to identify lessons learned from scaling-up the MSI in Ghana, Malawi and Uganda. We conducted 14 interviews with district health management team (DHMT) members, three scale-up assessments with 20 scale-up stakeholders, and three reflection discussions with 11 research team members. We also kept records of activities throughout MSI and scale-up implementation. Data were recorded, transcribed and analysed against the Theory of Change to identify both scale-up outcomes and the factors affecting these outcomes. The MSI was ultimately scaled-up across 27 districts. Repeated MSI cycles over time were found to foster greater feelings of autonomy among DHMTs to address longstanding local problems, a more innovative use of existing resources without relying on additional funding and improved teamwork. The use of 'resource teams' and the emergence of MSI 'champions' were instrumental in supporting scale-up efforts. Challenges to the sustainability of the MSI include limited government buy-in and lack of sustained financial investment.
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Affiliation(s)
- Joanna Raven
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke place, Liverpool L3 5QA, UK
| | - Wesam Mansour
- International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, United Kingdom
| | - Moses Aikins
- School of Public Health, College of Health Sciences, University of Ghana, PO Box LG13, Legon, Accra, Ghana
| | - Susan Bulthuis
- Royal Tropical Institute, Mauritskade 63, 1092 AD, Amsterdam, Netherlands
| | | | - Marjolein Dieleman
- Royal Tropical Institute, Mauritskade 63, 1092 AD, Amsterdam, Netherlands
| | - Maryse Kok
- Royal Tropical Institute, Mauritskade 63, 1092 AD, Amsterdam, Netherlands
| | - Tim Martineau
- International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, United Kingdom
| | - Freddie Ssengooba
- Department of Health Policy and Planning, School of Public Health, Makerere University, PO Box 7072, Kampala, Uganda
| | - Kaspar Wyss
- Swiss Tropical and Public Health Institute & University of Basel, Kreuzstrasse 2, 4123 Allschwil, Basel, Switzerland
| | - Frédérique Vallières
- Trinity Centre for Global Health, Trinity College Dublin, 7-9 Leinster Street South, Dublin D02 K104, Ireland
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Colombini M, Shrestha S, Pereira S, Kalichman B, Siriwardhana P, Silva T, Halaseh R, d’Oliveira AF, Rishal P, Bhatt PR, Shaheen A, Joudeh N, Rajapakse T, Alkaiyat A, Feder G, Moreno CG, Bacchus LJ. Comparing health systems readiness for integrating domestic violence services in Brazil, occupied Palestinian Territories, Nepal and Sri Lanka. Health Policy Plan 2024; 39:552-563. [PMID: 38758072 PMCID: PMC11145909 DOI: 10.1093/heapol/czae032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 02/29/2024] [Accepted: 04/26/2024] [Indexed: 05/18/2024] Open
Abstract
Domestic violence (DV) is a global prevalent health problem leading to adverse health consequences, yet health systems are often unprepared to address it. This article presents a comparative synthesis of the health system's pre-conditions necessary to enable integration of DV in health services in Brazil, Nepal, Sri Lanka and occupied Palestinian Territories (oPT). A cross-country, comparative analysis was conducted using a health systems readiness framework. Data collection involved multiple data sources, including qualitative interviews with various stakeholders; focus-group discussions with women; structured facility observations; and a survey with providers. Our findings highlight deficiencies in policy and practice that need to be addressed for an effective DV response. Common readiness gaps include unclear and limited guidance on DV, unsupportive leadership coupled with limited training and resources. Most providers felt unprepared, lacked guidance and felt unsupported and unprotected by managers and their health system. While in Brazil most providers felt they should respond to DV cases, many in Sri Lanka preferred not to. Such organizational and service delivery challenges, in turn, also affected how health providers responded to DV cases leaving them not confident, uncertain about their knowledge and unsure about their role. Furthermore, providers' personal beliefs and values on DV and gender norms also impacted their motivation and ability to respond, prompting some to become 'activists' while others were reluctant to intervene and prone to blame women. Our synthesis also pointed to a gap in women's use of health services for DV as they had low trust in providers. Our conceptual framework demonstrates the importance of having clear policies and highlights the need to engage leadership across every level of the system to reframe challenges and strengthen routine practices. Future research should also determine the ways in which women's understanding and needs related to DV help-seeking are addressed.
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Affiliation(s)
- Manuela Colombini
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London WC1H 9RA, United Kingdom
| | - Satya Shrestha
- Kathmandu University School of Medical Sciences, Nepal and Faculty of Health Sciences, Dhulikhel 45209, Nepal
- University of Bristol, Bristol BS81UD, United Kingdom
| | - Stephanie Pereira
- Faculty of Medicine, University of São Paulo Institute of Biomedical Sciences, Sao Paulo, Sao Paulo CEP 01246 903, Brazil
| | - Beatriz Kalichman
- Department of Preventive Medicine, Faculty of Medicine, Sao Paulo CEP 01246 903, Brazil
| | - Prabhash Siriwardhana
- Department of Social Sciences, Rajarata University of Sri Lanka, Mihintale 50300, Sri Lanka
- South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Peradeniya 20400, Sri Lanka
| | - Tharuka Silva
- Department of Psychiatry, Faculty of Medicine, Kandy, Sri Lanka
| | - Rana Halaseh
- Occupied Palestinian Territories, An-Najah National University, Palestine
| | - Ana Flavia d’Oliveira
- Faculty of Medicine, University of São Paulo Institute of Biomedical Sciences, Sao Paulo, Sao Paulo CEP 01246 903, Brazil
| | - Poonam Rishal
- Kathmandu University School of Medical Sciences, Dhulikhel Hospital, Dhulikhel 45209, Nepal
| | - Pusp Raj Bhatt
- Kathmandu University School of Medical Sciences, Dhulikhel Hospital, Dhulikhel 45209, Nepal
| | - Amira Shaheen
- Faculty of Medicine and Health Sciences, Occupied Palestinian Territories, An-Najah National University, Nablus, Palestine
| | - Nagham Joudeh
- Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
| | | | - Abdulsalam Alkaiyat
- Faculty of Medicine and Health Sciences, Occupied Palestinian Territories, An-Najah National University, Nablus, Palestine
| | - Gene Feder
- University of Bristol, Centre for Academic Primary Care, Bristol BS81UD, United Kingdom
| | - Claudia Garcia Moreno
- Formerly at Department of Reproductive Health and Research, World Health Organisation, Geneva 1211, Switzerland
| | - Loraine J Bacchus
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London WC1H 9RA, United Kingdom
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Kushitor M, Wright K, Biney A, Kanmiki EW, Kyei P, Phillips JF, Awoonor-Williams JK, Bawah AA. "The trip actually opened our eyes to things that we were supposed to do and we were not doing": developing primary health care system leadership in a low-income country with peer exchanges. RESEARCH IN HEALTH SERVICES & REGIONS 2023; 2:15. [PMID: 39177712 PMCID: PMC11281752 DOI: 10.1007/s43999-023-00030-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 09/27/2023] [Indexed: 08/24/2024]
Abstract
BACKGROUND Health care systems in low and middle-income countries are decentralizing and devolving power to the periphery. Transferring power without systematic processes to develop and nurture leaders at the district compromises the effectiveness and sustainability of the decentralized health system. To address this problem, we developed an approach to leadership learning by observation and experience that improved the organization and performance of the health care system in a district in Ghana. METHODOLOGY Using two rounds of a longitudinal qualitative study, the study explores the determinants of implementing the Community-Based Health Planning and Services (CHPS) initiative in a district in Ghana. Insights were gained concerning the leadership regimes of two leaders who administered health services in a common geographic area at different points in time with remarkably contrasting outcomes. Insights of health workers who participated in both periods were elicited to clarify interview contexts. Ten focus group discussions (FGDs) and five expert interviews were conducted for each round of the study. The study was informed by a systems appraisal approach that utilized a thematic analytical framework. RESULTS Providing district leaders with a practical observational experience had a significant influence on health care delivery in all aspects of health care provision at the district level. Exposing participants to models of best practices facilitated the replication of processes that improved the conduct of service delivery and CHPS implementation. Upon reflection, district leaders attributed performance constraints to their lack of understanding of practical ways of responding to complex district health system development needs. Observation from community members, volunteers, and health workers who witnessed the system development period corroborated narratives that leaders had expressed. CONCLUSION Effective leadership is optimally developed with participatory learning that provides leaders with direct access to fully functioning systems. Learning by observation can be structured and used to quicken the spread of managerial excellence.
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Affiliation(s)
- Mawuli Kushitor
- The Department of Health Policy, Planning and Management (UHAS), School of Public Health (SPH), University of Health and Allied Sciences (UHAS), Ho, Ghana.
| | - Kalifa Wright
- The Center for Health Information and Analysis, Boston, MA, USA
| | - Adriana Biney
- Regional Institute for Population Studies (RIPS), University of Ghana, Legon, Ghana
| | - Edmund W Kanmiki
- Institute for Social Science Research, The University of Queensland, Indooroopilly, QLD, 4068, Australia
| | - Pearl Kyei
- Regional Institute for Population Studies (RIPS), University of Ghana, Legon, Ghana
| | - James F Phillips
- Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA
| | | | - Ayaga A Bawah
- Regional Institute for Population Studies (RIPS), University of Ghana, Legon, Ghana
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Ayim A, Agyepong IA, Enyimayew N. Why district assemblies disburse resources to district health systems for service delivery at district level in the context of decentralization: a comparative study of two districts in the Volta Region of Ghana. Front Public Health 2023; 11:1136210. [PMID: 37645704 PMCID: PMC10461447 DOI: 10.3389/fpubh.2023.1136210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 05/24/2023] [Indexed: 08/31/2023] Open
Abstract
Objectives To explore why the District Assembly disburses financial and other resources to the District Health System. Design Multiple case study with a single unit of analysis (holistic) using quantitative and qualitative methods of data collection involving a desk review, analysis of routine health management information system data and key informant interviews. Setting Two districts in the Volta Region of Ghana. Participants Twelve key officials of each district assembly and the district health system (24 total) who had worked in the district at least a year or more. Interventions None. Results Both District Assemblies had moderate decision space which was influenced by their capacity, power and contextual factors like politics, economics, legal and situational factors. Disbursement of financial and other resources to the District Health Systems was influenced by financial capacity, use of power by stakeholders, context and the decision space of the District Assembly. Political actors appeared to have more power in resource disbursement decision making than community members and technocrats in a context of resource constraints and inadequate funding. The funding available was used predominantly for capital investments, mainly construction of Community Based Health Planning and Services (CHPS) compounds. Conclusion It is important to make policies that will regulate the relative power among the political appointees like the District Chief Executives (DCEs), public and civil servants in decentralized departments and agencies and Community members to make resource disbursement more sensitive to communities and decentralized departments.
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Affiliation(s)
- Andrews Ayim
- Policy, Planning, Monitoring and Evaluation Division, Ghana Health Service, Accra, Ghana
- Public Health Faculty Ministries, Ghana College of Physicians and Surgeons, Accra, Ghana
| | - Irene Akua Agyepong
- Dodowa Health Research Center, Research and Development Division, Ghana Health Service, Dodowa, Ghana
- Public Health Faculty Ministries, Ghana College of Physicians and Surgeons, Accra, Ghana
| | - Nana Enyimayew
- Public Health Faculty Ministries, Ghana College of Physicians and Surgeons, Accra, Ghana
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Bulthuis S, Kok M, Onvlee O, O’Byrne T, Amon S, Namakula J, Chikaphupha K, Gerold J, Mansour W, Raven J, Broerse JEW, Dieleman M. How to scale-up: a comparative case study of scaling up a district health management strengthening intervention in Ghana, Malawi and Uganda. BMC Health Serv Res 2023; 23:35. [PMID: 36642734 PMCID: PMC9840942 DOI: 10.1186/s12913-023-09034-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 01/04/2023] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The need to scale up public health interventions in low- and middle-income countries to ensure equitable and sustainable impact is widely acknowledged. However, there has been little understanding of how projects have sought to address the importance of scale-up in the design and implementation of their initiatives. This paper aims to gain insight into the facilitators of the scale-up of a district-level health management strengthening intervention in Ghana, Malawi and Uganda. METHODS The study took a comparative case study approach with two rounds of data collection (2019 and 2021) in which a combination of different qualitative methods was applied. Interviews and group discussions took place with district, regional and national stakeholders who were involved in the implementation and scale-up of the intervention. RESULTS A shared vision among the different stakeholders about how to institutionalize the intervention into the existing system facilitated scale-up. The importance of champions was also identified, as they influence buy-in from key decision makers, and when decision makers are convinced, political and financial support for scale-up can increase. In two countries, a specific window of opportunity facilitated scale-up. Taking a flexible approach towards scale-up, allowing adaptations of the intervention and the scale-up strategy to the context, was also identified as a facilitator. The context of decentralization and the politics and power relations between stakeholders involved also influenced scale-up. CONCLUSIONS Despite the identification of the facilitators of the scale-up, full integration of the intervention into the health system has proven challenging in all countries. Approaching scale-up from a systems change perspective could be useful in future scale-up efforts, as it focuses on sustainable systems change at scale (e.g. improving district health management) by testing a combination of interventions that could contribute to the envisaged change, rather than horizontally scaling up and trying to embed one particular intervention in the system.
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Affiliation(s)
- Susan Bulthuis
- grid.11503.360000 0001 2181 1687KIT Royal Tropical Institute, Amsterdam, The Netherlands ,grid.12380.380000 0004 1754 9227Athena Institute, VU University, Amsterdam, the Netherlands
| | - Maryse Kok
- grid.11503.360000 0001 2181 1687KIT Royal Tropical Institute, Amsterdam, The Netherlands
| | - Olivier Onvlee
- grid.11503.360000 0001 2181 1687KIT Royal Tropical Institute, Amsterdam, The Netherlands
| | - Thomasena O’Byrne
- grid.8217.c0000 0004 1936 9705Trinity College Dublin, Dublin, Ireland
| | - Samuel Amon
- grid.8652.90000 0004 1937 1485Department of Health Policy, Planning & Management, School of Public Health, College of Health Sciences, University of Ghana, Accra, Legon Ghana
| | - Justine Namakula
- grid.11194.3c0000 0004 0620 0548Makerere University School of Public Health, Kampala, Uganda
| | - Kingsley Chikaphupha
- grid.463633.7Research for Equity and Community Health (REACH) Trust, Lilongwe, Malawi
| | - Jana Gerold
- grid.416786.a0000 0004 0587 0574Swiss Centre for International Health, Swiss Tropical and Public Health Institute, University of Basel, Allschwil, Switzerland
| | - Wesam Mansour
- grid.48004.380000 0004 1936 9764Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Joanna Raven
- grid.48004.380000 0004 1936 9764Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Marjolein Dieleman
- grid.11503.360000 0001 2181 1687KIT Royal Tropical Institute, Amsterdam, The Netherlands ,grid.12380.380000 0004 1754 9227Athena Institute, VU University, Amsterdam, the Netherlands
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Zafar S, Fruchtman CS, Bilal Khalid M, Zia Z, Khalid Khan F, Iqbal S, Muñoz DC. Lessons learnt of the COVID-19 contact tracing strategy in Islamabad Capital Territory, Pakistan using systems thinking processes. Front Public Health 2022; 10:909931. [PMID: 36176531 PMCID: PMC9513613 DOI: 10.3389/fpubh.2022.909931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 08/04/2022] [Indexed: 01/22/2023] Open
Abstract
The strategy of test, trace and isolate has been promoted and seen as a crucial tool in the fight against the COVID-19 pandemic. As simple as the slogan sounds, effectively implementing it turns into a complex endeavor with multiple moving parts and the need for multisector collaboration. In this study, we apply a systems thinking lens to analyse the design and implementation of the contact tracing strategy for COVID-19 in the district of Islamabad, Pakistan. The data collection included participatory observation, reflective exercises, key informant interviews and participatory workshops with district health managers and health providers. The information gathered was structured using process and stakeholder mapping to identify the lessons learned of the COVID-19 contact tracing strategy. The results showed that the elements crucial for implementation were, good coordination during a crisis, available resources mobilized effectively and establishment of early active surveillance for contact tracing. Furthermore, the main aspects to be improved were lack of preparedness and existing surveillance systems and task shifting leading to impact on regular health services. The results of this study highlight the importance of developing information systems that are coherent with existing processes and resources, even in times of crisis.
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Affiliation(s)
- Shamsa Zafar
- Fazaia Medical College, Air University, Islamabad, Pakistan
| | - Carmen Sant Fruchtman
- University of Basel, Basel, Switzerland,Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Muhammad Bilal Khalid
- Child Advocacy International, Islamabad, Pakistan,*Correspondence: Muhammad Bilal Khalid
| | - Zaeem Zia
- Health Department ICT, Ministry of National Health Services, Regulations and Coordination, Islamabad, Pakistan
| | - Fawad Khalid Khan
- Health Department ICT, Ministry of National Health Services, Regulations and Coordination, Islamabad, Pakistan
| | - Shahid Iqbal
- Child Advocacy International, Islamabad, Pakistan
| | - Daniel Cobos Muñoz
- University of Basel, Basel, Switzerland,Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
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Ineza L, Bechtold K, Mwisongo A, Kwedi Nolna S, Linnander EL. Building leadership and management competencies of national immunization teams in 16 Gavi-eligible countries through the EPI leadership and management programme. Vaccine 2022; 40:3581-3587. [DOI: 10.1016/j.vaccine.2022.04.070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 04/22/2022] [Accepted: 04/23/2022] [Indexed: 11/30/2022]
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Orgill M, Marchal B, Shung-King M, Sikuza L, Gilson L. Bottom-up innovation for health management capacity development: a qualitative case study in a South African health district. BMC Public Health 2021; 21:587. [PMID: 33761911 PMCID: PMC7992952 DOI: 10.1186/s12889-021-10546-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 03/03/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND As part of health system strengthening in South Africa (2012-2017) a new district health manager, taking a bottom-up approach, developed a suite of innovations to improve the processes of monthly district management team meetings, and the practices of managers and NGO partners attending them. Understanding capacity as a property of the health system rather than only of individuals, the research explored the mechanisms triggered in context to produce outputs, including the initial sensemaking by the district manager, the subsequent sensegiving and sensemaking in the team and how these homegrown innovations interacted with existing social processes and norms within the system. METHODS We conducted a realist evaluation, adopting the case study design, over a two-year period (2013-2015) in the district of focus. The initial programme theory was developed from 10 senior manager interviews and a literature review. To understand the processes and mechanisms triggered in the local context and identify outputs, we conducted 15 interviews with managers in the management team and seven with non-state actors. These were supplemented by researcher notes based on time spent in the district. Thematic analysis was conducted using the Context-Mechanism-Outcome configuration alongside theoretical constructs. RESULTS The new district manager drew on systems thinking, tacit and experiential knowledge to design bottom-up innovations. Capacity was triggered through micro-practices of sensemaking and sensegiving which included using sticks (positional authority, enforcement of policies, over-coding), intentionally providing justifications for change and setting the scene (a new agenda, distributed leadership). These micro-practices in themselves, and by managers engaging with them, triggered a generative process of buy-in and motivation which influenced managers and partners to participate in new practices within a routine meeting. CONCLUSION District managers are well placed to design local capacity development innovations and must draw on systems thinking, tacit and experiential knowledge to enable relevant 'bottom-up' capacity development in district health systems. By drawing on soft skills and the policy resources (hardware) of the system they can influence motivation and buy-in to improve management practices. From a systems perspective, we argue that capacity development can be conceived of as part of the daily activity of managing within routine spaces.
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Affiliation(s)
- Marsha Orgill
- Health Policy and Systems Division, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
| | - Bruno Marchal
- Institute of Tropical Medicine Antwerp, Antwerpen, Belgium
| | - Maylene Shung-King
- Health Policy and Systems Division, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Lucy Gilson
- Health Policy and Systems Division, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- London School of Hygiene and Tropical Medicine, London, UK
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English M, Nzinga J, Irimu G, Gathara D, Aluvaala J, McKnight J, Wong G, Molyneux S. Programme theory and linked intervention strategy for large-scale change to improve hospital care in a low and middle-income country - A Study Pre-Protocol. Wellcome Open Res 2020; 5:265. [PMID: 33274301 PMCID: PMC7684682 DOI: 10.12688/wellcomeopenres.16379.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2020] [Indexed: 12/24/2023] Open
Abstract
In low and middle-income countries (LMIC) general hospitals are important for delivering some key acute care services. Neonatal care is emblematic of these acute services as averting deaths requires skilled care over many days from multiple professionals with at least basic equipment. However, hospital care is often of poor quality and large-scale change is needed to improve outcomes. In this manuscript we aim to show how we have drawn upon our understanding of contexts of care in Kenyan general hospital NBUs, and on social and behavioural theories that offer potential mechanisms of change in these settings, to develop an initial programme theory guiding a large scale change intervention to improve neonatal care and outcomes. Our programme theory is an expression of our assumptions about what actions will be both useful and feasible. It incorporates a recognition of our strengths and limitations as a research-practitioner partnership to influence change. The steps we employ represent the initial programme theory development phase commonly undertaken in many Realist Evaluations. However, unlike many Realist Evaluations that develop initial programme theories focused on pre-existing interventions or programmes, our programme theory informs the design of a new intervention that we plan to execute. Within this paper we articulate briefly how we propose to operationalise this new intervention. Finally, we outline the quantitative and qualitative research activities that we will use to address specific questions related to the delivery and effects of this new intervention, discussing some of the challenges of such study designs. We intend that this research on the intervention will inform future efforts to revise the programme theory and yield transferable learning.
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Affiliation(s)
- Mike English
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Jacinta Nzinga
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | - Grace Irimu
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | - David Gathara
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | | | - Jacob McKnight
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Geoffrey Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sassy Molyneux
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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English M, Nzinga J, Irimu G, Gathara D, Aluvaala J, McKnight J, Wong G, Molyneux S. Programme theory and linked intervention strategy for large-scale change to improve hospital care in a low and middle-income country - A Study Pre-Protocol. Wellcome Open Res 2020; 5:265. [PMID: 33274301 PMCID: PMC7684682 DOI: 10.12688/wellcomeopenres.16379.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2020] [Indexed: 01/25/2023] Open
Abstract
In low and middle-income countries (LMIC) general hospitals are important for delivering some key acute care services. Neonatal care is emblematic of these acute services as averting deaths requires skilled care over many days from multiple professionals with at least basic equipment. However, hospital care is often of poor quality and large-scale change is needed to improve outcomes. In this manuscript we aim to show how we have drawn upon our understanding of contexts of care in Kenyan general hospital NBUs, and on social and behavioural theories that offer potential mechanisms of change in these settings, to develop an initial programme theory guiding a large scale change intervention to improve neonatal care and outcomes. Our programme theory is an expression of our assumptions about what actions will be both useful and feasible. It incorporates a recognition of our strengths and limitations as a research-practitioner partnership to influence change. The steps we employ represent the initial programme theory development phase commonly undertaken in many Realist Evaluations. However, unlike many Realist Evaluations that develop initial programme theories focused on pre-existing interventions or programmes, our programme theory informs the design of a new intervention that we plan to execute. Within this paper we articulate briefly how we propose to operationalise this new intervention. Finally, we outline the quantitative and qualitative research activities that we will use to address specific questions related to the delivery and effects of this new intervention, discussing some of the challenges of such study designs. We intend that this research on the intervention will inform future efforts to revise the programme theory and yield transferable learning.
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Affiliation(s)
- Mike English
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Jacinta Nzinga
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | - Grace Irimu
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | - David Gathara
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | | | - Jacob McKnight
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Geoffrey Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sassy Molyneux
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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Heerdegen ACS, Gerold J, Amon S, Agyemang SA, Aikins M, Wyss K. How Does District Health Management Emerge Within a Complex Health System? Insights for Capacity Strengthening in Ghana. Front Public Health 2020; 8:270. [PMID: 32733833 PMCID: PMC7360672 DOI: 10.3389/fpubh.2020.00270] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 05/26/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: District health managers (DHMs) play a pivotal role in the operation of district health systems in low-and middle income countries, including Ghana. Their capacity is determined by their competencies, but also by the organization and system in which they are embedded. The objective of this paper is to explore how district health management emerges from contextual, organizational, and individual factors in order to demonstrate that capacity strengthening efforts at district level need to transcend individual competencies to take on more systemic approaches. Methods: Semi-structured interviews (n = 21) were conducted to gain insight into aspects that affect district health management in the Eastern Region of Ghana. Interviews were conducted with DHMs (n = 15) from six different districts, as well as with their superiors at the regional level (n = 4) and peers from non-governmental organizations (n = 2). A thematic analysis was conducted by using an analytical approach based on systems theory. Results: Contextual aspects, such as priorities among elected officials, poor infrastructure and working conditions, centralized decision-making, delayed disbursement of funds and staff shortages, affect organizational processes and the way DHMs carry out their role. Enabling organizational aspects that provide DHMs with direction and a clear perception of their role, include positive team dynamics, good relations with supervisors, job descriptions, appraisals, information systems, policies and guidelines. Meanwhile, hierarchical organizational structures, agendas driven by vertical programs and limited opportunities for professional development provide DHMs with limited authority to make decisions and dampens their motivation. The DHMs ability to carry out their role effectively depends on their perception of their role and the effort they expend, in addition to their competencies. In regards to competencies, a need for more general management and leadership skills were called for by DHMs as well as by their superiors and peers. Conclusion: Systemic approaches are called for in order to strengthen district health management capacity. This study can provide national policy-makers, donors and researchers with a deeper understanding of factors that should be taken into consideration when developing, planning, implementing, and assessing capacity-building strategies targeted at strengthening district health management.
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Affiliation(s)
| | - Jana Gerold
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Samuel Amon
- School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Samuel Agyei Agyemang
- School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Moses Aikins
- School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Kaspar Wyss
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
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12
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Bulthuis SE, Kok MC, Amon S, Agyemang SA, Nsabagasani X, Sanudi L, Raven J, Finn M, Gerold J, Tulloch O, Dieleman MA. How district health decision-making is shaped within decentralised contexts: A qualitative research in Malawi, Uganda and Ghana. Glob Public Health 2020; 16:120-135. [DOI: 10.1080/17441692.2020.1791213] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Susan E. Bulthuis
- KIT Royal Tropical Institute, Amsterdam, The Netherlands
- Athena Institute, VU University, Amsterdam, The Netherlands
| | - Maryse C. Kok
- KIT Royal Tropical Institute, Amsterdam, The Netherlands
| | - Samuel Amon
- Department of Health Policy, Planning & Management, School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Samuel Agyei Agyemang
- Department of Health Policy, Planning & Management, School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana
| | | | - Lifah Sanudi
- Research for Equity and Community Health (REACH) Trust, Lilongwe, Malawi
| | - Joanna Raven
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Mairead Finn
- Trinity Centre for Global Health, the University of Dublin, Trinity College, Dublin, Ireland
- Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Jana Gerold
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | | | - Marjolein A. Dieleman
- KIT Royal Tropical Institute, Amsterdam, The Netherlands
- Athena Institute, VU University, Amsterdam, The Netherlands
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13
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Heerdegen ACS, Aikins M, Amon S, Agyemang SA, Wyss K. Managerial capacity among district health managers and its association with district performance: A comparative descriptive study of six districts in the Eastern Region of Ghana. PLoS One 2020; 15:e0227974. [PMID: 31968010 PMCID: PMC6975551 DOI: 10.1371/journal.pone.0227974] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 01/03/2020] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION District health managers play a pivotal role in the delivery of basic health services in many countries, including Ghana, as they are responsible for converting inputs and resources such as, staff, supplies and equipment into effective services that are responsive to population needs. Weak management capacity among local health managers has been suggested as a major obstacle for responsive health service delivery. However, evidence on district health managers' competencies and its association with health system performance is scarce. AIM To examine managerial capacity among district health managers and its association with health system performance in six districts in the Eastern Region of Ghana. METHODS Fifty-nine district health managers' in six different performing districts in the Eastern Region of Ghana completed a self-administered questionnaire measuring their management competencies and skills. In addition, the participants provided information on their socio-demographic background; previous management experience and training; the extent of available management support systems, and the dynamics within their district health management teams. A non-parametric one-way analysis was applied to test the association between management capacity and district performance, which was measured by 17 health indicators. RESULTS Shortcomings within different aspects of district management were identified, however there were no significant differences observed in the availability of support systems, characteristics and qualifications of district health managers across the different performing districts. Overall management capacity among district health managers were significantly higher in high performing districts compared with lower performing districts (p = 0.02). Furthermore, district health managers in better performing districts reported a higher extent of teamwork (p = 0.02), communication within their teams (p<0.01) and organizational commitment (p<0.01) compared with lower performing districts. CONCLUSION The findings demonstrate individual and institutional capacity needs, and highlights the importance of developing management competencies and skills as well as positive team dynamics among health managers at district level.
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Affiliation(s)
- Anne Christine Stender Heerdegen
- Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Moses Aikins
- School of Public Health, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
| | - Samuel Amon
- School of Public Health, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
| | - Samuel Agyei Agyemang
- School of Public Health, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
| | - Kaspar Wyss
- Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
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Belrhiti Z, Van Damme W, Belalia A, Marchal B. Unravelling the role of leadership in motivation of health workers in a Moroccan public hospital: a realist evaluation. BMJ Open 2020; 10:e031160. [PMID: 31900266 PMCID: PMC6955542 DOI: 10.1136/bmjopen-2019-031160] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 12/06/2019] [Accepted: 12/10/2019] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES This study aimed at opening the black box of the relationship between leadership and motivation of health workers by focusing on a high-performance hospital in Morocco. DESIGN We adopted the realist evaluation approach and used the case study design to test the initial programme theory we formulated on the basis of a scoping review on complex leadership. We used the Intervention-Context-Actors-Mechanism-Outcome Configuration as a heuristic tool to identify plausible causal configurations. SETTINGS Since 2000, the Ministry of Health in Morocco initiated many reforms in the frame of the governmental deconcentration process called 'advanced regionalisation'. The implementation of these reforms is hampered by inadequate human resource management capacities of local health system managers. Yet, the National 'Concours Qualité', a national quality assurance programme implemented since 2007, demonstrated that there are many islands of excellence. We explore how leadership may play a role in explaining these islands of excellence. PARTICIPANTS We carried out a document review, 18 individual interviews and 3 group discussions (with doctors, administrators and nurses), and non-participant observations during a 2-week field visit in January-February 2018. RESULTS We confirmed that effective leaders adopt an appropriate mix of transactional, transformational and distributed leadership styles that fits the mission, goals, organisational culture and nature of tasks of the organisation and the individual characteristics of the personnel when organisational culture is conducive. Leadership effectiveness is conditioned by the degree of responsiveness to the basic psychological needs of autonomy, competence and relatedness, perceived organisational support and perceived supervisor support. Transactional and overcontrolling leadership behaviour decreased the satisfaction of the need for autonomy and mutual respect. By distributing leadership responsibilities, complex leaders create an enabling environment for collective efficacy and creative problem solving. CONCLUSIONS We found indications that in the Moroccan context, well-performing hospitals could be characterised by a good fit between leadership styles, organisational characteristics and individual staff attributes.
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Affiliation(s)
- Zakaria Belrhiti
- Ecole Nationale de Santé Publique, Rabat, Morocco
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Gerontology, Vrije Universiteit Brussel, Brussel, Belgium
| | - Wim Van Damme
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Gerontology, Vrije Universiteit Brussel, Brussel, Belgium
| | | | - Bruno Marchal
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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15
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Tumusiime P, Kwamie A, Akogun OB, Elongo T, Nabyonga-Orem J. Towards universal health coverage: reforming the neglected district health system in Africa. BMJ Glob Health 2019; 4:e001498. [PMID: 31681483 PMCID: PMC6797439 DOI: 10.1136/bmjgh-2019-001498] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 04/07/2019] [Accepted: 04/27/2019] [Indexed: 11/27/2022] Open
Abstract
In most African countries, the district sphere of governance is a colonial creation for harnessing resources from the communities that are located far away from the centre with the assistance of minimally skilled personnel who are subordinate to the central authority with respect to decision-making and initiative. Unfortunately, postcolonial reforms of district governance have retained the hierarchical structure of the local government. Anchored to such a district arrangement, the (district) health system (DHS) is too weak and impoverished to function in spite of enormous knowledge and natural resources for a seamless implementation of universal health coverage (UHC). Sadly, the quick-fix projects of the 1990s with the laudable intention to reduce the burden of disease within a specified time-point dealt the fatal blow on the DHS administration by diminishing it to a stop-post and a warehouse for commodities (such as bednets and vaccines) destined for the communities. We reviewed the situation of the district in sub-Saharan African countries and identified five attributes that are critical for developing a UHC-friendly DHS. In this analytical paper, we discuss decision-making authority, coordination, resource control, development initiative and management skills as critical factors. We highlight the required strategic shifts and recommend a dialogue for charting an African regional course for a reformed DHS for UHC. Further examination of these factors and perhaps other ancillary criteria will be useful for developing a checklist for assessing the suitability of a DHS for the UHC that Africa deserves.
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Affiliation(s)
- Prosper Tumusiime
- Health Systems and Services Cluster, WHO Regional office for Africa, Brazzaville, Congo
| | - Aku Kwamie
- School of Public Health, University of Ghana, Legon, Ghana
| | - Oladele B Akogun
- Tropical Health and Diseases Research, Federal University of Technology Yola, Yola, Nigeria
- Common Heritage Foundation, Common Heritage Foundation, Abuja, Nigeria
| | - Tarcisse Elongo
- Health Systems and Services Cluster, WHO Regional office for Africa, Brazzaville, Congo
| | - Juliet Nabyonga-Orem
- Health systems and services cluster, World Health Organization, Inter-Country Support Team for Eastern & Southern Africa, Harare, Zimbabwe
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16
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Belrhiti Z, Nebot Giralt A, Marchal B. Complex Leadership in Healthcare: A Scoping Review. Int J Health Policy Manag 2018; 7:1073-1084. [PMID: 30709082 PMCID: PMC6358662 DOI: 10.15171/ijhpm.2018.75] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Accepted: 08/04/2018] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Nowadays, health systems are generally acknowledged to be complex social systems. Consequently, scholars, academics, practitioners, and policy-makers are exploring how to adopt a complexity perspective in health policy and system research. While leadership and complexity has been studied extensively outside health, the implications of complexity theories for the study of leadership in healthcare have received limited attention. We carried out a scoping review of complex leadership (CL) in healthcare to investigate how CL in healthcare has been defined, theorised and conceptualised and to explore how 'CL' has been applied in healthcare settings. METHODS We followed the methodological steps proposed by (Arksey and O'Malley, 2005): (1) specifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, (5) collating and summarizing the findings, and (6) reporting the results. We searched using Medline, Psychinfo, Wiley online library, and Google Scholar. Our inclusion criteria were: publication type (peer reviewed articles, theses, and book chapters); phenomenon of interest: complex leadership; context: healthcare and period of publication: between 2000 and 2016. RESULTS Our search and selection resulted in 37 papers (16 conceptual papers, 14 empirical studies and 7 advocacy papers). We note that empirical studies on CL are few and almost all research reported by these papers was carried out in the North (mainly in USA and UK). We found that there is some variation in definitions of CL. Furthermore, the research papers adopt mostly an explorative or explanatory approach and do not focus on assessing effectiveness of CL approaches. Finally, we found that the majority of researchers seem to adhere to the mathematical complexity perspective. CONCLUSION Complexity concepts derived from natural sciences may not automatically fit management of health services. Further research into how social complexity theories may offer researchers useful grounds to empirically test CL theories in health settings is warranted. Specific attention should be paid to the multi-layered nature of leadership.
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Affiliation(s)
- Zakaria Belrhiti
- National School of Public Health, Rabat, Morocco
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
- Vrije Universiteit Brussel, Brussels, Belgium
| | | | - Bruno Marchal
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
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17
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George A, Campbell J, Ghaffar A. Advancing the science behind human resources for health: highlights from the Health Policy and Systems Research Reader on Human Resources for Health. HUMAN RESOURCES FOR HEALTH 2018; 16:35. [PMID: 30103757 PMCID: PMC6090660 DOI: 10.1186/s12960-018-0302-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 06/22/2018] [Indexed: 06/08/2023]
Abstract
Health workers are central to people-centred health systems, resilient economies and sustainable development. Given the rising importance of the health workforce, changing human resource for health (HRH) policy and practice and recent health policy and systems research (HPSR) advances, it is critical to reassess and reinvigorate the science behind HRH as part of health systems strengthening and social development more broadly. Building on the recently published Health Policy and Systems Research Reader on Human Resources for Health (the Reader), this commentary reflects on the added value of HPSR underpinning HRH. HPSR does so by strengthening the multi-disciplinary base and rigour of HRH research by (1) valuing diverse research inferences and (2) deepening research enquiry and quality. It also anchors the relevance of HRH research for HRH policy and practice by (3) broadening conceptual boundaries and (4) strengthening policy engagement. Most importantly, HPSR enables us to transform HRH from being faceless numbers or units of health producers to the heart and soul of health systems and vital change agents in our communities and societies. Health workers' identities and motivation, daily routines and negotiations, and training and working environments are at the centre of successes and failures of health interventions, health system functioning and broader social development. Further, in an increasingly complex globalised economy, the expansion of the health sector as an arena for employment and the liberalisation of labour markets has contributed to the unprecedented movement of health workers, many or most of whom are women, not only between public and private health sectors, but also across borders. Yet, these political, human development and labour market realities are often set aside or elided altogether. Health workers' lives and livelihoods, their contributions and commitments, and their individual and collective agency are ignored. The science of HRH, offering new discoveries and deeper understanding of how universal health coverage and the Sustainable Development Goals are dependent on millions of health workers globally, has the potential to overcome this outdated and ineffective orthodoxy.
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Affiliation(s)
- A.S. George
- School of Public Health, University of the Western Cape, Private Bag x17, Bellville, Cape Town, 7535 South Africa
| | - J. Campbell
- Health Workforce, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland
| | - A. Ghaffar
- The Alliance for Health Policy and Systems Research, 20 Avenue Appia, 1211 Geneva, Switzerland
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18
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George A, Campbell J, Ghaffar A. Advancing the science behind human resources for health: highlights from the Health Policy and Systems Research Reader on Human Resources for Health. Health Res Policy Syst 2018; 16:80. [PMID: 30103778 PMCID: PMC6090771 DOI: 10.1186/s12961-018-0346-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 06/22/2018] [Indexed: 11/10/2022] Open
Abstract
Health workers are central to people-centred health systems, resilient economies and sustainable development. Given the rising importance of the health workforce, changing human resource for health (HRH) policy and practice and recent health policy and systems research (HPSR) advances, it is critical to reassess and reinvigorate the science behind HRH as part of health systems strengthening and social development more broadly. Building on the recently published Health Policy and Systems Research Reader on Human Resources for Health (the Reader), this commentary reflects on the added value of HPSR underpinning HRH. HPSR does so by strengthening the multi-disciplinary base and rigour of HRH research by (1) valuing diverse research inferences and (2) deepening research enquiry and quality. It also anchors the relevance of HRH research for HRH policy and practice by (3) broadening conceptual boundaries and (4) strengthening policy engagement. Most importantly, HPSR enables us to transform HRH from being faceless numbers or units of health producers to the heart and soul of health systems and vital change agents in our communities and societies. Health workers' identities and motivation, daily routines and negotiations, and training and working environments are at the centre of successes and failures of health interventions, health system functioning and broader social development. Further, in an increasingly complex globalised economy, the expansion of the health sector as an arena for employment and the liberalisation of labour markets has contributed to the unprecedented movement of health workers, many or most of whom are women, not only between public and private health sectors, but also across borders. Yet, these political, human development and labour market realities are often set aside or elided altogether. Health workers' lives and livelihoods, their contributions and commitments, and their individual and collective agency are ignored. The science of HRH, offering new discoveries and deeper understanding of how universal health coverage and the Sustainable Development Goals are dependent on millions of health workers globally, has the potential to overcome this outdated and ineffective orthodoxy.
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Affiliation(s)
- A.S. George
- School of Public Health, University of the Western Cape, Private Bag x17, Bellville, Cape Town, 7535 South Africa
| | - J. Campbell
- Health Workforce, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland
| | - A. Ghaffar
- The Alliance for Health Policy and Systems Research, 20 Avenue Appia, 1211 Geneva, Switzerland
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19
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Agyepong IA, Lehmann U, Rutembemberwa E, Babich SM, Frimpong E, Kwamie A, Olivier J, Teddy G, Hwabamungu B, Gilson L. Strategic leadership capacity building for Sub-Saharan African health systems and public health governance: a multi-country assessment of essential competencies and optimal design for a Pan African DrPH. Health Policy Plan 2018; 33:ii35-ii49. [PMID: 30053033 PMCID: PMC6037058 DOI: 10.1093/heapol/czx162] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2017] [Indexed: 11/14/2022] Open
Abstract
Leadership capacity needs development and nurturing at all levels for strong health systems governance and improved outcomes. The Doctor of Public Health (DrPH) is a professional, interdisciplinary terminal degree focused on strategic leadership capacity building. The concept is not new and there are several programmes globally-but none within Africa, despite its urgent need for strong strategic leadership in health. To address this gap, a consortium of institutions in Sub-Saharan Africa, UK and North America have embarked on a collaboration to develop and implement a pan-African DrPH with support from the Rockefeller Foundation. This paper presents findings of research to verify relevance, identify competencies and support programme design and customization. A mixed methods cross sectional multi-country study was conducted in Ghana, South Africa and Uganda. Data collection involved a non-exhaustive desk review, 34 key informant (KI) interviews with past and present health sector leaders and a questionnaire with closed and open ended items administered to 271 potential DrPH trainees. Most study participants saw the concept of a pan-African DrPH as relevant and timely. Strategic leadership competencies identified by KI included providing vision and inspiration for the organization, core personal values and character qualities such as integrity and trustworthiness, skills in adapting to situations and context and creating and maintaining effective change and systems. There was consensus that programme design should emphasize learning by doing and application of theory to professional practice. Short residential periods for peer-to-peer and peer-to-facilitator engagement and learning, interspaced with facilitated workplace based learning, including coaching and mentoring, was the preferred model for programme implementation. The introduction of a pan-African DrPH with a focus on strategic leadership is relevant and timely. Core competencies, optimal design and customization for the sub-Saharan African context has broad consensus in the study setting.
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Affiliation(s)
- Irene Akua Agyepong
- Ghana Health Service, Division of Research and Development, Dodowa Health Research Center, Dodowa, Greater Accra, Ghana
- University of Ghana, School of Public Health, Department of Health Policy, Planning and Management, Legon, Accra, Ghana
| | - Uta Lehmann
- School of Public Health, University of the Western Cape, Robert Sobukwe Road, Cape Town, Bellville, South Africa
| | - Elizeus Rutembemberwa
- Department of Health Policy Planning and Management, Makerere University, School of Public Health, Uganda, East Africa
| | - Suzanne M Babich
- Indiana University, Richard M. Fairbanks School of Public Health Health Sciences Building (RG), 1050 Wishard Blvd, 6th Floor, Indianapolis, IN, USA
| | - Edith Frimpong
- Ghana Health Service, Division of Research and Development, Dodowa Health Research Center, Dodowa, Greater Accra, Ghana
| | - Aku Kwamie
- Ghana Health Service, Division of Research and Development, Dodowa Health Research Center, Dodowa, Greater Accra, Ghana
| | - Jill Olivier
- School of Public Health and Family Medicine, Anzio Road, Observatory, Cape Town, South Africa
| | - Gina Teddy
- School of Public Health and Family Medicine, Anzio Road, Observatory, Cape Town, South Africa
- Ghana Institute of Management and Public Administration, Center for Health Systems and Policy Research (CHESPOR), Achimota, Accra, Ghana
| | - Boroto Hwabamungu
- School of Public Health, University of the Western Cape, Robert Sobukwe Road, Cape Town, Bellville, South Africa
| | - Lucy Gilson
- School of Public Health and Family Medicine, Anzio Road, Observatory, Cape Town, South Africa
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK) and
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20
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Kwamie A, Asiamah M, Schaaf M, Agyepong IA. Postings and transfers in the Ghanaian health system: a study of health workforce governance. Int J Equity Health 2017; 16:85. [PMID: 28911337 PMCID: PMC5599893 DOI: 10.1186/s12939-017-0583-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 05/12/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Decision-making on postings and transfers - that is, the geographic deployment of the health workforce - is a key element of health workforce governance. When poorly managed, postings and transfers result in maldistribution, absenteeism, and low morale. At stake is managing the balance between organisational (i.e., health system) and individual (i.e., staff preference) needs. The negotiation of this potential convergence or divergence of interests provides a window on practices of postings and transfers, and on the micro-practices of governance in health systems more generally. This article explores the policies and processes, and the interplay between formal and informal rules and norms which underpin postings and transfers practice in two rural districts in the Greater Accra Region of Ghana. METHODS Semi-structured interviews were conducted with eight district managers and 87 frontline staff from the district health administration, district hospital, polyclinic, health centres and community outreach compounds across two districts. Interviews sought to understand how the postings and transfers process works in practice, factors in frontline staff and district manager decision-making, personal experiences in being posted, and study leave as a common strategy for obtaining transfers. RESULTS Differential negotiation-spaces at regional and district level exist and inform postings and transfers in practice. This is in contrast to the formal cascaded rules set to govern decision-making authority for postings and transfers. Many frontline staff lack policy clarity of postings and transfers processes and thus 'test' the system through informal staff lobbying, compounding staff perception of the postings and transfers process as being unfair. District managers are also challenged with limited decision-space embedded in broader policy contexts of systemic hierarchy and resource dependence. This underscores the negotiation process as ongoing, rather than static. CONCLUSIONS These findings point to tensions between individual and organisational goals. This article contributes to a burgeoning literature on postings and transfers as a distinct dynamic which bridges the interactions between health systems governance and health workforce development. Importantly, this article helps to expand the notion of health systems governance beyond 'good' governance towards understanding governance as a process of negotiation.
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Affiliation(s)
- Aku Kwamie
- Ghana Health Service, Research and Development Division, Ministries, P.O. Box MB190, Accra, Ghana
| | | | - Marta Schaaf
- Averting Maternal Death & Disability Program (AMDD) Heilbrunn Department of Population and Family Health Mailman School of Public Health, Columbia University, New York, USA
| | - Irene Akua Agyepong
- Ghana Health Service, Research and Development Division, Ministries, P.O. Box MB190, Accra, Ghana
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21
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Agyepong IA, Kwamie A, Frimpong E, Defor S, Ibrahim A, Aryeetey GC, Lokossou V, Sombie I. Spanning maternal, newborn and child health (MNCH) and health systems research boundaries: conducive and limiting health systems factors to improving MNCH outcomes in West Africa. Health Res Policy Syst 2017; 15:54. [PMID: 28722556 PMCID: PMC5516848 DOI: 10.1186/s12961-017-0212-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Despite improvements over time, West Africa lags behind global as well as sub-Saharan averages in its maternal, newborn and child health (MNCH) outcomes. This is despite the availability of an increasing body of knowledge on interventions that improve such outcomes. Beyond our knowledge of what interventions work, insights are needed on others factors that facilitate or inhibit MNCH outcome improvement. This study aimed to explore health system factors conducive or limiting to MNCH policy and programme implementation and outcomes in West Africa, and how and why they work in context. METHODS We conducted a mixed methods multi-country case study focusing predominantly, but not exclusively, on the six West African countries (Burkina Faso, Benin, Mali, Senegal, Nigeria and Ghana) of the Innovating for Maternal and Child Health in Africa initiative. Data collection involved non-exhaustive review of grey and published literature, and 48 key informant interviews. We validated our findings and conclusions at two separate multi-stakeholder meetings organised by the West African Health Organization. To guide our data collection and analysis, we developed a unique theoretical framework of the link between health systems and MNCH, in which we conceptualised health systems as the foundations, pillars and roofing of a shelter for MNCH, and context as the ground on which the foundation is laid. RESULTS A multitude of MNCH policies and interventions were being piloted, researched or implemented at scale in the sub-region, most of which faced multiple interacting conducive and limiting health system factors to effective implementation, as well as contextual challenges. Context acted through its effect on health system factors as well as on the social determinants of health. CONCLUSIONS To accelerate and sustain improvements in MNCH outcomes in West Africa, an integrated approach to research and practice of simultaneously addressing health systems and contextual factors alongside MNCH service delivery interventions is needed. This requires multi-level, multi-sectoral and multi-stakeholder engagement approaches that span current geographical, language, research and practice community boundaries in West Africa, and effectively link the efforts of actors interested in health systems strengthening with those of actors interested in MNCH outcome improvement.
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Affiliation(s)
- Irene Akua Agyepong
- Ghana Health Service, Research and Development Division, P.O. Box MB-190, Greater Accra region, Ghana
| | - Aku Kwamie
- Ghana Health Service, Research and Development Division, P.O. Box MB-190, Greater Accra region, Ghana
| | - Edith Frimpong
- Ghana Health Service, Research and Development Division, P.O. Box MB-190, Greater Accra region, Ghana
| | - Selina Defor
- Ghana Health Service, Research and Development Division, P.O. Box MB-190, Greater Accra region, Ghana
| | - Abdallah Ibrahim
- University of Ghana School of Public Health, P.O. Box LG13, Legon, Accra, Ghana
| | | | - Virgil Lokossou
- West African Health Organization, Bobo-Dioulasso, 01BP 153 Bobo-Dioulasso 01, Burkina Faso
| | - Issiaka Sombie
- West African Health Organization, Bobo-Dioulasso, 01BP 153 Bobo-Dioulasso 01, Burkina Faso
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Abimbola S, Negin J, Martiniuk AL, Jan S. Institutional analysis of health system governance. Health Policy Plan 2017; 32:1337-1344. [DOI: 10.1093/heapol/czx083] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Seye Abimbola
- School of Public Health, Sydney Medical School, University of Sydney, NSW 2006, Australia
- National Primary Health Care Development Agency, Abuja, FCT 900247, Nigeria
- The George Institute for Global Health, Sydney, NSW 2042, Australia and
| | - Joel Negin
- School of Public Health, Sydney Medical School, University of Sydney, NSW 2006, Australia
| | - Alexandra L Martiniuk
- School of Public Health, Sydney Medical School, University of Sydney, NSW 2006, Australia
- The George Institute for Global Health, Sydney, NSW 2042, Australia and
- Dalla Lana School of Public Health, University of Toronto, ON M4N 3 M5, Canada
| | - Stephen Jan
- School of Public Health, Sydney Medical School, University of Sydney, NSW 2006, Australia
- The George Institute for Global Health, Sydney, NSW 2042, Australia and
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Roman TE, Cleary S, McIntyre D. Exploring the Functioning of Decision Space: A Review of the Available Health Systems Literature. Int J Health Policy Manag 2017; 6:365-376. [PMID: 28812832 PMCID: PMC5505106 DOI: 10.15171/ijhpm.2017.26] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 02/18/2017] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The concept of decision space holds appeal as an approach to disaggregating the elements that may influence decision-making in decentralized systems. This narrative review aims to explore the functioning of decision space and the factors that influence decision space. METHODS A narrative review of the literature was conducted with searches of online databases and academic journals including PubMed Central, Emerald, Wiley, Science Direct, JSTOR, and Sage. The articles were included in the review based on the criteria that they provided insight into the functioning of decision space either through the explicit application of or reference to decision space, or implicitly through discussion of decision-making related to organizational capacity or accountability mechanisms. RESULTS The articles included in the review encompass literature related to decentralisation, management and decision space. The majority of the studies utilise qualitative methodologies to assess accountability mechanisms, organisational capacities such as finance, human resources and management, and the extent of decision space. Of the 138 articles retrieved, 76 articles were included in the final review. CONCLUSION The literature supports Bossert's conceptualization of decision space as being related to organizational capacities and accountability mechanisms. These functions influence the decision space available within decentralized systems. The exact relationship between decision space and financial and human resource capacities needs to be explored in greater detail to determine the potential influence on system functioning.
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Bonenberger M, Aikins M, Akweongo P, Wyss K. Factors influencing the work efficiency of district health managers in low-resource settings: a qualitative study in Ghana. BMC Health Serv Res 2016; 16:12. [PMID: 26769344 PMCID: PMC4712591 DOI: 10.1186/s12913-016-1271-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 01/12/2016] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND There is increasing evidence that good district management practices can improve health system performance and conversely, that poor and inefficient management practices have detrimental effects. The aim of the present study was to identify factors contributing to inefficient management practices of district health managers and ways to improve their overall efficiency. METHODS Nineteen semi-structured interviews were conducted with district health managers in three districts of the Eastern Region in Ghana. The 19 interviews conducted comprised 90% of the managerial workforce in these districts in 2013. A thematic analysis was carried out using the WHO's leadership and management strengthening framework to structure the results. RESULTS Key factors for inefficient district health management practices were identified to be: human resource shortages, inadequate planning and communication skills, financial constraints, and a narrow decision space that constrains the authority of district health managers and their ability to influence decision-making. Strategies that may improve managerial efficiency at both an individual and organizational level included improvements to planning, communication, and time management skills, and ensuring the timely release of district funds. CONCLUSIONS Filling District Health Management Team vacancies, developing leadership and management skills of district health managers, ensuring a better flow of district funds, and delegating more authority to the districts seems to be a promising intervention package, which may result in better and more efficient management practices and stronger health system performance.
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Affiliation(s)
- Marc Bonenberger
- Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Socinstrasse 57, Basel, 4002 Switzerland
- University of Basel, Basel, Switzerland
| | - Moses Aikins
- School of Public Health, University of Ghana, Legon, Ghana
| | | | - Kaspar Wyss
- Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Socinstrasse 57, Basel, 4002 Switzerland
- University of Basel, Basel, Switzerland
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25
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Kwamie A. Balancing Management and Leadership in Complex Health Systems Comment on "Management Matters: A Leverage Point for Health Systems Strengthening in Global Health". Int J Health Policy Manag 2015; 4:849-51. [PMID: 26673472 PMCID: PMC4663091 DOI: 10.15171/ijhpm.2015.152] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 08/11/2015] [Indexed: 11/09/2022] Open
Abstract
Health systems, particularly those in low- and middle-income countries (LMICs), need stronger management and leadership capacities. Management and leadership are not synonymous, yet should be considered together as there can be too much of one and not enough of the other. In complex adaptive health systems, the multiple interactions and relationships between people and elements of the system mean that management and leadership, so often treated as domains of the individual, are additionally systemic phenomena, emerging from these relational interactions. This brief commentary notes some significant implications for how we can support capacity strengthening interventions for complex management and leadership. These would necessarily move away from competency-based models focused on training for individuals, and would rather encompass longer-term initiatives explicitly focused on systemic goals of accountability, innovation, and learning.
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Affiliation(s)
- Aku Kwamie
- Department of Health Policy, Planning and Management, University of Ghana School of Public Health, Accra, Ghana
- Sociology and Development of Change Group, Wageningen University, Wageningen, The Netherlands
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