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Kiendrébéogo JA, Sory O, Kaboré I, Kafando Y, Kumar MB, George AS. Form and functioning: contextualising the start of the global financing facility policy processes in Burkina Faso. Glob Health Action 2024; 17:2360702. [PMID: 38910459 PMCID: PMC11198144 DOI: 10.1080/16549716.2024.2360702] [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: 09/20/2023] [Accepted: 05/23/2024] [Indexed: 06/25/2024] Open
Abstract
BACKGROUND Burkina Faso joined the Global Financing Facility for Women, Children and Adolescents (GFF) in 2017 to address persistent gaps in funding for reproductive, maternal, newborn, child, and adolescent health and nutrition (RMNCAH-N). Few empirical papers deal with how global funding mechanisms, and specifically GFF, support resource mobilisation for health nationally. OBJECTIVE This study describes the policy processes of developing the GFF planning documents (the Investment Case and Project Appraisal Document) in Burkina Faso. METHODS We conducted an exploratory qualitative policy analysis. Data collection included document review (N = 74) and in-depth semi-structured interviews (N = 23). Data were analysed based on the components of the health policy triangle. RESULTS There was strong national political support to RMNCAH-N interventions, and the process of drawing up the investment case (IC) and the project appraisal document was inclusive and multi-sectoral. Despite high-level policy commitments, subsequent implementation of the World Bank project, including the GFF contribution, was perceived by respondents as challenging, even after the project restructuring process occurred. These challenges were due to ongoing policy fragmentation for RMNCAH-N, navigation of differing procedures and perspectives between stakeholders in the setting up of the work, overcoming misunderstandings about the nature of the GFF, and weak institutional anchoring of the IC. Insecurity and political instability also contributed to observed delays and difficulties in implementing the commitments agreed upon. To tackle these issues, transformational and distributive leaderships should be promoted and made effective. CONCLUSIONS Few studies have examined national policy processes linked to the GFF or other global health initiatives. This kind of research is needed to better understand the range of challenges in aligning donor and national priorities encountered across diverse health systems contexts. This study may stimulate others to ensure that the GFF and other global health initiatives respond to local needs and policy environments for better implementation.
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Affiliation(s)
- Joël Arthur Kiendrébéogo
- Department of Public Health, University Joseph Ki-Zerbo, Ouagadougou, Burkina Faso
- Department of Research, Expertise and Capacity Building, Recherche pour la santé et le développement (RESADE), Ouagadougou, Burkina Faso
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Heidelberg, Germany
- Institute of Tropical Medicine, Department of Public Health, Antwerp, Belgium
| | - Orokia Sory
- Department of Research, Expertise and Capacity Building, Recherche pour la santé et le développement (RESADE), Ouagadougou, Burkina Faso
| | - Issa Kaboré
- Operations Division, Recherche pour la santé et le développement (RESADE), Ouagadougou, Burkina Faso
| | - Yamba Kafando
- Operations Division, Recherche pour la santé et le développement (RESADE), Ouagadougou, Burkina Faso
| | - Meghan Bruce Kumar
- London School of Hygiene and Tropical Medicine, Faculty of Public Health and Policy, London, UK
- Department of Health Systems and Research Ethics, KEMRI-Wellcome Trust Programme, Nairobi, Kenya
- Northumbria University, Department of Nursing, Midwifery and Health, Newcastle upon Tyne, UK
| | - Asha S. George
- School of Public Health, University of the Western Cape, Cape Town, South Africa
- Health Systems Extra-Mural Unit, South African Medical Research Council, Cape Town, South Africa
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Neyazi N, Mosadeghrad AM, Tajvar M, Safi N. Governance of noncommunicable diseases in Afghanistan. Chronic Dis Transl Med 2024; 10:238-246. [PMID: 39027200 PMCID: PMC11252431 DOI: 10.1002/cdt3.118] [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: 11/15/2023] [Revised: 12/28/2023] [Accepted: 01/09/2024] [Indexed: 07/20/2024] Open
Abstract
Background Noncommunicable diseases (NCDs) are the main reasons of mortality worldwide. One of every two person is dying due to NCDs in Afghanistan. International policy actors, mainly the World Health Organization (WHO), published several reports and declarations on controlling and preventing NCDs. This study aimed to provide a situation for governance of NCDs in Afghanistan and proper solutions for identified challenges. Methods We conducted qualitative research utilizing interpretive phenomenology. A self-developed questionnaire was developed to conduct the semi-structured interviews with 39 experts from Afghanistan. The results were analyzed using a deductive framework analysis. Six building block framework of health system developed by the WHO was used as predefined framework for this study. Results The governance building block of health system consists of five subthemes including policy making, planning, organizing, stewardship, and control. We identified main strengths, weaknesses, opportunities, and challenges for these subthemes. The experts also provided key recommendations to address the challenges. Conclusions Management of NCDs is a neglected part of the health system in Afghanistan. Strengthening evidence-based policy making with technical and indigenous planning, establishing responsive units with adequate financial and human resources within different ministries to address "health in all policies" concept, passing and implementing national laws and regulations to support national strategies for prevention and control of NCDs, and establishing decentralized monitoring systems to control the implementation of these strategies are the main recommendations of this study. Local government and international policy actors should invest and support the development of a multisectoral coordination system at national level for Afghanistan.
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Affiliation(s)
- Narges Neyazi
- International Campus, School of Public HealthTehran University of Medical SciencesTehranIran
- Department of Health System DevelopmentWorld Health OrganizationAfghanistan
| | - Ali M. Mosadeghrad
- Department of Health Management, Policy and Economics, School of Public HealthTehran University of Medical SciencesTehranIran
| | - Maryam Tajvar
- Department of Health Management, Policy and Economics, School of Public HealthTehran University of Medical SciencesTehranIran
| | - Najibullah Safi
- Department of Health System DevelopmentWorld Health OrganizationAfghanistan
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van der Westhuizen HM, Giddy J, Coetzee R, Makanda G, Tisile P, Galloway M, Bunyula S, Schoeman I, Nathavitharana RR. Strengthening accountability for tuberculosis policy implementation in South Africa: perspectives from policymakers, civil society, and communities. BMC GLOBAL AND PUBLIC HEALTH 2024; 2:48. [PMID: 39026933 PMCID: PMC11252195 DOI: 10.1186/s44263-024-00077-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 06/25/2024] [Indexed: 07/20/2024]
Abstract
Background Translating health policy into effective implementation is a core priority for responding effectively to the tuberculosis (TB) crisis. The national TB Recovery Plan was developed in response to the negative impact that the COVID-19 pandemic had on TB care in South Africa. We aimed to explore the implementation of the TB Recovery Plan and develop recommendations for strengthening accountability for policy implementation for this and future TB policies. Methods We interviewed 24 participants working on or impacted by TB policy implementation in South Africa. This included perspectives from national, provincial, and local health department representatives, civil society, and community representatives. In-depth interviews were conducted in English and isiXhosa and we drew on reflexive thematic methods for analysis. Results Participants felt that there was potential for COVID-19 innovations and urgency to influence TB policy development and implementation, including the use of data dashboards. Implementation of the TB Recovery Plan predominantly used a top-down approach to implementation (cascading from national policy to local implementers) but experienced bottlenecks at provincial level. Recommendations for closing the TB policy-implementation gap included using phased implementation and enhancing provincial-level accountability. Civil society organisations were concerned about the lack of provincial implementation data which impeded advocacy for improved accountability and inadequate resourcing for implementation. Community health workers were viewed as key to implementation but were not engaged in the policy development process and were often not aware of new TB policies. At local level, there were also opportunities to strengthen community engagement in policy implementation including through community-led monitoring. Participants recommended broader multi-stakeholder engagement that includes community and community health worker representatives in the development and implementation phases of new TB policies. Conclusions Communities affected by TB, with the support of civil society organisations, could play a bigger role in monitoring policy implementation at local level and need to be capacitated to do this. This bottom-up approach could complement existing top-down strategies and contribute to greater accountability for TB policy implementation. Supplementary Information The online version contains supplementary material available at 10.1186/s44263-024-00077-y.
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Affiliation(s)
| | | | - Renier Coetzee
- TB Proof, Cape Town, South Africa
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | | | | | | | | | | | - Ruvandhi R. Nathavitharana
- TB Proof, Cape Town, South Africa
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA USA
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Mériade L, Rochette C, Cassière F. Local implementation of public health policies revealed by the COVID-19 crisis: the French case. Implement Sci 2023; 18:25. [PMID: 37353837 DOI: 10.1186/s13012-023-01277-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 05/22/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND Improving health system performance depends on the quality of health policy implementation at the local level. However, in general, the attention of researchers is mainly directed towards issues of health policy design and evaluation rather than implementation at the local level. The management of the COVID-19 crisis, especially in Europe, has particularly highlighted the complexity of implementing health policies, decided at the national or supranational level, at the local level. METHODS We conducted 23 semi-structured interviews with the main stakeholders in the management of the COVID-19 crisis in the second largest French region in order to identify the different actors and modes of coordination of the local implementation of health policies that this crisis management illustrates in a very visible way. Our methodology is complemented by a content analysis of the main guidelines and decisions related to this implementation. RESULTS The analysis of these data allows us to identify three levels of implementation of health policies at the local level (administrative, organizational and operational). Interviews also reveal the existence of different types of coordination specific to each of these levels of local implementation of health policies. These results then make it possible to identify important managerial avenues for promoting global coordination of these three levels of implementation. CONCLUSIONS Although research on health services emphasizes the existence of several levels of local implementation of health policies, it offers little in the way of definition or characterization of these levels. The identification in this study of the three levels of local implementation of health policies and their specific forms of coordination contribute to a more precise characterization of this implementation in order to promote, in practice, its global coordination.
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Affiliation(s)
- Laurent Mériade
- IAE Clermont Auvergne, CleRMa, Research Chair "Santé Et Territoires", University Clermont Auvergne, 11 Boulevard Charles de Gaulle, Clermont-Ferrand, 63000, France.
| | - Corinne Rochette
- IAE Clermont Auvergne, CleRMa, Research Chair "Santé Et Territoires", University Clermont Auvergne, 11 Boulevard Charles de Gaulle, Clermont-Ferrand, 63000, France
| | - François Cassière
- IAE Clermont Auvergne, CleRMa, Research Chair "Santé Et Territoires", University Clermont Auvergne, 11 Boulevard Charles de Gaulle, Clermont-Ferrand, 63000, France
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Kc A, Waiswa P, Kinney MV. Research on high quality health care needs to move beyond what to how. Lancet Glob Health 2023; 11:e803-e804. [PMID: 37202008 DOI: 10.1016/s2214-109x(23)00209-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 04/06/2023] [Indexed: 05/20/2023]
Affiliation(s)
- Ashish Kc
- School of Public Health and Community Medicine, University of Gothenburg, Gothenburg, Sweden.
| | - Peter Waiswa
- School of Public Health and Global Health Division, Makerere University, Kampala, Uganda
| | - Mary V Kinney
- School of Public Health, Faculty of Community and Health Sciences, University of the Western Cape, Cape Town, South Africa
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Namagembe I, Beyeza-Kashesya J, Rujumba J, K.Kaye D, Mukuru M, Kiwanuka N, Moffett A, Nakimuli A, Byamugisha J. Barriers and facilitators to maternal death surveillance and response at a busy urban National Referral Hospital in Uganda. OPEN RESEARCH AFRICA 2023; 5:31. [PMID: 37346758 PMCID: PMC10280031 DOI: 10.12688/openresafrica.13438.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 06/23/2023]
Abstract
Background: Preventable maternal and newborn deaths remain a global concern, particularly in low- and- middle-income countries (LMICs) Timely maternal death surveillance and response (MDSR) is a recommended strategy to account for such deaths through identifying contextual factors that contributed to the deaths to inform recommendations to implement in order to reduce future deaths. Implementation of MDSR is still suboptimal due to barriers such as inadequate skills and leadership to support MDSR. With the leadership of WHO and UNFPA, there is momentum to roll out MDSR, however, the barriers and enablers for implementation have received limited attention. These have implications for successful implementation. The aim of this study was: To assess barriers and facilitators to implementation of MDSR at a busy urban National Referral Hospital as perceived by health workers, administrators, and other partners in Reproductive Health. Methods: Qualitative study using in-depth interviews (24), 4 focus-group discussions with health workers, 15 key-informant interviews with health sector managers and implementing partners in Reproductive-Health. We conducted thematic analysis drawing on the Theory of Planned Behaviour (TPB). Results: The major barriers to implementation of MDSR were: inadequate knowledge and skills; fear of blame / litigation; failure to implement recommendations; burn out because of workload and inadequate leadership- to support health workers. Major facilitators were involving all health workers in the MDSR process, eliminate blame, strengthen leadership, implement recommendations from MDSR and functionalize lower health facilities (especially Health Centre -IVs). Conclusions: The barriers of MDSR include knowledge and skills gaps, fear of blame and litigation, and other health system factors such as erratic emergency supplies, and leadership/governance challenges. Recommendation: Efforts to strengthen MDSR for impact should use health system responsiveness approach to address the barriers identified, constructive participation of health workers to harness the facilitators and addressing the required legal framework.
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Affiliation(s)
- Imelda Namagembe
- Department of Obstetrics and Gynaecology, School of Medicine, Makerere University College of Health Sciences, Uganda, P.O Box 7072, Kampala, Uganda, Makerere University and Mulago Specialized Women Neonatal Hospital, Kampala, Uganda, +256, Uganda, Makerere University and MSWNH, Kampala, Uganda, +256, Uganda
| | - Jolly Beyeza-Kashesya
- Department of Obstetrics and Gynaecology, School of Medicine, Makerere University College of Health Sciences, Uganda, P.O Box 7072, Kampala, Uganda, Makerere University and Mulago Specialized Women Neonatal Hospital, Kampala, Uganda, +256, Uganda, Makerere University /MSWNH, Kampala, Uganda, +256, Uganda
| | - Joseph Rujumba
- Department of Paediatrics and Child Health, School of Medicine, Makerere University College of Health Sciences, Uganda, P.O Box 7072, Kampala, Uganda, Makerere University, Kampala, Uganda, +256, Uganda
| | - Dan K.Kaye
- Department of Obstetrics and Gynaecology, School of Medicine, Makerere University College of Health Sciences, Uganda, P.O Box 7072, Kampala, Uganda, Makerere University, Kampala, Uganda, +256, Uganda
| | - Moses Mukuru
- Department of Health Policy Planning and Management, School of Public Health, Makerere University College of Health Sciences, Uganda, P.O Box 7072, Kampala, Uganda, MakCHS, Kampala, Uganda, +256, Uganda
| | - Noah Kiwanuka
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University College of Health Sciences, Uganda, P.O Box 7072, Kampala, Uganda, MakCHS, Kampala, Uganda, +256, Uganda
| | - Ashley Moffett
- Department of Pathology and Centre for Trophoblast Research, University of Cambridge, Cambridge, United Kingdom, University of Cambridge, Cambridge, United Kingdom, +44, UK
| | - Annettee Nakimuli
- Department of Obstetrics and Gynaecology, School of Medicine, Makerere University College of Health Sciences, Uganda, P.O Box 7072, Kampala, Uganda, MakCHS, Kampala, Uganda, +256, Uganda
| | - Josaphat Byamugisha
- Department of Obstetrics and Gynaecology, School of Medicine, Makerere University College of Health Sciences, Uganda, P.O Box 7072, Kampala, Uganda, Mak- CHS, Kampala, Uganda, +256, Uganda
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Karuga R, Dieleman M, Mbindyo P, Ozano K, Wairiuko J, Broerse JEW, Kok M. Community participation in the health system: analyzing the implementation of community health committee policies in Kenya. Prim Health Care Res Dev 2023; 24:e33. [PMID: 37114463 PMCID: PMC10156468 DOI: 10.1017/s1463423623000208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Community health committees (CHCs) are a mechanism for communities to voluntarily participate in making decisions and providing oversight of the delivery of community health services. For CHCs to succeed, governments need to implement policies that promote community participation. Our research aimed to analyze factors influencing the implementation of CHC-related policies in Kenya. METHODS Using a qualitative study design, we extracted data from policy documents and conducted 12 key informant interviews with health workers and health managers in two counties (rural and urban) and the national Ministry of Health. We applied content analysis for both the policy documents and interview transcripts and summarized the factors that influenced the implementation of CHC-related policies. FINDINGS Since the inception of the community health strategy, the roles of CHCs in community participation have been consistently vague. Primary health workers found the policy content related to CHCs challenging to translate into practice. They also had an inadequate understanding of the roles of CHCs, partly because policy content was not adequately disseminated at the primary healthcare level. It emerged that actors involved in organizing and providing community health services did not perceive CHCs as valuable mechanisms for community participation. County governments did not allocate funds to support CHC activities, and policies focused more on incentivizing community health volunteers (CHVs) who, unlike CHCs, provide health services at the household level. CHVs are incorporated in CHCs. CONCLUSION Kenya's community health policy inadvertently created role conflict and competition for resources and recognition between community health workers involved in service delivery and those involved in overseeing community health services. Community health policies and related bills need to clearly define the roles of CHCs. County governments can promote the implementation of CHC policies by including CHCs in the agenda during the annual review of performance in the health sector.
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Affiliation(s)
- Robinson Karuga
- LVCT Health, Nairobi, Kenya
- Athena Institute, Vrije University, Amsterdam, The Netherlands
| | | | - Patrick Mbindyo
- Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Kim Ozano
- The SCL Agency, Five Fords Gate, Wrexham, Wales, UK
| | - Judy Wairiuko
- Directorate of Preventive and Promotive Health, Nairobi City County, City Hall Way, Nairobi, Kenya
| | | | - Maryse Kok
- KIT Royal Tropical Institute, Amsterdam, Netherlands
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Rodríguez DC, Balaji LN, Chamdimba E, Kafumba J, Koon AD, Mazalale J, Mkombe D, Munywoki J, Mwase-Vuma T, Namakula J, Nambiar B, Neel AH, Nsabagasani X, Paina L, Rogers B, Tsoka M, Waweru E, Munthali A, Ssengooba F, Tsofa B. Political economy analysis of subnational health management in Kenya, Malawi and Uganda. Health Policy Plan 2023; 38:631-647. [PMID: 37084282 DOI: 10.1093/heapol/czad021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 01/27/2023] [Accepted: 04/10/2023] [Indexed: 04/23/2023] Open
Abstract
The need to bolster primary health care (PHC) to achieve the Sustainable Development Goal (SDG) targets for health is well recognized. In Eastern and Southern Africa, where governments have progressively decentralized health decision-making, health management is critical to PHC performance. While investments in health management capacity are important, so is improving the environment in which managers operate. Governance arrangements, management systems and power dynamics of actors can have a significant influence on health managers' ability to improve PHC access and quality. We conducted a problem-driven political economy analysis (PEA) in Kenya, Malawi and Uganda to explore local decision-making environments and how they affect management and governance practices for health. This PEA used document review and key informant interviews (N = 112) with government actors, development partners and civil societies in three districts or counties in each country (N = 9). We found that while decentralization should improve PHC by supporting better decisions in line with local priorities from community input, it has been accompanied by thick bureaucracy, path-dependent and underfunded budgets that result in trade-offs and unfulfilled plans, management support systems that are less aligned to local priorities, weak accountability between local government and development partners, uneven community engagement and insufficient public administration capacity to negotiate these challenges. Emergent findings suggest that coronavirus disease 2019 (COVID-19) not only resulted in greater pressures on health teams and budgets but also improved relations with central government related to better communication and flexible funding, offering some lessons. Without addressing the disconnection between the vision for decentralization and the reality of health managers mired in unhelpful processes and politics, delivering on PHC and universal health coverage goals and the SDG agenda will remain out of reach.
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Affiliation(s)
- Daniela C Rodríguez
- International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205, USA
| | | | - Elita Chamdimba
- Centre for Social Research, University of Malawi, P.O. Box 280, Zomba, Malawi
| | - Juba Kafumba
- Centre for Social Research, University of Malawi, P.O. Box 280, Zomba, Malawi
| | - Adam D Koon
- International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205, USA
| | - Jacob Mazalale
- Centre for Social Research, University of Malawi, P.O. Box 280, Zomba, Malawi
| | - Dadirai Mkombe
- Centre for Social Research, University of Malawi, P.O. Box 280, Zomba, Malawi
| | - Joshua Munywoki
- KEMRI-Wellcome Trust Research Programme, Hospital Road, P.O. Box 230, Kilifi, Kenya
| | - Tawonga Mwase-Vuma
- Centre for Social Research, University of Malawi, P.O. Box 280, Zomba, Malawi
| | - Justine Namakula
- School of Public Health, Makerere University, New Mulago Hill Road, Mulago, Kampala, Uganda
| | - Bejoy Nambiar
- UNICEF Malawi, PO Box 30375, Airtel Complex Area 40/31, Lilongwe, Malawi
| | - Abigail H Neel
- International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205, USA
| | - Xavier Nsabagasani
- School of Public Health, Makerere University, New Mulago Hill Road, Mulago, Kampala, Uganda
| | - Ligia Paina
- International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205, USA
| | - Braeden Rogers
- Health Section, UNICEF Eastern and Southern Africa Regional Office, United Nations Complex, Gigiri, P.O. Box 44145-00100, Nairobi, Kenya
| | - Maxton Tsoka
- Centre for Social Research, University of Malawi, P.O. Box 280, Zomba, Malawi
| | - Evelyn Waweru
- KEMRI-Wellcome Trust Research Programme, Hospital Road, P.O. Box 230, Kilifi, Kenya
| | - Alister Munthali
- Centre for Social Research, University of Malawi, P.O. Box 280, Zomba, Malawi
| | - Freddie Ssengooba
- School of Public Health, Makerere University, New Mulago Hill Road, Mulago, Kampala, Uganda
| | - Benjamin Tsofa
- KEMRI-Wellcome Trust Research Programme, Hospital Road, P.O. Box 230, Kilifi, Kenya
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Brooke-Sumner C, Petersen-Williams P, Sorsdahl K, Kruger J, Mahomed H, Myers B. Strategies for supporting the implementation of a task-shared psychological intervention in South Africa's chronic disease services: qualitative insights from health managers' experiences of project MIND. Glob Health Action 2022; 15:2123005. [PMID: 36178292 PMCID: PMC9542686 DOI: 10.1080/16549716.2022.2123005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Although evidence indicates that task-shared psychological interventions can reduce mental health treatment gaps in resource-constrained settings, systemic barriers have limited their widespread implementation. Evidence on how to sustain and scale such approaches is scant. This study responds to this gap by examining the experiences of South African health managers involved in the implementation of a task-shared counselling service for Project MIND. OBJECTIVES To qualitatively describe managers' experiences of implementing the MIND programme and their insights into potential strategies for supporting sustained implementation. METHODS Two focus group discussions (FGDs) and eight in-depth interviews (IDIs) were conducted with managers of urban and rural primary care facilities in the Western Cape province. All managers were female and 30-50 years old. FGDs and IDIs used an identical semi-structured topic guide to explore the experiences of the MIND programme and perceived barriers to sustained implementation. Normalisation process theory (NPT) guided the thematic analysis. RESULTS Four themes emerged that mapped onto the NPT constructs. First, managers noted that their relational work with staff to promote support for the intervention and reduce resistance was key to facilitating implementation. Second, managers emphasised the need for staff reorientation and upskilling to foster openness to mental health practice and for adequate time for quality counselling. Third, managers underscored the importance of strengthening linkages between the health and social service sectors to facilitate delivery of comprehensive mental health services. Finally, managers recommended ongoing monitoring of the service and communication about its impacts as strategies for supporting integration into routine practice. CONCLUSIONS Findings contribute to the emerging literature on strategies to support implementation of task-shared interventions in low- and middle-income countries. The findings highlight the leadership role of managers in identifying and actioning these strategies. Investing in managers' capacity to support implementation of psychological interventions is critical for scale-up of these mental health innovations.
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Affiliation(s)
- Carrie Brooke-Sumner
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Rondebosch, South Africa
| | - Petal Petersen-Williams
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Psychiatry and Mental Health, University of Cape Town, J-Block, Groote Schuur Hospital, Observatory, Cape Town, South Africa
| | - Katherine Sorsdahl
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Rondebosch, South Africa
| | - James Kruger
- Metro Health Services, Western Cape Government: Health, Bellville Health Park, Cape Town, South Africa
| | - Hassan Mahomed
- Metro Health Services, Western Cape Government: Health, Bellville Health Park, Cape Town, South Africa
- Division of Health Systems and Public Health, Department of Global Health, Faculty of Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Bronwyn Myers
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Psychiatry and Mental Health, University of Cape Town, J-Block, Groote Schuur Hospital, Observatory, Cape Town, South Africa
- Curtin enAble Institute, Faculty of Health Sciences, Curtin University, Bentley, WA, Australia
- CONTACT Bronwyn Myers Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Francie Van Zijl Drive, Parow Valley, Cape Town7501, South Africa
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Coleman A, MacInnes JD, Mikelyte R, Croke S, Allen PW, Checkland K. What makes a socially skilled leader? Findings from the implementation and operation of New Care Models (Vanguards) in England. J Health Organ Manag 2022; ahead-of-print. [PMID: 35976876 DOI: 10.1108/jhom-02-2022-0037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The article aims to argue that the concept of "distributed leadership" lacks the specificity required to allow a full understanding of how change happens. The authors therefore utilise the "Strategic Action Field Framework" (SAF) (Moulton and Sandfort, 2017) as a more sensitive framework for understanding leadership in complex systems. The authors use the New Care Models (Vanguard) Programme as an exemplar. DESIGN/METHODOLOGY/APPROACH Using the SAF framework, the authors explored factors affecting whether and how local Vanguard initiatives were implemented in response to national policy, using a qualitative case study approach. The authors apply this to data from the focus groups and interviews with a variety of respondents in six case study sites, covering different Vanguard types between October 2018 and July 2019. FINDINGS While literature already acknowledges that leadership is not simply about individual leaders, but about leading together, this paper emphasises that a further interdependence exists between leaders and their organisational/system context. This requires actors to use their skills and knowledge within the fixed and changing attributes of their local context, to perform the roles (boundary spanning, interpretation and mobilisation) necessary to allow the practical implementation of complex change across a healthcare setting. ORIGINALITY/VALUE The SAF framework was a useful framework within which to interrogate the data, but the authors found that the category of "social skills" required further elucidation. By recognising the importance of an intersection between position, personal characteristics/behaviours, fixed personal attributes and local context, the work is novel.
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Affiliation(s)
- Anna Coleman
- School of Health Sciences, University of Manchester, Manchester, UK
| | - Julie D MacInnes
- Centre for Health Services Studies, University of Kent, Canterbury, UK
| | - Rasa Mikelyte
- Centre for Health Services Studies, University of Kent, Canterbury, UK
| | - Sarah Croke
- School of Health Sciences, University of Manchester, Manchester, UK
| | - Pauline W Allen
- Department of Health Services Research and Policy, London School of Hygiene, London, UK
| | - Kath Checkland
- Centre for Primary Care and Health Services Research, The University of Manchester, Manchester, UK
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Ribic E, Sikira H, Dzubur Kulenovic A, Pemovska T, Russo M, Jovanovic N, Radojicic T, Repisti S, Milutinović M, Blazevska B, Konjufca J, Ramadani F, Jerotic S, Savic B. Perceived sustainability of psychosocial treatment in low- and middle-income countries in South-Eastern Europe. BJPsych Open 2022; 8:e156. [PMID: 35968901 PMCID: PMC9438482 DOI: 10.1192/bjo.2022.539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND DIALOG+ is an evidence-based, generic, cost-saving and easily deliverable psychosocial intervention, adaptable to clinicians' personal manner of interaction with patients. It was implemented in mental health services in five low- and middle-income countries in South-Eastern Europe during a 12-month randomised-controlled trial (IMPULSE) to improve the effectiveness of out-patient treatment for people with psychotic disorders. AIMS To investigate barriers and facilitators to the perceived sustainability of DIALOG+ that has been successfully implemented as a part of the IMPULSE project. METHOD Three months after the IMPULSE trial's end, perceived sustainability of the DIALOG+ intervention was assessed via a short survey of clinicians and patients who took part in the trial. Quantitative data collected from the survey were analysed using descriptive statistics; content analysis assessed qualitative survey data. The views and experiences of key informants (patients, clinicians and healthcare policy influencers) regarding the sustainability and scale-up of DIALOG+ were further explored through semi-structured interviews. These data were explored using framework analysis. RESULTS Clinicians mostly appreciated the comprehensiveness of DIALOG+, and patients described DIALOG+ meetings as empowering and motivating. The barrier most commonly identified by key informants was availability of financial resources; the most important facilitators were the clinically relevant structure and comprehensiveness of the DIALOG+ intervention. CONCLUSIONS Participants showed a willingness to sustain the implementation of DIALOG+. It is important to maintain collaboration with healthcare policy influencers to improve implementation of DIALOG+ across different levels of healthcare systems and ensure availability of resources for implementing psychosocial interventions such as DIALOG+.
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Affiliation(s)
- Emina Ribic
- Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Hana Sikira
- Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | | | - Tamara Pemovska
- Unit for Social and Community Psychiatry, Queen Mary University of London, London, UK; and WHO Collaborating Centre for Mental Health Services Development, Bart's and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Manuela Russo
- Unit for Social and Community Psychiatry, Queen Mary University of London, London, UK
| | - Nikolina Jovanovic
- Unit for Social and Community Psychiatry, Queen Mary University of London, London, UK; and Newham Centre for Mental Health, London, UK
| | | | | | | | | | - Jon Konjufca
- Department of Psychology, University of Prishtina 'Hasan Prishtina', Prishtina, Kosovo, Albania; and University of Prishtina, Kosovska Mitrovica, Serbia
| | - Fjolla Ramadani
- Department of Psychology, University of Prishtina 'Hasan Prishtina', Prishtina, Kosovo, Albania
| | - Stefan Jerotic
- Department of Psychiatry, University Clinical Center of Serbia, Belgrade, Serbia; and Department of Psychiatry, Clinic for Psychiatry, Clinical Centre of Serbia, Belgrade, Serbia
| | - Bojana Savic
- University Clinical Center of Serbia, Belgrade, Serbia
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Teame K, Debie A, Tullu M. Healthcare leadership effectiveness among managers in Public Health institutions of Addis Ababa, Central Ethiopia: a mixed methods study. BMC Health Serv Res 2022; 22:540. [PMID: 35459173 PMCID: PMC9034590 DOI: 10.1186/s12913-022-07879-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 03/31/2022] [Indexed: 11/21/2022] Open
Abstract
Background Leadership is the ability to influence the attitudes, beliefs, and abilities of employees to achieve organisational goals. It is crucial for the successes or failures of organisational performance. Healthcare organizations need effective leadership to manage the health service delivery reforms efficiently and effectively. However, there was no adequate evidence on the current status of the healthcare leaders to make evidence-based decisions. Therefore, this study aims to assess the effectiveness of healthcare leadership and associated factors among managers working at public health institutions in Addis Ababa, Ethiopia. Methods Institution-based cross-sectional study triangulated with the qualitative study was employed from 01 April to 01 June 2021. A total sample of 844 healthcare managers were used to assess their leadership effectiveness. Multi-stage sampling followed by a simple random sampling technique was used to select the participants. Binary logistic regression model was fitted to identify the factors associated with healthcare leadership effectiveness. Adjusted odds ratio (AOR) with 95% confidence interval (CI) and p-value less than 0.05 during multivariable logistic regression were used to declare the factors associated with the outcome variable. We conducted key informant interviews (KIIs) to explore the views of healthcare managers on their leadership practices, mainly on vision creation, developing followership and implementing vision. We also tape-recorded the KIIs and then transcribed word by word and finally translated it into English. We conducted a thematic analysis to supplement the quantitative findings. Results In this study, 46.8% (95% CI: 43.4 -50.2) of the participants had effective healthcare leadership practices. Emotional intelligence (AOR = 7.86; 95% CI; 4.56, 13.56), democratic managers (AOR = 4.01, 95% CI; 1.98, 8.14), master or above education (AOR = 5.1; 95% CI; 2.07, 12.61) and work experience (AOR = 3.44, 95% CI; 1.24, 9.55) were positively associated with healthcare effective leadership. The challenges in healthcare leadership were mainly associated with lack of leadership knowledge and skills. In addition, autocratic leaders negatively influenced managers ability to work closely with the staffs and affected employee’s motivation. On the contrary, emotionally intelligent managers were effective on employee handling, providing chance to talk, understanding their feelings and needs. Conclusion Healthcare managers had low capacity on vision creation, implementation and developing followership, particularly the ability of vision creation was very low. Lack of leadership knowledge and skills and frequent use of autocratic leadership were the challenges for healthcare leadership effectiveness. This could also negatively influence organisational performances, managers’ ability to work closely with the staffs and reduced employee’s motivation. Therefore, strengthening emotional intelligence and empowering managers will be very helpful to improve leading health cares. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07879-6.
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Affiliation(s)
- Kiros Teame
- Sub-City Health Office, Addis Ababa City Administration, Addis Ababa, Ethiopia
| | - Ayal Debie
- Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
| | - Mikiyas Tullu
- School of Public Health, College of Health Sciences, Kotebe Metropolitan University, Addis Ababa, Ethiopia
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Schneider H, Mukinda F, Tabana H, George A. Expressions of actor power in implementation: a qualitative case study of a health service intervention in South Africa. BMC Health Serv Res 2022; 22:207. [PMID: 35168625 PMCID: PMC8848975 DOI: 10.1186/s12913-022-07589-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 02/03/2022] [Indexed: 11/10/2022] Open
Abstract
Background Implementation frameworks and theories acknowledge the role of power as a factor in the adoption (or not) of interventions in health services. Despite this recognition, there is a paucity of evidence on how interventions at the front line of health systems confront or shape existing power relations. This paper reports on a study of actor power in the implementation of an intervention to improve maternal, neonatal and child health care quality and outcomes in a rural district of South Africa. Methods A retrospective qualitative case study based on interviews with 34 actors in three ‘implementation units’ – a district hospital and surrounding primary health care services – of the district, selected as purposefully representing full, moderate and low implementation of the intervention, some three years after it was first introduced. Data are analysed using Veneklasen and Miller’s typology of the forms of power – namely ‘power over’, ‘power to’, ‘power within’ and ‘power with’. Results Multiple expressions of actor power were evident during implementation and played a plausible role in shaping variable implementation, while the intervention itself acted to change power relations. As expected, a degree of buy-in of managers (with power over) in implementation units was necessary for the intervention to proceed. Beyond this, the ability to mobilise collective action (power with), combined with support from champions with agency (power within) were key to successful implementation. However, local empowerment may pose a threat to hierarchical power (power over) at higher levels (district and provincial) of the system, potentially affecting sustainability. Conclusions A systematic approach to the analysis of power in implementation research may provide insights into the fate of interventions. Intervention designs need to consider how they shape power relations, especially where interventions seek to widen participation and responsiveness in local health systems.
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Affiliation(s)
- Helen Schneider
- School of Public Health/SAMRC Health Services To Systems Research Unit, University of the Western Cape, Cape Town, South Africa.
| | - Fidele Mukinda
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Hanani Tabana
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Asha George
- School of Public Health/SAMRC Health Services To Systems Research Unit, University of the Western Cape, Cape Town, South Africa
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14
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Compliance of Healthcare Worker's toward Tuberculosis Preventive Measures in Workplace: A Systematic Literature Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182010864. [PMID: 34682604 PMCID: PMC8536031 DOI: 10.3390/ijerph182010864] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 09/30/2021] [Accepted: 10/13/2021] [Indexed: 11/17/2022]
Abstract
Despite several guidelines published by the World Health Organization (WHO) and national authorities, there is a general increase in the number of healthcare workers (HCWs) contracting tuberculosis. This review sought to evaluate the compliance of the HCWs toward tuberculosis preventive measures (TPMs) in their workplace. Both electronic databases and manual searches were conducted to retrieve articles regarding the compliance of HCWs in the workplace published from 2010 onwards. Independent reviewers extracted, reviewed, and analyzed the data using the mixed methods appraisal tool (MMAT) 2018, comprising 15 studies, 1572 HCWs, and 249 health facilities. The results showed there was low compliance toward TPMs in the workplace among HCWs and health facilities from mostly high-burden tuberculosis countries. The failure to comply with control measures against tuberculosis was mainly reported at administrative levels, followed by engineering and personnel protective control measures. In addition, low managerial support and negative attitudes of the HCWs influenced the compliance. Further studies are needed to elucidate how to improve the compliance of HCWs toward the preventive measures against tuberculosis in order to reduce the disease burden among HCWs worldwide.
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Belrhiti Z, Van Belle S, Criel B. How medical dominance and interprofessional conflicts undermine patient-centred care in hospitals: historical analysis and multiple embedded case study in Morocco. BMJ Glob Health 2021; 6:bmjgh-2021-006140. [PMID: 34261759 PMCID: PMC8280911 DOI: 10.1136/bmjgh-2021-006140] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 06/29/2021] [Indexed: 12/02/2022] Open
Abstract
Background In Morocco’s health systems, reforms were accompanied by increased tensions among doctors, nurses and health managers, poor interprofessional collaboration and counterproductive power struggles. However, little attention has focused on the processes underlying these interprofessional conflicts and their nature. Here, we explored the perspective of health workers and managers in four Moroccan hospitals. Methods We adopted a multiple embedded case study design and conducted 68 interviews, 8 focus group discussions and 11 group discussions with doctors, nurses, administrators and health managers at different organisational levels. We analysed what health workers (doctors and nurses) and health managers said about their sources of power, perceived roles and relationships with other healthcare professions. For our iterative qualitative data analysis, we coded all data sources using NVivo V.11 software and carried out thematic analysis using the concepts of ‘negotiated order’ and the four worldviews. For context, we used historical analysis to trace the development of medical and nursing professions during the colonial and postcolonial eras in Morocco. Results Our findings highlight professional hierarchies that counterbalance the power of formal hierarchies. Interprofessional interactions in Moroccan hospitals are marked by conflicts, power struggles and daily negotiated orders that may not serve the best interests of patients. The results confirm the dominance of medical specialists occupying the top of the professional hierarchy pyramid, as perceived at all levels in the four hospitals. In addition, health managers, lacking institutional backing, resources and decision spaces, often must rely on soft power when dealing with health workers to ensure smooth collaboration in care. Conclusion The stratified order of care professions creates hierarchical professional boundaries in Moroccan hospitals, leading to partitioning of care and poor interprofessional collaboration. More attention should be placed on empowering health workers in delivering quality care by ensuring smooth interprofessional collaboration.
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Affiliation(s)
| | - Sara Van Belle
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Bart Criel
- Unit of Equity and Health, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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16
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Johnson O, Sahr F, Begg K, Sevdalis N, Kelly AH. To bend without breaking: a qualitative study on leadership by doctors in Sierra Leone. Health Policy Plan 2021; 36:1644-1658. [PMID: 34226922 PMCID: PMC8597969 DOI: 10.1093/heapol/czab076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 06/08/2021] [Accepted: 06/17/2021] [Indexed: 11/25/2022] Open
Abstract
Strong leadership capabilities are essential for effective health services, yet definitions of leadership remain contested. Despite the acknowledged contextual specificity of leadership styles, most leadership theories draw heavily from Western conceptualizations. This cultural bias may attenuate the effectiveness of programmes intended to transform healthcare practice in Sub-Saharan Africa, where few empirical studies on health leadership have been conducted. This paper examines how effective leadership by doctors was perceived by stakeholders in one particular context, Sierra Leone. Drawing together extensive experience of in-country healthcare provision with a series of in-depth interviews with 27 Sierra Leonean doctors, we extended a grounded-theory approach to come to grips with the reach and relevance of contemporary leadership models in capturing the local experiences and relevance of leadership. We found that participants conceptualized leadership according to established leadership models, such as transformational and relational theories. However, participants also pointed to distinctive challenges attendant to healthcare provision in Sierra Leone that required specific leadership capabilities. Context-specific factors included health system breakdown, politicization in the health sector and lack of accountability, placing importance on skills such as persistence, role modelling and taking initiative. Participants also described pressure to behave in ways they deemed antithetical to their personal and professional values and also necessary in order to continue a career in the public sector. The challenge of navigating such ethical dilemmas was a defining feature of leadership in Sierra Leone. Our research demonstrates that while international leadership models were relevant in this context, there is strong emphasis on contingent or situational leadership theories. We further contribute to policy and practice by informing design of leadership development programmes and the establishment of a more enabling environment for medical leadership by governments and international donors.
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Affiliation(s)
- Oliver Johnson
- Centre for Implementation Science, Health Services and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, David Goldberg Centre, De Crespigny Park, London SE5 8AF, UK.,Centre for Health Policy, School of Public Health, University of Witwatersrand, 60 York Road, 2193 Johannesburg, South Africa
| | - Foday Sahr
- Department of Microbiology, College of Medicine and Allied Health Sciences, University of Sierra Leone, 12 Victoria Street, Kossoh Town, Freetown, Sierra Leone.,Joint Medical Unit (34 Military Hospital), Wilberforce Barracks, Wilberforce Village, Freetown, Sierra Leone
| | - Kerrin Begg
- School of Public Health and Family Medicine, University of Cape Town, Falmouth Building, Anzio Road, Cape Town 7925, South Africa
| | - Nick Sevdalis
- Centre for Implementation Science, Health Services and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, David Goldberg Centre, De Crespigny Park, London SE5 8AF, UK
| | - Ann H Kelly
- Department of Global Health and Social Medicine, School of Global Affairs, Faculty of Social Science & Public Policy, King's College London, London WC2R 2LS, UK
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Kinney MV, Walugembe DR, Wanduru P, Waiswa P, George A. Maternal and perinatal death surveillance and response in low- and middle-income countries: a scoping review of implementation factors. Health Policy Plan 2021; 36:955-973. [PMID: 33712840 PMCID: PMC8227470 DOI: 10.1093/heapol/czab011] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2021] [Indexed: 11/13/2022] Open
Abstract
Maternal and perinatal death surveillance and response (MPDSR), or any form of maternal and/or perinatal death review or audit, aims to improve health services and pre-empt future maternal and perinatal deaths. With expansion of MPDSR across low- and middle-income countries (LMIC), we conducted a scoping review to identify and describe implementation factors and their interactions. The review adapted an implementation framework with four domains (intervention, individual, inner and outer settings) and three cross-cutting health systems lenses (service delivery, societal and systems). Literature was sourced from six electronic databases, online searches and key experts. Selection criteria included studies from LMIC published in English from 2004 to July 2018 detailing factors influencing implementation of MPDSR, or any related form of MPDSR. After a systematic screening process, data for identified records were extracted and analysed through content and thematic analysis. Of 1027 studies screened, the review focuses on 58 studies from 24 countries, primarily in Africa, that are mainly qualitative or mixed methods. The literature mostly examines implementation factors related to MPDSR as an intervention, and to its inner and outer setting, with less attention to the individuals involved. From a health systems perspective, almost half the literature focuses on the tangible inputs addressed by the service delivery lens, though these are often measured inadequately or through incomparable ways. Though less studied, the societal and health system factors show that people and their relationships, motivations, implementation climate and ability to communicate influence implementation processes; yet their subjective experiences and relationships are inadequately explored. MPDSR implementation contributes to accountability and benefits from a culture of learning, continuous improvement and accountability, but few have studied the complex interplay and change dynamics involved. Better understanding MPDSR will require more research using health policy and systems approaches, including the use of implementation frameworks.
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Affiliation(s)
- Mary V Kinney
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | - David Roger Walugembe
- School of Health Studies and Faculty of Information and Media Studies, The University of Western Ontario, London, ON, Canada
| | - Phillip Wanduru
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Peter Waiswa
- Global Health Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Asha George
- School of Public Health, University of the Western Cape, Bellville, South Africa
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Anderson M, Pitchforth E, Asaria M, Brayne C, Casadei B, Charlesworth A, Coulter A, Franklin BD, Donaldson C, Drummond M, Dunnell K, Foster M, Hussey R, Johnson P, Johnston-Webber C, Knapp M, Lavery G, Longley M, Clark JM, Majeed A, McKee M, Newton JN, O'Neill C, Raine R, Richards M, Sheikh A, Smith P, Street A, Taylor D, Watt RG, Whyte M, Woods M, McGuire A, Mossialos E. LSE-Lancet Commission on the future of the NHS: re-laying the foundations for an equitable and efficient health and care service after COVID-19. Lancet 2021; 397:1915-1978. [PMID: 33965070 DOI: 10.1016/s0140-6736(21)00232-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 12/10/2020] [Accepted: 01/07/2021] [Indexed: 02/06/2023]
Affiliation(s)
- Michael Anderson
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Emma Pitchforth
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Miqdad Asaria
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Carol Brayne
- Cambridge Public Health, University of Cambridge, Cambridge, UK
| | - Barbara Casadei
- Radcliffe Department of Medicine, BHF Centre of Research Excellence, NIHR Biomedical Research Centre, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Anita Charlesworth
- The Health Foundation, London, UK; College of Social Sciences, Health Services Management Centre, University of Birmingham, Birmingham, UK
| | - Angela Coulter
- Green Templeton College, University of Oxford, Oxford, UK; Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Bryony Dean Franklin
- UCL School of Pharmacy, University College London, London, UK; NIHR Imperial Patient Safety Translational Research Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Cam Donaldson
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK
| | | | | | - Margaret Foster
- National Health Service Wales Shared Services Partnership, Cardiff, UK
| | | | | | | | - Martin Knapp
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Gavin Lavery
- Belfast Health and Social Care Trust, Belfast, UK
| | - Marcus Longley
- Welsh Institute for Health and Social Care, University of South Wales, Pontypridd, UK
| | | | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Martin McKee
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Ciaran O'Neill
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Rosalind Raine
- Department of Applied Health Research, University College London, London, UK
| | - Mike Richards
- Department of Health Policy, London School of Economics and Political Science, London, UK; The Health Foundation, London, UK
| | - Aziz Sheikh
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Peter Smith
- Centre for Health Economics, University of York, York, UK; Centre for Health Economics and Policy Innovation, Imperial College London, London, UK
| | - Andrew Street
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - David Taylor
- UCL School of Pharmacy, University College London, London, UK
| | - Richard G Watt
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Moira Whyte
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Michael Woods
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Alistair McGuire
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Elias Mossialos
- Department of Health Policy, London School of Economics and Political Science, London, UK; Institute of Global Health Innovation, Imperial College London, London, UK.
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Kielmann K, Dickson-Hall L, Jassat W, Le Roux S, Moshabela M, Cox H, Grant AD, Loveday M, Hill J, Nicol MP, Mlisana K, Black J. 'We had to manage what we had on hand, in whatever way we could': adaptive responses in policy for decentralized drug-resistant tuberculosis care in South Africa. Health Policy Plan 2021; 36:249-259. [PMID: 33582787 PMCID: PMC8059133 DOI: 10.1093/heapol/czaa147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2020] [Indexed: 11/16/2022] Open
Abstract
In 2011, the South African National TB Programme launched a policy of decentralized management of drug-resistant tuberculosis (DR-TB) in order to expand the capacity of facilities to treat patients with DR-TB, minimize delays to access care and improve patient outcomes. This policy directive was implemented to varying degrees within a rapidly evolving diagnostic and treatment landscape for DR-TB, placing new demands on already-stressed health systems. The variable readiness of district-level systems to implement the policy prompted questions not only about differences in health systems resources but also front-line actors' capacity to implement change in resource-constrained facilities. Using a grounded theory approach, we analysed data from in-depth interviews and small group discussions conducted between 2016 and 2018 with managers (n = 9), co-ordinators (n = 15), doctors (n = 7) and nurses (n = 18) providing DR-TB care. Data were collected over two phases in district-level decentralized sites of three South African provinces. While health systems readiness assessments conventionally map the availability of 'hardware', i.e. resources and skills to deliver an intervention, a notable absence of systems 'hardware' meant that systems 'software', i.e. health care workers (HCWs) agency, behaviours and interactions provided the basis of locally relevant strategies for decentralized DR-TB care. 'Software readiness' was manifest in four areas of DR-TB care: re-organization of service delivery, redressal of resource shortages, creation of treatment adherence support systems and extension of care parameters for vulnerable patients. These strategies demonstrate adaptive capacity and everyday resilience among HCW to withstand the demands of policy change and innovation in stressed systems. Our work suggests that a useful extension of health systems 'readiness' assessments would include definition and evaluation of HCW 'software' and adaptive capacities in the face of systems hardware gaps.
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Affiliation(s)
- Karina Kielmann
- Institute of Global Health and Development, Queen Margaret University, Edinburgh EH21 6UU, UK
| | - Lindy Dickson-Hall
- Division of Medical Microbiology, Faculty of Medicine, University of Cape Town, South Africa
| | | | - Sacha Le Roux
- Division of Medical Microbiology, Faculty of Medicine, University of Cape Town, South Africa
| | - Mosa Moshabela
- Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, South Africa
| | - Helen Cox
- Institute for Infectious Disease and Molecular Medicine and Wellcome Centre for Infectious Disease Research in Africa, University of Cape Town, Cape Town, South Africa
| | - Alison D Grant
- Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, South Africa
- London School of Hygiene & Tropical Medicine, TB Centre, UK
- School of Public Health, University of the Witwatersrand, South Africa
| | - Marian Loveday
- Health Systems Research Unit, South African Medical Research Council
| | - Jeremy Hill
- Division of Medical Microbiology, Faculty of Medicine, University of Cape Town, South Africa
- London School of Hygiene & Tropical Medicine, TB Centre, UK
| | - Mark P Nicol
- Division of Medical Microbiology, Faculty of Medicine, University of Cape Town, South Africa
- Infection and Immunity, School of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia
| | - Koleka Mlisana
- Department of Medical Microbiology, University of KwaZulu-Natal, Durban, South Africa
| | - John Black
- Department of Infectious Diseases, Livingstone Hospital, Lindsay Rd, Industrial, Port Elizabeth, 6020, South Africa
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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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Clarke JM, Waring J, Bishop S, Hartley J, Exworthy M, Fulop NJ, Ramsay A, Roe B. The contribution of political skill to the implementation of health services change: a systematic review and narrative synthesis. BMC Health Serv Res 2021; 21:260. [PMID: 33743695 PMCID: PMC7981881 DOI: 10.1186/s12913-021-06272-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 03/11/2021] [Indexed: 12/25/2022] Open
Abstract
Background The implementation of strategic health system change is often complicated by informal ‘politics’ in healthcare organisations. Leadership development programmes increasingly call for the development and use of ‘political skill’ as a means for understanding and managing the politics of healthcare organisations. The primary purpose of this review is to determine how political skill contributes to the implementation of health services change, within and across organisations. The secondary purpose is to demonstrate the conceptual variations within the literature. Methods The article is based upon a narrative synthesis that included quantitative, qualitative and mixed methods research papers, review articles and professional commentaries that deployed the concept of political skill (or associated terms) to describe and analyse the implementation of change in healthcare services. Results Sixty-two papers were included for review drawn from over four decades of empirically and conceptually diverse research. The literature is comprised of four distinct literatures with a lack of conceptual coherence. Within and across these domains, political skill is described as influencing health services change through five dimensions of leadership: personal performance; contextual awareness; inter-personal influence; stakeholder engagement, networks and alliances; and influence on policy processes. Conclusion There is a growing body of evidence showing how political skill can contribute to the implementation of health services change, but the evidence on explanatory processes is weak. Moreover, the conceptualisation of political skill is variable making comparative analysis difficult, with research often favouring individual-level psychological and behavioural properties over more social or group processes. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06272-z.
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Affiliation(s)
- Jenelle M Clarke
- School of Social Policy, HSMC, University of Birmingham, Park House, 40 Edgbaston Park Road, Birmingham, B15 2RT, UK.
| | - Justin Waring
- School of Social Policy, HSMC, University of Birmingham, Park House, 40 Edgbaston Park Road, Birmingham, B15 2RT, UK
| | - Simon Bishop
- Business School North, University of Nottingham, Jubilee Campus, Triumph Road, Nottingham, NG8 1BB, UK
| | - Jean Hartley
- Open University Business School, Open University, Walton Hall, Kents Hill, Milton Keynes, MK7 6BH, UK
| | - Mark Exworthy
- School of Social Policy, HSMC, University of Birmingham, Park House, 40 Edgbaston Park Road, Birmingham, B15 2RT, UK
| | - Naomi J Fulop
- Department of Applied Health Research, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
| | - Angus Ramsay
- Department of Applied Health Research, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
| | - Bridget Roe
- School of Social Policy, HSMC, University of Birmingham, Park House, 40 Edgbaston Park Road, Birmingham, B15 2RT, UK
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Saddi FDC, Harris M, Parreira FR, Pêgo RA, Coelho GA, Lozano RB, Mundim PDS, Peckham S. Exploring frontliners' knowledge, participation and evaluation in the implementation of a pay-for-performance program (PMAQ) in primary health care in Brazil. J Health Organ Manag 2021. [DOI: 10.1108/jhom-04-2020-0154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeThis paper employs implementation theory and the political literature on performance measurement to understand how frontline health workers know, participate and evaluate the Brazilian National Program for Improving Access and Quality of Primary Care (PMAQ, 2nd round).Design/methodology/approachThis paper develops an implementation theory-driven qualitative analysis. The research is developed in the city of Goiania (Brazil): a challenging organizational context in primary care (PHC). Interviews were carried out with 25 frontliners – managers, doctors, nurses and community health workers. Data were thematically and hierarchically analysed according to theoretical concepts such as policy knowledge, policy adherence, forms of accountability, alternative logics, organizational capacity and policy feedback.FindingsResults show the need to foster organizational capacity, knowledge, participation and policy feedback at the frontline. Successful implementation would require those adaptations to counteract policy challenges/failures or the emergence of alternative logics.Research limitations/implicationsThe study was conducted in only one setting, however, our sample includes different types of professionals working in units with different levels of organization capacity, located in distinct HDs, expressing well the implementation of PMAQ/P4P. Qualitative researches need to be developed for further exploring the same/other factors.Social implicationsFindings can be used to improve discussions/planning and design of P4P programs in the city and State of Goias.Originality/valueThe majority of analysis of PMAQ are of a quantitative or results-based nature. This article focuses on politically significant and unanswered questions regarding the implementation of PMAQ.
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Van Pinxteren M, Cooper S, Colvin CJ. Barriers and opportunities to using health information in policy implementation: The case of adolescent and youth friendly health services in the Western Cape. Afr J Prim Health Care Fam Med 2021; 13:e1-e9. [PMID: 33764136 PMCID: PMC8008031 DOI: 10.4102/phcfm.v13i1.2654] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 12/18/2020] [Accepted: 12/22/2020] [Indexed: 11/24/2022] Open
Abstract
Background The production, use and exchange of health information is an essential part of the health services, as it is used to inform daily decision-making and to develop new policies, guidelines and programmes. However, there is little insight into how health care workers (HCWs) get access to and use health information when implementing new health programmes. Aim This study explored the multifaceted role of health information within policy implementation processes and aimed to understand the complexities experienced by HCWs who need to develop adolescent health profiles (AHPs), a criterion of implementing a larger Adolescent and Youth Friendly Services Programme (AYFSP). Setting This case study was undertaken in Gugulethu, a peri-urban, low-income neighbourhood in Cape Town, South Africa. Methods Data were collected through ethnographic qualitative methods, including participant observation, interviews and workshops, and 15 participants were enrolled for this purpose. Results Findings showed that HCWs experienced different barriers when accessing information to develop the AHPs, including a lack of access to databases, a lack of support and inadequate guidelines. Nevertheless, HCWs were resourceful in using informal information and building strategic relationships to navigate and gain access to the necessary data to develop AHPs. Conclusion This case study provided insights into the practical difficulties and innovative strategies which arise when HCWs attempt to access and use health information within a real-life health programme. Findings highlighted the need for more training, support and guidance for HCWs to improve the meaningful use of health information during policy implementation processes and to strengthen health services in South African primary care clinics.
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Affiliation(s)
- Myrna Van Pinxteren
- Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town.
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Mgawe P, Maluka SO. Integration of community health workers into the health system in Tanzania: Examining the process and contextual factors. Int J Health Plann Manage 2021; 36:703-714. [PMID: 33474757 DOI: 10.1002/hpm.3114] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 12/22/2020] [Accepted: 12/28/2020] [Indexed: 11/09/2022] Open
Abstract
Integration of community health workers (CHWs) into the health systems has become a global concern. Recently, the Government of Tanzania through the then Ministry of Health and Social Welfare initiated different strategies that aimed at integrating CHWs into the health system. This paper discusses the process and factors that influence the integration of CHWs into the health system in Tanzania. The study employed qualitative case study design using in-depth interviews (n = 37). In addition, various documents including health policies, Community-based Health Policy, community health workers guideline and Community health workers training curriculum were reviewed. Data were analysed by using thematic analysis. The findings indicated that potential CHWs were selected based on the National Council for Technical Education standards that required an applicant to have four (4) passes in the ordinary level examination. None of the CHWs who had undergone training had been employed by the government. This differed from what was prescribed in the CHWs guidelines. Integration of CHWs into health system in Tanzania has not been optimal because of inadequate preparations in terms of stakeholders engagement, infrastructure, legal and policy frameworks, technical expertise and financial resources. Effective integration of CHWs into the health system requires working with different actors to communicate objectives, achieve ownership of the stakeholders, manage conflict and cooperation, and sustain changes.
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Affiliation(s)
- Peter Mgawe
- Institute of Social Work, Dar es Salaam, Tanzania
| | - Stephen O Maluka
- Dar es Salaam University College of Education (DUCE) & Institute of Development Studies (IDS), University of Dar s Salaam, Dar es Salaam, Tanzania
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Kagwanja N, Waithaka D, Nzinga J, Tsofa B, Boga M, Leli H, Mataza C, Gilson L, Molyneux S, Barasa E. Shocks, stress and everyday health system resilience: experiences from the Kenyan coast. Health Policy Plan 2020; 35:522-535. [PMID: 32101609 PMCID: PMC7225571 DOI: 10.1093/heapol/czaa002] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2020] [Indexed: 11/13/2022] Open
Abstract
Health systems are faced with a wide variety of challenges. As complex adaptive systems, they respond differently and sometimes in unexpected ways to these challenges. We set out to examine the challenges experienced by the health system at a sub-national level in Kenya, a country that has recently undergone rapid devolution, using an 'everyday resilience' lens. We focussed on chronic stressors, rather than acute shocks in examining the responses and organizational capacities underpinning those responses, with a view to contributing to the understanding of health system resilience. We drew on learning and experiences gained through working with managers using a learning site approach over the years. We also collected in-depth qualitative data through informal observations, reflective meetings and in-depth interviews with middle-level managers (sub-county and hospital) and peripheral facility managers (n = 29). We analysed the data using a framework approach. Health managers reported a wide range of health system stressors related to resource scarcity, lack of clarity in roles and political interference, reduced autonomy and human resource management. The health managers adopted absorptive, adaptive and transformative strategies but with mixed effects on system functioning. Everyday resilience seemed to emerge from strategies enacted by managers drawing on a varying combination of organizational capacities depending on the stressor and context.
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Affiliation(s)
- Nancy Kagwanja
- KEMRI Wellcome Trust Research Programme, Health Systems and Ethics Research Unit, Bofa Road, Kilifi, Kenya
| | - Dennis Waithaka
- KEMRI Wellcome Trust Research Programme, Health Systems and Ethics Research Unit, Bofa Road, Kilifi, Kenya
| | - Jacinta Nzinga
- KEMRI Wellcome Trust Research Programme, Health Systems and Ethics Research Unit, Bofa Road, Kilifi, Kenya.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Benjamin Tsofa
- KEMRI Wellcome Trust Research Programme, Health Systems and Ethics Research Unit, Bofa Road, Kilifi, Kenya.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Mwanamvua Boga
- KEMRI Wellcome Trust Research Programme, Health Systems and Ethics Research Unit, Bofa Road, Kilifi, Kenya
| | - Hassan Leli
- Kilifi County Department of Health, P.O BOX 9-80108, Bofa Road, Kilifi, Kenya
| | - Christine Mataza
- Kilifi County Department of Health, P.O BOX 9-80108, Bofa Road, Kilifi, Kenya
| | - Lucy Gilson
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Sassy Molyneux
- KEMRI Wellcome Trust Research Programme, Health Systems and Ethics Research Unit, Bofa Road, Kilifi, Kenya.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Edwine Barasa
- KEMRI Wellcome Trust Research Programme, Health Systems and Ethics Research Unit, Bofa Road, Kilifi, Kenya.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Rogers L, De Brún A, Birken SA, Davies C, McAuliffe E. The micropolitics of implementation; a qualitative study exploring the impact of power, authority, and influence when implementing change in healthcare teams. BMC Health Serv Res 2020; 20:1059. [PMID: 33228702 PMCID: PMC7684932 DOI: 10.1186/s12913-020-05905-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 11/06/2020] [Indexed: 11/27/2022] Open
Abstract
Background Healthcare organisations are complex social entities, comprising of multiple stakeholders with differing priorities, roles, and expectations about how care should be delivered. To reach agreement among these diverse interest groups and achieve safe, cost-effective patient care, healthcare staff must navigate the micropolitical context of the health service. Micropolitics in this study refers to the use of power, authority, and influence to affect team goals, vision, and decision-making processes. Although these concepts are influential when cultivating change, there is a dearth of literature examining the mechanisms through which micropolitics influences implementation processes among teams. This paper addresses this gap by exploring the role of power, authority, and influence when implementing a collective leadership intervention in two multidisciplinary healthcare teams. Methods The multiple case study design adopted employed a triangulation of qualitative research methods. Over thirty hours of observations (Case A = 16, Case B = 15) and twenty-five interviews (Case A = 13, Case B = 12) were completed. An in-depth thematic analysis of the data using an inductive coding approach was completed to understand the mechanisms through which contextual factors influenced implementation success. A context coding framework was also employed throughout implementation to succinctly collate the data into a visual display and to provide a high-level overview of implementation effect (i.e. the positive, neutral, or negative impact of contextual determinants on implementation). Results The findings emphasised that implementing change in healthcare teams is an inherently political process influenced by prevailing power structures. Two key themes were generated which revealed the dynamic role of these concepts throughout implementation: 1) Exerting hierarchical influence for implementation; and 2) Traditional power structures constraining implementation. Gaining support across multiple levels of leadership was influential to implementation success as the influence exercised by these individuals persuaded follower engagement. However, the historical dynamics of each team determined how this influence was exerted and perceived, which negatively impacted some participants’ experiences of the implementation process. Conclusion To date, micropolitics has received scant attention in implementation science literature. This study introduces the micropolitical concepts of power, authority and influence as essential contextual determinants and outlines the mechanisms through which these concepts influence implementation processes. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-020-05905-z.
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Affiliation(s)
- Lisa Rogers
- University College Dublin Centre for Interdisciplinary Research, Education, and Innovation in Health Systems (UCD IRIS), University College Dublin School of Nursing, Midwifery and Health Systems, Dublin, Ireland.
| | - Aoife De Brún
- University College Dublin Centre for Interdisciplinary Research, Education, and Innovation in Health Systems (UCD IRIS), University College Dublin School of Nursing, Midwifery and Health Systems, Dublin, Ireland
| | - Sarah A Birken
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, Noth Carolina, USA
| | - Carmel Davies
- University College Dublin Centre for Interdisciplinary Research, Education, and Innovation in Health Systems (UCD IRIS), University College Dublin School of Nursing, Midwifery and Health Systems, Dublin, Ireland
| | - Eilish McAuliffe
- University College Dublin Centre for Interdisciplinary Research, Education, and Innovation in Health Systems (UCD IRIS), University College Dublin School of Nursing, Midwifery and Health Systems, Dublin, Ireland
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Hernández A, Hurtig AK, Goicolea I, San Sebastián M, Jerez F, Hernández-Rodríguez F, Flores W. Building collective power in citizen-led initiatives for health accountability in Guatemala: the role of networks. BMC Health Serv Res 2020; 20:416. [PMID: 32404089 PMCID: PMC7218564 DOI: 10.1186/s12913-020-05259-6] [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: 10/07/2019] [Accepted: 04/28/2020] [Indexed: 11/30/2022] Open
Abstract
Background Citizen-led accountability initiatives are a critical strategy for redressing the causes of health inequalities and promoting better health system governance. A growing body of evidence points to the need for putting power relations at the forefront of understanding and operationalizing citizen-led accountability, rather than technical tools and best practices. In this study, we apply a network lens to the question of how initiatives build collective power to redress health system failures affecting marginalized communities in three municipalities in Guatemala. Methods Network mapping and interpretive discussions were used to examine relational qualities of citizen-led initiatives’ networks and explore the resources they offer for mobilizing action and influencing health accountability. Participants in the municipal-level initiatives responded to a social network analysis questionnaire focused on their ties of communication and collaboration with other initiative participants and their interactions with authorities regarding health system problems. Discussions with participants about the maps generated enriched our view of what the ties represented and their history of collective action and also provided space for planning action to strengthen their networks. Results Our findings indicate that network qualities like cohesiveness and centralization reflected the initiative participants’ agency in adapting to their sociopolitical context, and participants’ social positions were a key resource in providing connection to a broad base of support for mobilizing collective action to document health service deficiencies and advocate for solutions. Their legitimacy as “representatives of the people” enabled them to engage with authorities from a bolstered position of power, and their iterative interactions with authorities further contributed to develop their advocacy capabilities and resulted in accountability gains. Conclusions Our study provided evidence to counter the tendency to underestimate the assets and capabilities that marginalized citizens have for building power, and affirmed the idea that best-fit, with-the-grain approaches are well-suited for highly unequal settings characterized by weak governance. Efforts to support and understand change processes in citizen-led initiatives should include focus on adaptive network building to enable contextually-embedded approaches that leverage the collective power of the users of health services and grassroots leaders on the frontlines of accountability.
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Affiliation(s)
- Alison Hernández
- Center for the Study of Equity and Governance in Health Systems (CEGSS), 11 calle 0-48 Zona 10, Edificio Diamond, oficina 504, Ciudad de Guatemala, Guatemala.
| | - Anna-Karin Hurtig
- Division of Epidemiology and Global Health, Umeå University, Umeå, Sweden
| | - Isabel Goicolea
- Division of Epidemiology and Global Health, Umeå University, Umeå, Sweden
| | | | - Fernando Jerez
- Center for the Study of Equity and Governance in Health Systems (CEGSS), 11 calle 0-48 Zona 10, Edificio Diamond, oficina 504, Ciudad de Guatemala, Guatemala
| | | | - Walter Flores
- Center for the Study of Equity and Governance in Health Systems (CEGSS), 11 calle 0-48 Zona 10, Edificio Diamond, oficina 504, Ciudad de Guatemala, Guatemala
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28
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Belrhiti Z, Van Damme W, Belalia A, Marchal B. The effect of leadership on public service motivation: a multiple embedded case study in Morocco. BMJ Open 2020; 10:e033010. [PMID: 31900272 PMCID: PMC6955481 DOI: 10.1136/bmjopen-2019-033010] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 11/21/2019] [Accepted: 11/22/2019] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES We aimed at exploring the underlying mechanisms and contextual conditions by which leadership may influence 'public service motivation' of health providers in Moroccan hospitals. DESIGN We used the realist evaluation (RE) approach in the following steps: eliciting the initial programme theory, designing the study, carrying out the data collection, doing the data analysis and synthesis. In practice, we adopted a multiple embedded case study design. SETTINGS We used purposive sampling to select hospitals representing extreme cases displaying contrasting leadership practices and organisational performance scores using data from the Ministry of Health quality assurance programmes from 2011 to 2016. PARTICIPANTS We carried out, on average, 17 individual in-depth interviews in 4 hospitals as well as 7 focus group discussions and 8 group discussions with different cadres (administrators, nurses and doctors). We collected relevant documents (eg, performance audit, human resource availability) and carried out observations. RESULTS Comparing the Intervention-Context-Actor-Mechanism-Outcome configurations across the hospitals allowed us to confirm and refine our following programme theory: "Complex leaders, applying an appropriate mix of transactional, transformational and distributed leadership styles that fit organisational and individuals characteristics [I] can increase public service motivation, organisational commitment and extra role behaviours [O] by increasing perceived supervisor support and perceived organizational support and satisfying staff basic psychological needs [M], if the organisational culture is conducive and in the absence of perceived organisational politics [C]". CONCLUSIONS In hospitals, the archetype of complex professional bureaucracies, leaders need to be able to balance between different leadership styles according to the staff's profile, the nature of tasks and the organisational culture if they want to enhance public service motivation, intrinsic motivation and organisational commitment.
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Affiliation(s)
- Zakaria Belrhiti
- Ecole Nationale de Sante Publique, Rabat, Morocco
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Gerontology, Vrije Universiteit Brussel, Brussels, Belgium
| | - Wim Van Damme
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Gerontology, Vrije Universiteit Brussel, Brussels, Belgium
| | | | - Bruno Marchal
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Abstract
Any effort to improve health system performance must address the challenges of policy implementation. This article examines one aspect of implementation-the politics of policy implementation for the health sector, particularly the management of stakeholders in order to help change teams improve the chances of achieving policy objectives. Based on a literature scan of political analyses and descriptions of health policy implementation in low- and middle-income countries, we propose six major categories of stakeholder groups that are likely to influence implementation: interest group politics, bureaucratic politics, budget politics, leadership politics, beneficiary politics, and external actor politics. The categories of stakeholders can be overlapping. We examine the politics of these different stakeholder categories, and then present selected examples of published case studies that show the types of implementation challenges that arise for each category and how implementers can use political strategies to manage specific stakeholder groups and related political processes. Understanding the political dimensions of implementation can help those responsible for implementation drive policy into practice more effectively. Understanding and addressing conflict, resistance and cooperation among stakeholders are key to managing the implementation process. Systematic and continuous political analysis can help decision makers and change teams improve the chances for successful implementation.
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Affiliation(s)
- Paola Abril Campos
- Doctor of Public Health Candidate, Harvard T.H. Chan School of Public Health , Boston , MA , USA
| | - Michael R Reich
- Taro Takemi Research Professor of International Health Policy, Harvard T.H. Chan School of Public Health , Boston , MA , USA
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30
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Ramani S, Sivakami M, Gilson L. How context affects implementation of the Primary Health Care approach: an analysis of what happened to primary health centres in India. BMJ Glob Health 2019; 3:e001381. [PMID: 31354968 PMCID: PMC6626469 DOI: 10.1136/bmjgh-2018-001381] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 02/27/2019] [Accepted: 03/16/2019] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION In this paper, we elucidate challenges posed by contexts to the implementation of the Primary Health Care (PHC) approach, using the example of primary health centres (rural peripheral health units) in India. We first present a historical review of 'written' policies in India-to understand macro contextual influences on primary health centres. Then we highlight micro level issues at primary health centres using a contemporary case study. METHODS To elucidate macro level factors, we reviewed seminal policy documents in India and some supporting literature. To examine the micro context, we worked with empirical qualitative data from a rural district in Maharashtra-collected through 12 community focus group discussions, 12 patient interviews and 34 interviews with health system staff. We interpret these findings using a combination of top-down and bottom-up lenses of the policy process. RESULTS Primary health centres were originally envisaged as 'social models' of service delivery; front-line institutions that delivered integrated care close to people's homes. However, macro issues of chronic underfunding and verticalisation have resulted in health centres with poor infrastructure, that mainly deliver vertical programmes. At micro levels, service provision at primary health centres is affected by doctors' disinterest in primary care roles and an institutional context that promotes risk-averseness and disregard of outpatient care. Primary health centres do not meet community expectations in terms of services, drugs and attention provided; and hence, private practitioners are preferred. Thus, primary health centres today, despite having the structure of a primary-level care unit, no longer embody PHC ideals. CONCLUSIONS This paper highlights some contextual complexities of implementing PHC-considering macro (pertaining to ideologies and fiscal priorities) and micro (pertaining to everyday behaviours and practices of actors) level issues. As we recommit to Alma-Ata, we must be cautious of the ceremonial adoption of interventions, that look like PHC-but cannot deliver on its ideals.
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Affiliation(s)
- Sudha Ramani
- Tata Institute of Social Sciences, Mumbai, India
| | - Muthusamy Sivakami
- School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai, India
| | - Lucy Gilson
- University of Cape Town, Cape Town, South Africa
- London School of Hygiene and Tropical Medicine, London, UK
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31
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Brooke-Sumner C, Petersen-Williams P, Kruger J, Mahomed H, Myers B. 'Doing more with less': a qualitative investigation of perceptions of South African health service managers on implementation of health innovations. Health Policy Plan 2019; 34:132-140. [PMID: 30863845 PMCID: PMC6481285 DOI: 10.1093/heapol/czz017] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2019] [Indexed: 11/12/2022] Open
Abstract
Building resilience in health systems is an imperative for low- and middle- income countries. Health service managers' ability to implement health innovations may be a key aspect of resilience in primary healthcare facilities, promoting adaptability and functionality. This study investigated health service managers' perceptions and experiences of adopting health innovations. We aimed to identify perceptions of constraints to adoption and emergent behaviours in response to these constraints. A convenience sample of 34 facility, clinical service and sub-district level managers was invited to participate. Six did not respond and were not contactable. In-depth individual interviews in a private space at participants' place of work were conducted with 28 participants. Interviews were audio recorded and transcribed verbatim. NVivo 11 was used to store data and facilitate framework analysis. Study participants described constraints to innovation adoption including: staff lack of understanding of potential benefits; staff personalities, attitudes and behaviours which lead to resistance to change; high workload related to resource constraints and frequent policy changes inducing resistance to change; and suboptimal communication through health system structures. Managers reported employing various strategies to mitigate these constraints. These comprised (1) technical skills including participatory management skills, communication skills, community engagement skills and programme monitoring and evaluation skills, and (2) non-technical skills including role modelling positive attitudes, understanding staff personalities, influencing perceptions of innovations, influencing organizational climate and building trusting relationships. Managers have a vital role in the embedding of service innovations into routine practice. We present a framework of technical and non-technical skills that managers need to facilitate the adoption of health innovations. Future efforts to build managers' capacity to implement health innovations should target these competencies.
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Affiliation(s)
- Carrie Brooke-Sumner
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Francie Van Zijl Drive, Parow Valley, Cape Town, South Africa
- Department of Psychiatry and Mental Health, University of Cape Town, J-Block, Groote Schuur Hospital, Observatory, Cape Town, South Africa
| | - Petal Petersen-Williams
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Francie Van Zijl Drive, Parow Valley, Cape Town, South Africa
- Department of Psychiatry and Mental Health, University of Cape Town, J-Block, Groote Schuur Hospital, Observatory, Cape Town, South Africa
| | - James Kruger
- Western Cape Government: Health, Norton Rose House, 8 Riebeeck Street, Cape Town, South Africa and
| | - Hassan Mahomed
- Western Cape Government: Health, Norton Rose House, 8 Riebeeck Street, Cape Town, South Africa and
- Division of Health Systems and Public Health, Department of Global Health, Faculty of Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Cape Town, South Africa
| | - Bronwyn Myers
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Francie Van Zijl Drive, Parow Valley, Cape Town, South Africa
- Department of Psychiatry and Mental Health, University of Cape Town, J-Block, Groote Schuur Hospital, Observatory, Cape Town, South Africa
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Dahlin C, Sanders J, Calton B, DeSanto-Madeya S, Donesky D, Lakin JR, Roeland E, Scherer JS, Walling A, Williams B. The Cambia Sojourns Scholars Leadership Program: Projects and Reflections on Leadership in Palliative Care. J Palliat Med 2019; 22:823-829. [PMID: 30810459 DOI: 10.1089/jpm.2018.0523] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Effective leadership is necessary to meet the complex care needs of patients with serious, life-limiting illness. The Cambia Health Foundation Sojourns Scholars Program is advancing leadership in palliative care through supporting emerging leaders. The 2016 Cohort has implemented a range of projects to promote their leadership development. Objective: To describe the leadership themes emerging from individual project implementation of the 2016 Sojourns Leadership. Methods: We summarize the synthesized leadership themes derived from both remote and in-person meetings and written reflections of the 2016 Cambia Sojourn Leadership Cohort. Results: The 2016 Cambia Sojourn Leadership Scholar Cohort projects are described. We identified three leadership themes related to palliative care initiatives: openness and flexibility, partnership and team building, and leveraging expertise and risk. Discussion: Unprecedented challenges in a rapidly changing health environment demand palliative care leadership to influence care quality, delivery, policy, and clinical care. Flexibility and openness; partnership and team building; and expertise to implement change emerged as critical themes to advancing the care of patients with serious, life-limiting illness. These leadership themes are consistent with both previous Cambia Sojourns Scholar cohorts and the literature, are essential for the next generation of leaders to implement new models of quality palliative care, payment for palliative care, and education for patients, caregivers, and health care providers. Conclusion: In order to design and implement quality palliative care, leadership development is essential. Use of flexibility and openness; partnership and team building; and expertise to implement change are important themes for success. Whether through the Cambia Health Foundation Sojourns Leadership Program or opportunities within professional organizations, cultivation of the next generation of leaders is critical.
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Affiliation(s)
- Constance Dahlin
- 1 Hospice and Palliative Nurses Association, Pittsburgh Pennsylvania
| | - Justin Sanders
- 2 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, and Ariadne Labs, Boston, Massachusetts
| | - Brook Calton
- 3 Division of Palliative Medicine, Department of Medicine, University of California-San Francisco, San Francisco, California
| | | | - DorAnne Donesky
- 5 School of Nursing, Touro University of California, Vallejo, California
| | - Joshua R Lakin
- 2 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, and Ariadne Labs, Boston, Massachusetts
| | - Eric Roeland
- 6 Massachusetts General Hospital Cancer Center, Boston, Massachusetts
| | - Jennifer S Scherer
- 7 Division of Palliative Care and Division of Nephrology, Department of Medicine, New York University School of Medicine, New York, New York
| | - Anne Walling
- 8 Division of General Internal Medicine and Health Services Research, Department of Medicine, Division of Palliative Medicine, Department of Medicine, University of California-Los Angeles, Los Angeles, California.,9 VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Brie Williams
- 10 Division of Geriatrics, Department of Medicine, University of California-San Francisco, San Francisco, California
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Barson S, Gauld R, Gray J, Henriks G, Krause C, Lachman P, Maher L, Massoud MR, Mathias L, Wagner M, Villa L. What initiatives do healthcare leaders agree are needed for healthcare system improvement? Results of a modified-Delphi study. J Health Organ Manag 2018; 32:1002-1012. [PMID: 30468416 DOI: 10.1108/jhom-08-2017-0216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The purpose of this paper is to identify five quality improvement initiatives for healthcare system leaders, produced by such leaders themselves, and to provide some guidance on how these could be implemented. DESIGN/METHODOLOGY/APPROACH A multi-stage modified-Delphi process was used, blending the Delphi approach of iterative information collection, analysis and feedback, with the option for participants to revise their judgments. FINDINGS The process reached consensus on five initiatives: change information privacy laws; overhaul professional training and work in the workplace; use co-design methods; contract for value and outcomes across health and social care; and use data from across the public and private sectors to improve equity for vulnerable populations and the sickest people. RESEARCH LIMITATIONS/IMPLICATIONS Information could not be gathered from all participants at each stage of the modified-Delphi process, and the participants did not include patients and families, potentially limiting the scope and nature of input. PRACTICAL IMPLICATIONS The practical implications are a set of findings based on what leaders would bring to a decision-making table in an ideal world if given broad scope and capacity to make policy and organisational changes to improve healthcare systems. ORIGINALITY/VALUE This study adds to the literature a suite of recommendations for healthcare quality improvement, produced by a group of experienced healthcare system leaders from a range of contexts.
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Affiliation(s)
- Stuart Barson
- Otago Business School, University of Otago , Dunedin, New Zealand
| | - Robin Gauld
- Otago Business School, University of Otago , Dunedin, New Zealand
| | - Jonathon Gray
- Ko Awatea, Counties Manukau Health, Auckland, New Zealand
| | - Goran Henriks
- Qulturum, Jönköping County Council, Jönköping, Sweden
| | - Christina Krause
- British Columbia Patient Safety and Quality Council, Vancouver, Canada
| | - Peter Lachman
- International Society for Quality in Health Care, Dublin, Ireland
| | - Lynne Maher
- Ko Awatea, Counties Manukau Health, Auckland, New Zealand
| | | | - Lee Mathias
- Auckland District Health Board, Auckland, New Zealand
| | - Mike Wagner
- The Advisory Board Company, Washington, District of Columbia, USA
| | - Luis Villa
- Ko Awatea, Counties Manukau Health, Auckland, New Zealand
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Mathole T, Lembani M, Jackson D, Zarowsky C, Bijlmakers L, Sanders D. Leadership and the functioning of maternal health services in two rural district hospitals in South Africa. Health Policy Plan 2018; 33:ii5-ii15. [PMID: 30053038 PMCID: PMC6037108 DOI: 10.1093/heapol/czx174] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2017] [Indexed: 12/02/2022] Open
Abstract
Maternal mortality remains high in Eastern Cape Province, South Africa, despite over 90% of pregnant women utilizing maternal health services. A recent survey showed wide variation in performance among districts in the province. Heterogeneity was also found at the district level, where maternal health outcomes varied considerably among district hospitals. In ongoing research, leadership emerged as one of the key health systems factors affecting the performance of maternal health services at facility level. This article reports on a subsequent case study undertaken to examine leadership practices and the functioning of maternal health services in two resource-limited hospitals with disparate maternal health outcomes. An exploratory mixed-methods case study was undertaken with the two rural district hospitals as the units of analysis. The hospitals were purposively selected based on their maternal health outcomes: one reported good maternal health outcomes (pseudonym: Chisomo) and the other had poor outcomes (pseudonym: Tinyade). Comparative data were collected through a facility survey, non-participant observation of management and perinatal meetings, record reviews and interviews with hospital leadership, staff and patients to elicit information about leadership practices including supervision, communication and teamwork. Descriptive and thematic data analysis was undertaken. The two hospitals had similar infrastructure and equipment. Hospital managers at Chisomo used their innovation and entrepreneurial skills to improve quality of care, and leadership style was described as supportive, friendly, approachable but 'firm'. They also undertook frequent and supportive supervisory meetings. Each department at Chisomo developed its own action plan and used data to monitor their actions. Good performers were acknowledged in group meetings. Staff in this facility were motivated and patients were happy about the quality of services. The situation was different at Tinyade hospital. Participants described the leadership style of their senior managers as authoritarian. Managers were rarely available in the office and did not hold regular meetings, leading to poor communication across teams and poor coordination to address resource constraints. This demotivated the staff. The differences in leadership style, structures, processes and work culture affected teamwork, managerial supervision and support. The study demonstrates how leadership styles and practices influence maternal health care services in resource limited hospitals. Supportive leadership manifested itself in the form of focused efforts to build teamwork, enhance entrepreneurship and in management systems that are geared to improving maternal care.
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Affiliation(s)
- T Mathole
- University of the Western Cape, Robert Sobukwe Road, Bellville, South Africa
| | - M Lembani
- University of the Western Cape, Robert Sobukwe Road, Bellville, South Africa
| | - D Jackson
- University of the Western Cape, Robert Sobukwe Road, Bellville, South Africa
| | - C Zarowsky
- University of the Western Cape, Robert Sobukwe Road, Bellville, South Africa
- University of Montreal Hospital Research Centre (CR-CHUM), 850, rue St-Denis, Montreal (Québec) Canada
- Department of Social and Preventive Medicine, School of Public Health, University of Montreal 7101 av du Parc, Ste, Montreal, Québec H3N 1X9 Canada
| | - L Bijlmakers
- Radboud University Medical Centre, Radboud Institute for Health Sciences (RIHS), Geert Grooteplein-Noord 21 EZ Nijmegen, The Netherlands and
| | - D Sanders
- University of the Western Cape, Robert Sobukwe Road, Bellville, South Africa
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Doherty J, Gilson L, Shung-King M. Achievements and challenges in developing health leadership in South Africa: the experience of the Oliver Tambo Fellowship Programme 2008-2014. Health Policy Plan 2018; 33:ii50-ii64. [PMID: 30053036 PMCID: PMC6037070 DOI: 10.1093/heapol/czx155] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2017] [Indexed: 11/19/2022] Open
Abstract
The Oliver Tambo Fellowship Programme is convened by the School of Public Health and Family Medicine, University of Cape Town, South Africa. It is a health leadership training programme with a post-graduate Diploma at its core, supplemented by management seminars, mentorship and alumni networking. An external evaluation was conducted in 2015 for the period since 2008. This rapid, descriptive study made use of mixed methods-including a document review of existing Programme material (management reports, anonymized alumni's implementation project reports, exit interviews, field interviews and e-mailed questionnaires), a brief e-mailed questionnaire, and 18 semi-structured telephonic interviews conducted by the evaluator with Programme alumni, convenors and senior government line managers. Data were analysed according to indicators and associated criteria developed by the evaluator on the basis of the Programme's objectives, international experience, the nature of the South African health system and the particular philosophy of the Programme. The evaluation found that the Diploma offered a unique contribution. This is because it sought less to convey new technical knowledge, than to empower and galvanize students to become change agents in the complex settings of their workplaces. Reflective practice was an important part of this process. Alumni were able to point to a number of positive changes in their management practice and motivation, translating these into improved performance by their teams and more effective health services. Alumni also helped to build the capacity of their own and other staff, sharing the knowledge and skills they had gained through the Programme, and leading by example. However, the Programme found it difficult to arrange adequate mentorship or peer support for alumni once they returned to their workplaces, pointing to the need for human resource development units in government to become more active in supporting alumni and holding them accountable for improving practice.
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Affiliation(s)
- Jane Doherty
- School of Public Health Building, University of the Witwatersrand, (Education Campus), 27 St Andrew's Road, Parktown, Johannesburg, South Africa
| | - Lucy Gilson
- Division of Health Policy and Systems, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, Cape Town, South Africa
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - Maylene Shung-King
- Division of Health Policy and Systems, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, Cape Town, South Africa
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Reddy KS, Mathur MR, Negi S, Krishna B. Redefining public health leadership in the sustainable development goal era. Health Policy Plan 2017; 32:757-759. [PMID: 28369486 DOI: 10.1093/heapol/czx006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2017] [Indexed: 11/12/2022] Open
Abstract
Adoption of the Sustainable Development Goals (SDGs) by member states of the United Nations (UN) has set a new agenda for public health action at national and global levels. The changed context calls for a reframing of what constitutes effective leadership in public health, through a construct that reflects the interdependence of leadership at multiple levels across the health system and its partners in other sectors. This is especially important in the context of Low and Middle Income Countries (LMICs) that are facing complex demographic and epidemiological transitions. The health system needs to exercise leadership that effectively mobilises all its resources for maximising health impact, and channels trans-disciplinary learning into well-coordinated multi-sectoral action on the wider determinants of health. Leadership is essential not only at the level of inspirational individuals who can create collective vision and commitment but also at the level of supportive institutions situated in or aligned to the health system. In turn, the health system as a whole has to exercise leadership that advances public health in the framework of sustainable development. This commentary examines the desirable attributes of effective leadership at each of these levels and explores the nature of their inter-dependence.
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Affiliation(s)
- K Srinath Reddy
- Public Health Foundation of India, Plot No 47, Sector 44, Institutional Area, Gurgaon - 122002, India
| | - Manu Raj Mathur
- Public Health Foundation of India, Plot No 47, Sector 44, Institutional Area, Gurgaon - 122002, India
| | - Sagri Negi
- Public Health Foundation of India, Plot No 47, Sector 44, Institutional Area, Gurgaon - 122002 (India)
| | - Bhargav Krishna
- Centre for Environmental Health, Public Health Foundation of India, Plot No 47, Sector 44, Institutional Area, Gurgaon - 122002, India
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Erasmus E, Gilson L, Govender V, Nkosi M. Organisational culture and trust as influences over the implementation of equity-oriented policy in two South African case study hospitals. Int J Equity Health 2017; 16:164. [PMID: 28911338 PMCID: PMC5599896 DOI: 10.1186/s12939-017-0659-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 08/23/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND This paper uses the concepts of organisational culture and organisational trust to explore the implementation of equity-oriented policies - the Uniform Patient Fee Schedule (UPFS) and Patients' Rights Charter (PRC) - in two South African district hospitals. It contributes to the small literatures on organisational culture and trust in low- and middle-income country health systems, and broader work on health systems' people-centeredness and "software". METHODS The research entailed semi-structured interviews (Hospital A n = 115, Hospital B n = 80) with provincial, regional, district and hospital managers, as well as clinical and non-clinical hospital staff, hospital board members, and patients; observations of policy implementation, organisational functioning, staff interactions and patient-provider interactions; and structured surveys operationalising the Competing Values Framework for measuring organisational culture (Hospital A n = 155, Hospital B n = 77) and Organisational Trust Inventory (Hospital A n = 185, Hospital B n = 92) for assessing staff-manager trust. RESULTS Regarding the UPFS, the hospitals' implementation approaches were similar in that both primarily understood it to be about revenue generation, granting fee exemptions was not a major focus, and considerable activity, facility management support, and provincial support was mobilised behind the UPFS. The hospitals' PRC paths diverged quite significantly, as Hospital A was more explicit in communicating and implementing the PRC, while the policy also enjoyed stronger managerial support in Hospital A than Hospital B. Beneath these experiences lie differences in how people's values, decisions and relationships influence health system functioning and in how the nature of policies, culture, trust and power dynamics can combine to create enabling or disabling micro-level implementation environments. CONCLUSIONS Achieving equity in practice requires managers to take account of "unseen" but important factors such as organisational culture and trust, which are key aspects of the organisational context that can profoundly influence policies. In addition to implementation "hardware" such as putting in place necessary staff and resources, it emphasises "software" implementation tasks such as relationship management and the negotiation of values, where equity-oriented policies might be interpreted as challenging health workers' status and values, and paying careful attention to how policies are practically framed and translated into practice, to ensure key equity aspects are not neglected.
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Affiliation(s)
- Ermin Erasmus
- Health Policy and Systems Division, School of Public Health and Family Medicine University of Cape Town, Rondebosch, South Africa
| | - Lucy Gilson
- Health Policy and Systems Division, School of Public Health and Family Medicine, University of Cape Town, Rondebosch, South Africa
- Department of Global Health and Development, Faculty of Public Health and Policy London School of Hygiene and Tropical Medicine, London, UK
| | - Veloshnee Govender
- Alliance for Health Policy and Systems Research, World Health Organization, Geneva, Switzerland
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