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Erixy Naluso S, Isaac Kanyangale M. Decentralisation of the Health System Derailed by Organisational Inertia in Machinga, Malawi. Int J Health Policy Manag 2024; 13:7956. [PMID: 39099492 PMCID: PMC11365077 DOI: 10.34172/ijhpm.7956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 07/07/2024] [Indexed: 08/06/2024] Open
Abstract
BACKGROUND Managing the transition of a health system (HS) from a centralised to a decentralised model has been touted as a panacea to the complex challenges in developing countries like Malawi. However, recent studies have demonstrated that decentralisation of the HS has had mixed effects in service provision with more dominant negative outcomes than positive results. The aim of this study was to develop a substantive grounded theory (GT) that elaborates on how activities of central decision-makers and local healthcare mangers shape the process of shifting the HS to a decentralised model in Machinga, Malawi. METHODS The study was qualitative in nature and employed the Straussian version of GT. Some participants were interviewed twice, and a total of 36 semi-structured interviews were conducted with 25 purposively selected participants using an interview guide. The interviews were conducted at the headquarters of the Ministry of Health (MoH) and other ministries and agencies, and in Machinga District. Data were analysed using open, axial, and selective coding processes of the GT methodology; and the conditional matrix and paradigm model were used as data analysis tools. RESULTS The findings of this study revealed seven different activities, forming two opposing and interactional sub-processes of enabling and impeding patterns that derailed the decentralisation drive. The study generated a GT labelled "decentralisation of the HS derailed by organisational inertia," which elaborates that decentralisation of the HS produced mixed results with more predominant negative outcomes than positive effects due to resistance at the upper organisational echelons and members of the District Health Management Team (DHMT). CONCLUSION This article concludes that organisational inertia at the personal and strategic levels of leadership entrusted with decentralising the HS in Malawi, contributed immensely to the derailment of shifting the HS from the centralised to the decentralised model of health service provision.
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Affiliation(s)
- Sandram Erixy Naluso
- Graduate School of Business and Leadership Studies, University of KwaZulu-Natal, Durban, South Africa
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Tancred T, Falkenbach M, Raven J, Caffrey M. How can intersectoral collaboration and action help improve the education, recruitment, and retention of the health and care workforce? A scoping review. Int J Health Plann Manage 2024; 39:757-780. [PMID: 38319787 DOI: 10.1002/hpm.3773] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/12/2024] [Accepted: 01/25/2024] [Indexed: 02/08/2024] Open
Abstract
Inadequate numbers, maldistribution, attrition, and inadequate skill-mix are widespread health and care workforce (HCWF) challenges. Intersectoral-inclusive of different government sectors, non-state actors, and the private sector-collaboration and action are foundational to the development of a responsive and sustainable HCWF. This review presents evidence on how to work across sectors to educate, recruit, and retain a sustainable HCWF, highlighting examples of the benefits and challenges of intersectoral collaboration. We carried out a scoping review of scientific and grey literature with inclusion criteria around intersectoral governance and mechanisms for the HCWF. A framework analysis to identify and collate factors linked to the education, recruitment, and retention of the HCWF was carried out. Fifty-six documents were included. We identified a wide array of recommendations for intersectoral activity to support the education, recruitment, and retention of the HCWF. For HCWF education: formalise intersectoral decision-making bodies; align HCWF education with population health needs; expand training capacity; engage and regulate private sector training; seek international training opportunities and support; and innovate in training by leveraging digital technologies. For HCWF recruitment: ensure there is intersectoral clarity and cooperation; ensure bilateral agreements are ethical; carry out data-informed recruitment; and learn from COVID-19 about mobilising the domestic workforce. For HCWF retention: innovate around available staff, especially where staff are scarce; improve working and employment conditions; and engage the private sector. Political will and commensurate investment must underscore any intersectoral collaboration for the HCWF.
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Affiliation(s)
- Tara Tancred
- Liverpool School of Tropical Medicine (LSTM), Liverpool, UK
| | | | - Joanna Raven
- Liverpool School of Tropical Medicine (LSTM), Liverpool, UK
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Sankar D H, Benny G, Jaya S, Nambiar D. National Rural Health Mission reforms in light of decentralised planning in Kerala, India: a realist analysis of data from three witness seminars. BMC Public Health 2024; 24:678. [PMID: 38439025 PMCID: PMC10910830 DOI: 10.1186/s12889-024-18181-x] [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: 12/07/2023] [Accepted: 02/22/2024] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND The People's Planning Campaign (PPC) in the southern Indian state of Kerala started in 1996, following which the state devolved functions, finances, and functionaries to Local Self-Governments (LSGs). The erstwhile National Rural Health Mission (NRHM), subsequently renamed the National Health Mission (NHM) was a large-scale, national architectural health reform launched in 2005. How decentralisation and NRHM interacted and played out at the ground level is understudied. Our study aimed to fill this gap, privileging the voices and perspectives of those directly involved with this history. METHODS We employed the Witness Seminar (WS), an oral history technique where witnesses to history together reminisce about historical events and their significance as a matter of public record. Three virtual WS comprised of 23 participants (involved with the PPC, N(R)HM, civil society, and the health department) were held from June to Sept 2021. Inductive thematic analysis of transcripts was carried out by four researchers using ATLAS. ti 9. WS transcripts were analyzed using a realist approach, meaning we identified Contexts, Mechanisms, and Outcomes (CMO) characterising NRHM health reform in the state as they related to decentralised planning. RESULTS Two CMO configurations were identified, In the first one, witnesses reflected that decentralisation reforms empowered LSGs, democratised health planning, brought values alignment among health system actors, and equipped communities with the tools to identify local problems and solutions. Innovation in the health sector by LSGs was nurtured and incentivised with selected programs being scaled up through N(R)HM. The synergy of the decentralised planning process and N(R)HM improved health infrastructure, human resources and quality of care delivered by the state health system. The second configuration suggested that community action for health was reanimated in the context of the emergence of climate change-induced disasters and communicable diseases. In the long run, N(R)HM's frontline health workers, ASHAs, emerged as leaders in LSGs. CONCLUSION The synergy between decentralised health planning and N(R)HM has significantly shaped and impacted the health sector, leading to innovative and inclusive programs that respond to local health needs and improved health system infrastructure. However, centralised health planning still belies the ethos and imperative of decentralisation - these contradictions may vex progress going forward and warrant further study.
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Affiliation(s)
- Hari Sankar D
- The George Institute for Global Health India, 308, Third Floor, Elegance Tower, Plot No. 8, Jasola District Centre, New Delhi, 110025, India.
| | - Gloria Benny
- The George Institute for Global Health India, 308, Third Floor, Elegance Tower, Plot No. 8, Jasola District Centre, New Delhi, 110025, India
| | | | - Devaki Nambiar
- The George Institute for Global Health India, 308, Third Floor, Elegance Tower, Plot No. 8, Jasola District Centre, New Delhi, 110025, India
- George Institute for Global Health , University of New South Wales, Sydney, Australia
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
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Zakumumpa H, Paina L, Ssegujja E, Shroff ZC, Namakula J, Ssengooba F. The impact of shifts in PEPFAR funding policy on HIV services in Eastern Uganda (2015-21). Health Policy Plan 2024; 39:i21-i32. [PMID: 38253438 PMCID: PMC10803197 DOI: 10.1093/heapol/czad096] [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: 01/24/2023] [Revised: 09/19/2023] [Accepted: 10/20/2023] [Indexed: 01/24/2024] Open
Abstract
Although donor transitions from HIV programmes are increasingly common in low-and middle-income countries, there are limited analyses of long-term impacts on HIV services. We examined the impact of changes in President's Emergency Plan for AIDS Relief (PEPFAR) funding policy on HIV services in Eastern Uganda between 2015 and 2021.We conducted a qualitative case study of two districts in Eastern Uganda (Luuka and Bulambuli), which were affected by shifts in PEPFAR funding policy. In-depth interviews were conducted with PEPFAR officials at national and sub-national levels (n = 46) as well as with district health officers (n = 8). Data were collected between May and November 2017 (Round 1) and February and June 2022 (Round 2). We identified four significant donor policy transition milestones: (1) between 2015 and 2017, site-level support was withdrawn from 241 facilities following the categorization of case study districts as having a 'low HIV burden'. Following the implementation of this policy, participants perceived a decline in the quality of HIV services and more frequent commodity stock-outs. (2) From 2018 to 2020, HIV clinic managers in transitioned districts reported drastic drops in investments in HIV programming, resulting in increased patient attrition, declining viral load suppression rates and increased reports of patient deaths. (3) District officials reported a resumption of site-level PEPFAR support in October 2020 with stringent targets to reverse declines in HIV indicators. However, PEPFAR declared less HIV-specific funding. (4) In December 2021, district health officers reported shifts by PEPFAR of routing aid away from international to local implementing partner organizations. We found that, unlike districts that retained PEPFAR support, the transitioned districts (Luuka and Bulambuli) fell behind the rest of the country in implementing changes to the national HIV treatment guidelines adopted between 2017 and 2020. Our study highlights the heavy dependence on PEPFAR and the need for increasing domestic financial responsibility for the national HIV response.
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Affiliation(s)
- Henry Zakumumpa
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University, P O Box 7061, Kampala, Uganda
| | - Ligia Paina
- Bloomberg School of Public Health, Johns Hopkins University, P O Box 7062, Kampala, Uganda
| | - Eric Ssegujja
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University, P O Box 7061, Kampala, Uganda
| | - Zubin Cyrus Shroff
- Alliance for Health Policy and Systems, World Health Organization, 20 Avenue Appia, Geneva 1211, Switzerland
| | - Justin Namakula
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University, P O Box 7061, Kampala, Uganda
| | - Freddie Ssengooba
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University, P O Box 7061, Kampala, Uganda
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Bigirinama RN, Makali SL, Mothupi MC, Chiribagula CZ, St Louis P, Mwene-Batu PL, Bisimwa GB, Mwembo AT, Porignon DG. Ensuring leadership at the operational level of a health system in protracted crisis context: a cross-sectional qualitative study covering 8 health districts in Eastern Democratic Republic of Congo. BMC Health Serv Res 2023; 23:1362. [PMID: 38057862 DOI: 10.1186/s12913-023-10336-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 11/16/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND This study examines how leadership is provided at the operational level of a health system in a protracted crisis context. Despite advances in medical science and technology, health systems in low- and middle-income countries struggle to deliver quality care to all their citizens. The role of leadership in fostering resilience and positive transformation of a health system is established. However, there is little literature on this issue in Democratic Republic of the Congo (DRC). This study describes leadership as experienced and perceived by health managers in crisis affected health districts in Eastern DRC. METHODS A qualitative cross-sectional study was conducted in eight rural health districts (corresponding to health zones, in DRC's health system organization), in 2021. Data were collected through in-depth interviews and non-participatory observations. Participants were key health actors in each district. The study deductively explored six themes related to leadership, using an adapted version of the Leadership Framework conceptual approach to leadership from the United Kingdom National Health Service's Leadership Academy. From these themes, a secondary analysis extracted emerging subthemes. RESULTS The study has revealed deficiencies regarding management and organization of the health zones, internal collaboration within their management teams as well as collaboration between these teams and the health zone's external partners. Communication and clinical and managerial capacities were identified as key factors to be strengthened in improving leadership within the districts. The findings have also highlighted the detrimental influence of vertical interventions from external partners and hierarchical supervisors in health zones on planning, human resource management and decision-making autonomy of district leaders, weakening their leadership. CONCLUSIONS Despite their decentralized basic operating structure, which has withstood decades of crisis and insufficient government investment in healthcare, the districts still struggle to assert their leadership and autonomy. The authors suggest greater support for personal and professional development of the health workforce, coupled with increased government investment, to further strengthen health system capacities in these settings.
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Affiliation(s)
- Rosine N Bigirinama
- Ecole Régionale de Santé Publique, Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo.
- School of Medicine, Université Catholique de Bukavu, Avenue Michombero No. 02, Bukavu, Democratic Republic of Congo.
- Ecole de Santé Publique, University of Lubumbashi, Lubumbashi, Democratic Republic of Congo.
| | - Samuel L Makali
- Ecole Régionale de Santé Publique, Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo
- Centre de Recherche Politiques, Systèmes de Santé, Santé Internationale (CR3), Ecole de Santé Publique, Université Libre de Bruxelles, Bruxelles, Belgique
| | - Mamothena C Mothupi
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Christian Z Chiribagula
- Ecole Régionale de Santé Publique, Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo
| | - Patricia St Louis
- Centre de Recherche Politiques, Systèmes de Santé, Santé Internationale (CR3), Ecole de Santé Publique, Université Libre de Bruxelles, Bruxelles, Belgique
| | - Pacifique L Mwene-Batu
- Ecole Régionale de Santé Publique, Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo
- School of Medicine, Université Catholique de Bukavu, Avenue Michombero No. 02, Bukavu, Democratic Republic of Congo
- School of Medicine, Université de Kaziba, Bukavu, Democratic Republic of Congo
| | - Ghislain B Bisimwa
- Ecole Régionale de Santé Publique, Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo
- School of Medicine, Université Catholique de Bukavu, Avenue Michombero No. 02, Bukavu, Democratic Republic of Congo
- Centre de Recherche en Sciences Naturelles, Lwiro, Democratic Republic of Congo
| | - Albert T Mwembo
- Ecole de Santé Publique, University of Lubumbashi, Lubumbashi, Democratic Republic of Congo
| | - Denis G Porignon
- Département des Sciences de la Santé Publique, School of Medicine, Université de Liège, Liège, Belgium
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Onvlee O, Kok M, Buchan J, Dieleman M, Hamza M, Herbst C. Human Resources for Health in Conflict Affected Settings: A Scoping Review of Primary Peer Reviewed Publications 2016-2022. Int J Health Policy Manag 2023; 12:7306. [PMID: 38618826 PMCID: PMC10590254 DOI: 10.34172/ijhpm.2023.7306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 05/20/2023] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND Conflict has devastating effects on health systems, especially on healthcare workers (HCWs) working in under-resourced and hostile environments. However, little evidence is available on how policy-makers, often together with development partners, can optimize the organization of the health workforce and support HCWs to deliver accessible and trustworthy health services in conflict-affected settings (CAS). METHODS A scoping review was conducted to review recent evidence (2016-2022) on human resources for health (HRH) in CAS, and critically discuss HRH challenges in these settings. Thirty-six studies were included in the review and results were presented using an adapted version of the health labour market (HLM) framework. RESULTS Evidence from CAS highlights that conflict causes specific constraints in both the education sector and in the HLM, and deepens any existing disconnect between those sectors. Parallel and inadequate education and performance management systems, attacks on health facilities, and increased workload and stress, amongst other factors, affect HCW motivation, performance, distribution, and attrition. Short-term, narrowly focused policy-making undermines the long-term sustainability and resilience of the health workforce in CAS, and also contributes to the limited and narrow available research base. CONCLUSION While HRH and workforce issues in CAS include those found in many other low- and middle-income countries (LMICs), an additional set of challenges for HCWs, governance dynamics and institutional constraints in CAS 'multiply' negative effects on the health workforce. HRH policies, programmes and interventions must be aligned with the political and broader societal context, including the stage, severity and other dynamics of conflict. During conflict, it is important to try to monitor in- and outflow of HCWs and provide HCWs the support they need at local level or through remote measures. The post-conflict situation may present opportunities for improvement in HRH, but a clear understanding of political economy dynamics is required to better act on any such a window of opportunity.
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Affiliation(s)
- Olivier Onvlee
- KIT Royal Tropical Institute, Amsterdam, The Netherlands
| | - Maryse Kok
- KIT Royal Tropical Institute, Amsterdam, The Netherlands
| | - James Buchan
- Faculty of Health, WHO Collaborating Centre, University of Technology, Sydney, NSW, Australia
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Martineau T, Mansour W, Dieleman M, Akweongo P, Amon S, Chikaphupha K, Mubiri P, Raven J. Using the integration of human resource management strategies at district level to improve workforce performance: analysis of workplan designs in three African countries. HUMAN RESOURCES FOR HEALTH 2023; 21:57. [PMID: 37488651 PMCID: PMC10367416 DOI: 10.1186/s12960-023-00838-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 06/15/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND There is a worldwide shortage of health workers against WHO recommended staffing levels to achieve Universal Health Coverage. To improve the performance of the existing health workforce a set of integrated human resources (HR) strategies are needed to address the root causes of these shortages. The PERFORM2Scale project uses an action research approach to support district level management teams to develop appropriate workplans to address service delivery and workforce-related problems using a set of integrated human resources strategies. This paper provides evidence of the feasibility of supporting managers at district level to design appropriate integrated workplans to address these problems. METHODS The study used content analysis of documents including problem trees and 43 workplans developed by 28 district health management teams (DHMT) across three countries between 2018 and 2021 to identify how appropriate basic planning principles and the use of integrated human resource and health systems strategies were used in the design of the workplans developed. Four categories of HR strategies were used for the analysis (availability, direction, competencies, rewards and sanctions) and the relationship between HR and wider health systems strategies was also examined. RESULTS About half (49%) of the DHMTs selected service-delivery problems while others selected workforce performance (46%) or general management (5%) problems, yet all workplans addressed health workforce-related causes through integrated workplans. Most DHMTs used a combination of strategies for improving direction and competencies. The use of strategies to improve availability and the use of rewards and sanctions was more common amongst DHMTs in Ghana; this may be related to availability of decision-space in these areas. Other planning considerations such as link between problem and strategy, inclusion of gender and use of indicators were evident in the design of the workplans. CONCLUSIONS The study has demonstrated that, with appropriate support using an action research approach, DHMTs are able to design workplans which include integrated HR strategies. This process will help districts to address workforce and other service delivery problems as well as improving 'health workforce literacy' of DHMT members which will benefit the country more broadly if and when any of the team members is promoted.
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Affiliation(s)
- Tim Martineau
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Wesam Mansour
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
| | - Marjolein Dieleman
- KIT Royal Tropical Institute, Amsterdam, The Netherlands
- Athena Institute, VU University, Amsterdam, The Netherlands
| | - Patricia Akweongo
- Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
| | - Samuel Amon
- Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
| | | | - Paul Mubiri
- Makerere University School of Public Health, Kampala, Uganda
| | - Joanna Raven
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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Feldhaus I, Chatterjee S, Clarke-Deelder E, Brenzel L, Resch S, Bossert TJ. Examining decentralization and managerial decision making for child immunization program performance in India. Soc Sci Med 2023; 317:115457. [PMID: 36493499 PMCID: PMC9870749 DOI: 10.1016/j.socscimed.2022.115457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 09/03/2022] [Accepted: 10/09/2022] [Indexed: 11/05/2022]
Abstract
Despite widespread adoption of decentralization reforms, the impact of decentralization on health system attributes, such as access to health services, responsiveness to population health needs, and effectiveness in affecting health outcomes, remains unclear. This study examines how decision space, institutional capacities, and accountability mechanisms of the Intensified Mission Indradhanush (IMI) in India relate to measurable performance of the immunization program. Data on decision space and its related dimensions of institutional capacity and accountability were collected by conducting structured interviews with managers based in 24 districts, 61 blocks, and 279 subcenters. Two measures by which to assess performance were selected: (1) proportion reduction in the DTP3 coverage gap (i.e., effectiveness), and (2) total IMI doses delivered per incremental USD spent on program implementation (i.e., efficiency). Descriptive statistics on decision space, institutional capacity, and accountability for IMI managers were generated. Structural equation models (SEM) were specified to detect any potential associations between decision space dimensions and performance measures. The majority of districts and blocks indicated low levels of decision space. Institutional capacity and accountability were similar across areas. Increases in decision space were associated with less progress towards closing the immunization coverage gap in the IMI context. Initiatives to support health workers and managers based on their specific contextual challenges could further improve outcomes of the program. Similar to previous studies, results revealed strong associations between each of the three decentralization dimensions. Health systems should consider the impact that management structures have on the efficiency and effectiveness of health services delivery. Future research could provide greater evidence for directionality of direct and indirect effects, interaction effects, and/or mediators of relationships.
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Affiliation(s)
- Isabelle Feldhaus
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | | | | | | | - Stephen Resch
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Thomas J. Bossert
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Razavi SD, Kapiriri L, Abelson J, Wilson M. Barriers to Equitable Public Participation in Health-System Priority Setting Within the Context of Decentralization: The Case of Vulnerable Women in a Ugandan District. Int J Health Policy Manag 2022; 11:1047-1057. [PMID: 33590740 PMCID: PMC9808191 DOI: 10.34172/ijhpm.2020.256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 12/09/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Decentralization of healthcare decision-making in Uganda led to the promotion of public participation. To facilitate this, participatory structures have been developed at sub-national levels. However, the degree to which the participation structures have contributed to improving the participation of vulnerable populations, specifically vulnerable women, remains unclear. We aim to understand whether and how vulnerable women participate in health-system priority setting; identify any barriers to vulnerable women's participation; and to establish how the barriers to vulnerable women's participation can be addressed. METHODS We used a qualitative description study design involving interviews with district decision-makers (n=12), sub-county leaders (n=10), and vulnerable women (n=35) living in Tororo District, Uganda. Data was collected between May and June 2017. The analysis was conducting using an editing analysis style. RESULTS The vulnerable women expressed interest in participating in priority setting, believing they would make valuable contributions. However, both decision-makers and vulnerable women reported that vulnerable women did not consistently participate in decision-making, despite participatory structures that were instituted through decentralization. There are financial (transportation and lack of incentives), biomedical (illness/disability and menstruation), knowledge-based (lack of knowledge and/or information about participation), motivational (perceived disinterest, lack of feedback, and competing needs), socio-cultural (lack of decision-making power), and structural (hunger and poverty) barriers which hamper vulnerable women's participation. CONCLUSION The identified barriers hinder vulnerable women's participation in health-system priority setting. Some of the barriers could be addressed through the existing decentralization participatory structures. Respondents made both short-term, feasible recommendations and more systemic, ideational recommendations to improve vulnerable women's participation. Integrating the vulnerable women's creative and feasible ideas to enhance their participation in health-system decision-making should be prioritized.
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Affiliation(s)
- S. Donya Razavi
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada
| | - Lydia Kapiriri
- Department of Health, Aging and Society, Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada
| | - Julia Abelson
- Department of Health Research Methods, Evidence, and Impact (HEI), Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada
| | - Michael Wilson
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster Health Forum, Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada
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Gile PP, van de Klundert J, Buljac-Samardzic M. Human resource management in Ethiopian public hospitals. BMC Health Serv Res 2022; 22:763. [PMID: 35689209 PMCID: PMC9188153 DOI: 10.1186/s12913-022-08046-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 05/06/2022] [Indexed: 11/10/2022] Open
Abstract
Background In Ethiopia, public hospitals deal with a persistent human resource crisis, even by Sub-Saharan Africa (SSA) standards. Policy and hospital reforms, however, have thus far resulted in limited progress towards addressing the strategic human resource management (SHRM) challenges Ethiopia’s public hospitals face. Methods To explore the contextual factors influencing these SHRM challenges of Ethiopian public hospitals, we conducted a qualitative study based on the Contextual SHRM framework of Paauwe. A total of 19 structured interviews were conducted with Chief Executive Officers (CEOs) and HR managers from a purposive sample of 15 hospitals across Ethiopia. An additional four focus groups were held with professionals and managers. Results The study found that hospitals compete on the supply side for scarce resources, including skilled professionals. There was little reporting on demand-side competition for health services provided, service quality, and service innovation. Governmental regulations were the main institutional mechanism in place. These regulations also emphasized human resources and were perceived to tightly regulate employee numbers, salaries, and employment arrangements at detailed levels. These regulations were perceived to restrict the autonomy of hospitals regarding SHRM. Regulation-induced differences in allowances and external employment arrangements were among the concerns that decreased motivation and job satisfaction and caused employees to leave. The mismatch between regulation and workforce demands posed challenges for leadership and caused leaders to be perceived as incompetent and unable when they could not successfully address workforce needs. Conclusions Bottom-up involvement in SHRM may help resolve the aforementioned persistent problems. The Ethiopian government might better loosen regulations and provide more autonomy to hospitals to develop SHRM and implement mechanisms that emphasize the quality of the health services demanded rather than the quantity of human resources supplied. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08046-7.
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Affiliation(s)
- Philipos Petros Gile
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, The Netherlands and Higher Education Institutions' Partnership, CMC Road, PO Box 14051, Addis Ababa, Ethiopia.
| | - Joris van de Klundert
- Prince Mohammad Bin Salman College (MBSC) of Business and Entrepreneurship, 7082-BayLaSun-Juman St. Unit No. 1, King Abdullah Economic City, 23964-2522, Saudi Arabia, Kingdom of Saudi Arabia.,Erasmus University Rotterdam, Erasmus School of Health Policy and Management, PO Box 1738, 3000, DR, Rotterdam, The Netherlands
| | - Martina Buljac-Samardzic
- Erasmus University Rotterdam, Erasmus School of Health Policy and Management, PO Box 1738, 3000, DR, Rotterdam, The Netherlands
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Saulnier DD, Thol D, Por I, Hanson C, von Schreeb J, Alvesson HM. 'We have a plan for that': a qualitative study of health system resilience through the perspective of health workers managing antenatal and childbirth services during floods in Cambodia. BMJ Open 2022; 12:e054145. [PMID: 34980624 PMCID: PMC8724583 DOI: 10.1136/bmjopen-2021-054145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE Health system resilience can increase a system's ability to deal with shocks like floods. Studying health systems that currently exhibit the capacity for resilience when shocked could enhance our understanding about what generates and influences resilience. This study aimed to generate empirical knowledge on health system resilience by exploring how public antenatal and childbirth health services in Cambodia have absorbed, adapted or transformed in response to seasonal and occasional floods. DESIGN A qualitative study using semi-structured interviews and thematic analysis and informed by the Dimensions of Resilience Governance framework. SETTING Public sector healthcare facilities and health departments in two districts exposed to flooding. PARTICIPANTS Twenty-three public sector health professionals with experience providing or managing antenatal and birth services during recent flooding. RESULTS The theme 'Collaboration across the system creates adaptability in the response' reflects how collaboration and social relationships among providers, staff and the community have delineated boundaries for actions and decisions for services during floods. Floods were perceived as having a modest impact on health services. Knowing the boundaries on decision-making and having preparation and response plans let staff prepare and respond in a flexible yet stable way. The theme was derived from ideas of (1) seasonal floods as a minor strain on the system compared with persistent, system-wide organisational stresses the system already experiences, (2) the ability of the health services to adjust and adapt flood plans, (3) a shared purpose and working process during floods, (4) engagement at the local level to fulfil a professional duty to the community, and (5) creating relationships between health system levels and the community to enable flood response. CONCLUSION The capacity to absorb and adapt to floods was seen among the public sector services. Strategies that enhance stability and flexibility may foster the capacity for health system resilience.
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Affiliation(s)
- Dell D Saulnier
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Dawin Thol
- National Institute of Public Health, Phnom Penh, Cambodia
| | - Ir Por
- National Institute of Public Health, Phnom Penh, Cambodia
| | - Claudia Hanson
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, UK
| | - Johan von Schreeb
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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12
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Mansour W, Aryaija-Karemani A, Martineau T, Namakula J, Mubiri P, Ssengooba F, Raven J. Management of human resources for health in health districts in Uganda: A decision space. Int J Health Plann Manage 2021; 37:770-789. [PMID: 34698403 PMCID: PMC9298089 DOI: 10.1002/hpm.3359] [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: 12/29/2020] [Revised: 07/26/2021] [Accepted: 10/04/2021] [Indexed: 12/01/2022] Open
Abstract
Background Decentralisation has been adopted by many governments to strengthen national systems, including the health system. Decision space is used to describe the decision‐making power devolved to local government. Human resource Management (HRM) is a challenging area that District Health Management Teams (DHMT) need some control over its functions to develop innovative ways of improving health services. The study aims to examine the use of DHMTs' reported decision space for HRM functions in Uganda. Methods Mixed methods approach was used to examine the DHMTs' reported decision space for HRM functions in three districts in Uganda, which included self‐assessment questionnaires and focus group discussions (FGDs). Results The decision space available for the DHMTs varied across districts, with Bunyangabu and Ntoroko DHMTs reporting having more control than Kabarole. All DHMTs reported full control over the functions of performance management, monitoring policy implementation, forecasting staffing needs, staff deployment, and identifying capacity needs. However, they reported narrow decision space for developing job descriptions, resources mobilisation, and organising training; and no control over modifying staffing norms, setting salaries and developing an HR information system (HRIS). Nevertheless, DHMTs tried to overcome their limitations by adjusting HR policies locally, better utilising available resources and adapting the HRIS to local needs. Conclusions Decentralisation provides a critical opportunity to strengthen HRM in low‐and‐middle‐income countries. Examining decision space for HRM functions can help identify areas where district health managers can change or improve their actions. In Uganda, decentralisation helped the DHMTs be more responsive to the local workforce needs and analysing decision space helped identify areas for improvement in HRM. There are some limitations and more power over HRM functions and strong management competencies would help them become more resourceful.
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Affiliation(s)
- Wesam Mansour
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Adelaine Aryaija-Karemani
- Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda
| | - Tim Martineau
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Justine Namakula
- Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda
| | - Paul Mubiri
- Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda
| | - Freddie Ssengooba
- Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda
| | - Joanna Raven
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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13
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Zakumumpa H, Tumwine C, Milliam K, Spicer N. Dispensing antiretrovirals during Covid-19 lockdown: re-discovering community-based ART delivery models in Uganda. BMC Health Serv Res 2021; 21:692. [PMID: 34256756 PMCID: PMC8276217 DOI: 10.1186/s12913-021-06607-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 06/04/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The notion of health-system resilience has received little empirical attention in the current literature on the Covid-19 response. We set out to explore health-system resilience at the sub-national level in Uganda with regard to strategies for dispensing antiretrovirals during Covid-19 lockdown. METHODS We conducted a qualitative case-study of eight districts purposively selected from Eastern and Western Uganda. Between June and September 2020, we conducted qualitative interviews with district health team leaders (n = 9), ART clinic managers (n = 36), representatives of PEPFAR implementing organizations (n = 6).In addition, six focus group discussions were held with recipients of HIV care (48 participants). Qualitative data were analyzed using thematic approach. RESULTS Five broad strategies for distributing antiretrovirals during 'lockdown' emerged in our analysis: accelerating home-based delivery of antiretrovirals,; extending multi-month dispensing from three to six months for stable patients; leveraging the Community Drug Distribution Points (CDDPs) model for ART refill pick-ups at outreach sites in the community; increasing reliance on health information systems, including geospatial technologies, to support ART refill distribution in unmapped rural settings. District health teams reported leveraging Covid-19 outbreak response funding to deliver ART refills to homesteads in rural communities. CONCLUSION While Covid-19 'lockdown' restrictions undoubtedly impeded access to facility-based HIV services, they revived interest by providers and demand by patients for community-based ART delivery models in case-study districts in Uganda.
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Affiliation(s)
- Henry Zakumumpa
- Makerere University, School of Public Health, Kampala, Uganda.
| | | | - Kiconco Milliam
- Department of Sociology, Kyambogo University, Kampala, Uganda
| | - Neil Spicer
- London School of Hygiene and Tropical Medicine, London, UK
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14
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Zakumumpa H, Rujumba J, Amde W, Damian RS, Maniple E, Ssengooba F. Transitioning health workers from PEPFAR contracts to the Uganda government payroll. Health Policy Plan 2021; 36:1397-1407. [PMID: 34240177 PMCID: PMC8505860 DOI: 10.1093/heapol/czab077] [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: 12/20/2020] [Revised: 05/28/2021] [Accepted: 06/25/2021] [Indexed: 11/14/2022] Open
Abstract
Although increasing public spending on health worker (HW) recruitments could reduce workforce shortages in sub-Saharan Africa, effective strategies for achieving this are still unclear. We aimed to understand the process of transitioning HWs from President's Emergency Plan for AIDS Relief (PEPFAR) to Government of Uganda (GoU) payrolls and to explore the facilitators and barriers encountered in increasing domestic financial responsibility for absorbing this expanded workforce. We conducted a multiple case study of 10 (out of 87) districts in Uganda which received PEPFAR support between 2013 and 2015 to expand their health workforce. We purposively selected eight districts with the highest absorption rates ('high absorbers') and two with the lowest absorption rates ('low absorbers'). A total of 66 interviews were conducted with high-level officials in three Ministries of Finance, Health and Public Service (n = 14), representatives of PEPFAR-implementing organizations (n = 16), district health teams (n = 15) and facility managers (n = 22). Twelve focus groups were conducted with 87 HWs absorbed on GoU payrolls. We utilized the Consolidated Framework for Implementation Research to guide thematic analysis. At the sub-national level, facilitators of transition in 'high absorber' districts were identified as the presence of transition 'champions', prioritizing HWs in district wage bill commitments, host facilities providing 'bridge financing' to transition workforce during salary delays and receiving donor technical support in district wage bill analysis-attributes that were absent in 'low absorber' districts. At the national level, multi-sectoral engagements (incorporating the influential Ministry of Finance), developing a joint transition road map, aligning with GoU salary scales and recruitment processes emerged as facilitators of the transition process. Our case studies offer implementation research lessons on effective donor transition and insights into pragmatic strategies for increasing public spending on expanding the health workforce in a low-income setting.
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Affiliation(s)
- Henry Zakumumpa
- School of Public Health, University of the Western Cape, Private Bag x17, Bellville, 7535 Republic of South Africa
| | - Joseph Rujumba
- Makerere University, School of Medicine, P O Box 7062, Kampala, Uganda
| | - Woldekidan Amde
- School of Public Health, University of the Western Cape, Private Bag x17, Bellville, 7535 Republic of South Africa
| | | | - Everd Maniple
- School of Medicine, Kabale University, P O Box 317, Kabale, Uganda
| | - Freddie Ssengooba
- Makerere University, School of Public Health, P O Box 7072, Kampala, Uganda
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15
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Newton-Lewis T, Munar W, Chanturidze T. Performance management in complex adaptive systems: a conceptual framework for health systems. BMJ Glob Health 2021; 6:e005582. [PMID: 34326069 PMCID: PMC8323386 DOI: 10.1136/bmjgh-2021-005582] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 07/07/2021] [Indexed: 12/14/2022] Open
Abstract
Existing performance management approaches in health systems in low-income and middle-income countries are generally ineffective at driving organisational-level and population-level outcomes. They are largely directive: they try to control behaviour using targets, performance monitoring, incentives and answerability to hierarchies. In contrast, enabling approaches aim to leverage intrinsic motivation, foster collective responsibility, and empower teams to self-organise and use data for shared sensemaking and decision-making.The current evidence base is too limited to guide reforms to strengthen performance management in a particular context. Further, existing conceptual frameworks are undertheorised and do not consider the complexity of dynamic, multilevel health systems. As a result, they are not able to guide reforms, particularly on the contextually appropriate balance between directive and enabling approaches. This paper presents a framework that attempts to situate performance management within complex adaptive systems. Building on theoretical and empirical literature across disciplines, it identifies interdependencies between organisational performance management, organisational culture and software, system-level performance management, and the system-derived enabling environment. It uses these interdependencies to identify when more directive or enabling approaches may be more appropriate. The framework is intended to help those working to strengthen performance management to achieve greater effectiveness in organisational and system performance. The paper provides insights from the literature and examples of pitfalls and successes to aid this thinking. The complexity of the framework and the interdependencies it describes reinforce that there is no one-size-fits-all blueprint for performance management, and interventions must be carefully calibrated to the health system context.
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Affiliation(s)
| | - Wolfgang Munar
- Department of Global Health, George Washington University Milken Institute of Public Health, Washington, District of Columbia, USA
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16
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Chen J, Ssennyonjo A, Wabwire-Mangen F, Kim JH, Bell G, Hirschhorn L. Does decentralization of health systems translate into decentralization of authority? A decision space analysis of Ugandan healthcare facilities. Health Policy Plan 2021; 36:1408-1417. [PMID: 34165146 PMCID: PMC8505862 DOI: 10.1093/heapol/czab074] [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: 12/08/2020] [Revised: 04/28/2021] [Accepted: 06/14/2021] [Indexed: 11/14/2022] Open
Abstract
Since the 1990s, following similar reforms to its general politico-administrative systems, Uganda has decentralized its public healthcare system by shifting decision-making power away from its central Ministry of Health and towards more distal administrative levels. Previous research has used decision space—the decision-making autonomy demonstrated by entities in an administrative hierarchy—to measure overall health system decentralization. This study aimed to determine how the decision-making autonomy reported by managers of Ugandan healthcare facilities (de facto decision space) differs from that which they are allocated by official policies (de jure decision space). Additionally, it sought to determine associations between decision space and indicators of managerial performance. Using quantitative primary healthcare data from Ugandan healthcare facilities, our study determined the decision space expressed by facility managers and the performance of their facilities on measures of essential drug availability, quality improvement and performance management. We found managers reported greater facility-level autonomy than expected in disciplining staff compared with recruitment and promotion, suggesting that managerial functions that require less financial or logistical investment (i.e. discipline) may be more susceptible to differences in de jure and de facto decision space than those that necessitate greater investment (i.e. recruitment and promotion). Additionally, we found larger public health facilities expressed significantly greater facility-level autonomy in drug ordering compared with smaller facilities, which indicates ongoing changes in the Ugandan medical supply chain to a hybrid ‘push-pull’ system. Finally, we found increased decision space was significantly positively associated with some managerial performance indicators, such as essential drug availability, but not others, such as our performance management and quality improvement measures. We conclude that increasing managerial autonomy alone is not sufficient for improving overall health facility performance and that many factors, specific to individual managerial functions, mediate relationships between decision space and performance.
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Affiliation(s)
- John Chen
- Northwestern University Feinberg School of Medicine, 420 East Superior Street, Chicago, IL 60611, USA
| | - Aloysius Ssennyonjo
- School of Public Health, College of Health Sciences, Makerere University, PO Box 7062, Kampala, Uganda
| | - Fred Wabwire-Mangen
- School of Public Health, College of Health Sciences, Makerere University, PO Box 7062, Kampala, Uganda
| | - June-Ho Kim
- Makerere University, Kampala, Uganda.,Ariadne Labs, 401 Park Drive, Boston, MA 02215, USA
| | | | - Lisa Hirschhorn
- Northwestern University Feinberg School of Medicine, 420 East Superior Street, Chicago, IL 60611, USA.,Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
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17
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Jamal Z, Alameddine M, Diaconu K, Lough G, Witter S, Ager A, Fouad FM. Health system resilience in the face of crisis: analysing the challenges, strategies and capacities for UNRWA in Syria. Health Policy Plan 2020; 35:26-35. [PMID: 31625558 DOI: 10.1093/heapol/czz129] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2019] [Indexed: 11/13/2022] Open
Abstract
Health system resilience reflects the ability to continue service delivery in the face of extraordinary shocks. We examined the case of the United Nations Relief and Works Agency (UNRWA) and its delivery of services to Palestine refugees in Syria during the ongoing crisis to identify factors enabling system resilience. The study is a retrospective qualitative case study utilizing diverse methods. We conducted 35 semi-structured interviews with UNRWA clinical and administrative professionals engaged in health service delivery over the period of the Syria conflict. Through a group model building session with a sub-group of eight of these participants, we then elicited a causal loop diagram of health system functioning over the course of the war, identifying pathways of threat and mitigating resilience strategies. We triangulated analysis with data from UNRWA annual reports and routine health management information. The UNRWA health system generally sustained service provision despite individual, community and system challenges that arose during the conflict. We distinguish absorptive, adaptive and transformative capacities of the system facilitating this resilience. Absorptive capacities enabled immediate crisis response, drawing on available human and organizational resources. Adaptive capacities sustained service delivery through revised logistical arrangements, enhanced collaborative mechanisms and organizational flexibility. Transformative capacity was evidenced by the creation of new services in response to changing community needs. Analysis suggests factors such as staff commitment, organizational flexibility and availability of collaboration mechanisms were important assets in maintaining service continuity and quality. This evidence regarding alternative strategies adopted to sustain service delivery in Syria is of clear relevance to other actors seeking organizational resilience in crisis contexts.
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Affiliation(s)
- Zeina Jamal
- Institute for Global Health and Development, Queen Margaret University, Edinburgh EH21 6UU, UK
| | - Mohamad Alameddine
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, P.O. Box 11-0236, Riad El-Solh/Beirut 1107 2020, Lebanon
| | - Karin Diaconu
- Institute for Global Health and Development, Queen Margaret University, Edinburgh EH21 6UU, UK
| | - Graham Lough
- Institute for Global Health and Development, Queen Margaret University, Edinburgh EH21 6UU, UK
| | - Sophie Witter
- Institute for Global Health and Development, Queen Margaret University, Edinburgh EH21 6UU, UK
| | - Alastair Ager
- Institute for Global Health and Development, Queen Margaret University, Edinburgh EH21 6UU, UK
| | - Fouad M Fouad
- Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, P.O. Box 11-0236, Riad El-Solh/Beirut 1107 2020, Lebanon
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18
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Bulthuis SE, Kok MC, Amon S, Agyemang SA, Nsabagasani X, Sanudi L, Raven J, Finn M, Gerold J, Tulloch O, Dieleman MA. How district health decision-making is shaped within decentralised contexts: A qualitative research in Malawi, Uganda and Ghana. Glob Public Health 2020; 16:120-135. [DOI: 10.1080/17441692.2020.1791213] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Susan E. Bulthuis
- KIT Royal Tropical Institute, Amsterdam, The Netherlands
- Athena Institute, VU University, Amsterdam, The Netherlands
| | - Maryse C. Kok
- KIT Royal Tropical Institute, Amsterdam, The Netherlands
| | - Samuel Amon
- Department of Health Policy, Planning & Management, School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Samuel Agyei Agyemang
- Department of Health Policy, Planning & Management, School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana
| | | | - Lifah Sanudi
- Research for Equity and Community Health (REACH) Trust, Lilongwe, Malawi
| | - Joanna Raven
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Mairead Finn
- Trinity Centre for Global Health, the University of Dublin, Trinity College, Dublin, Ireland
- Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Jana Gerold
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | | | - Marjolein A. Dieleman
- KIT Royal Tropical Institute, Amsterdam, The Netherlands
- Athena Institute, VU University, Amsterdam, The Netherlands
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19
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Nanyonjo A, Kertho E, Tibenderana J, Källander K. District Health Teams' Readiness to Institutionalize Integrated Community Case Management in the Uganda Local Health Systems: A Repeated Qualitative Study. GLOBAL HEALTH: SCIENCE AND PRACTICE 2020; 8:190-204. [PMID: 32606091 PMCID: PMC7326515 DOI: 10.9745/ghsp-d-19-00318] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 03/04/2020] [Indexed: 11/28/2022]
Abstract
District health teams failed to transition from partner-supported integrated community case management (iCCM) programs to locally-run and fully-institutionalized programs. Successful iCCM institutionalization requires local ownership with increased coordination among governmental and nongovernmental actors at the national and district levels. Introduction: Several countries have adopted integrated community case management (iCCM) as a strategy for improved health service delivery in areas with poor health facility coverage. Early implementation of iCCM is often run by nongovernmental organizations financed by donors through projects. Such projects risk failure to transition into programs run by the local health system upon project closure. Engagement of subnational health authorities such as district health teams (DHTs) is essential for a smooth transition. Methods: We used a repeated qualitative study design to assess the readiness of and progress made by DHTs in institutionalizing iCCM into the functions of locally decentralized health systems in 9 western Uganda districts. Readiness data were derived from structured group interviews with DHTs before iCCM policy adoption in 2010 and again in 2015. Progressive institutionalization achievements were assessed through key informant interviews with targeted DHT members and local government district planners in the same areas. Findings: In the readiness study, DHTs expressed commitment to institutionalize iCCM into the local health system through the development of district-specific iCCM activity work plans and budgets. The DHTs further suggested that they would implement district-led training, motivation, and supervision of community health workers; procurement of iCCM medicines and supplies; and advocacy activities for inclusion of iCCM indicators into the national health information systems. After iCCM policy adoption, follow-up study data findings showed that iCCM was largely not institutionalized into the local district health system functions. The poor institutionalization was attributed to lack of stewardship on how to transition from externally supported implementation to district-led programming, conflicting guidelines on community distribution of medicines, poor community-level accountability systems, and limited decision-making autonomy at the district level. Conclusion: Successful institutionalization of iCCM requires local ownership with increased coordination and cooperation among governmental and nongovernmental actors at both the national and district levels.
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Affiliation(s)
| | | | | | - Karin Källander
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
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20
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Razavi SD, Kapiriri L, Abelson J, Wilson M. Who is in and who is out? A qualitative analysis of stakeholder participation in priority setting for health in three districts in Uganda. Health Policy Plan 2020; 34:358-369. [PMID: 31180489 DOI: 10.1093/heapol/czz049] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2019] [Indexed: 11/12/2022] Open
Abstract
Stakeholder participation is relevant in strengthening priority setting processes for health worldwide, since it allows for inclusion of alternative perspectives and values that can enhance the fairness, legitimacy and acceptability of decisions. Low-income countries operating within decentralized systems recognize the role played by sub-national administrative levels (such as districts) in healthcare priority setting. In Uganda, decentralization is a vehicle for facilitating stakeholder participation. Our objective was to examine district-level decision-makers' perspectives on the participation of different stakeholders, including challenges related to their participation. We further sought to understand the leverages that allow these stakeholders to influence priority setting processes. We used an interpretive description methodology involving qualitative interviews. A total of 27 district-level decision-makers from three districts in Uganda were interviewed. Respondents identified the following stakeholder groups: politicians, technical experts, donors, non-governmental organizations (NGO)/civil society organizations (CSO), cultural and traditional leaders, and the public. Politicians, technical experts and donors are the principal contributors to district-level priority setting and the public is largely excluded. The main leverages for politicians were control over the district budget and support of their electorate. Expertise was a cross-cutting leverage for technical experts, donors and NGO/CSOs, while financial and technical resources were leverages for donors and NGO/CSOs. Cultural and traditional leaders' leverages were cultural knowledge and influence over their followers. The public's leverage was indirect and exerted through electoral power. Respondents made no mention of participation for vulnerable groups. The public, particularly vulnerable groups, are left out of the priority setting process for health at the district. Conflicting priorities, interests and values are the main challenges facing stakeholders engaged in district-level priority setting. Our findings have important implications for understanding how different stakeholder groups shape the prioritization process and whether representation can be an effective mechanism for participation in health-system priority setting.
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Affiliation(s)
- S Donya Razavi
- Department of Health Research Methods, Evidence, and Impact (HEI), Centre for Health Economics and Policy Analysis, McMaster University, 1280 Main St. West, Hamilton, ON, Canada
| | - Lydia Kapiriri
- Department of Health, Aging and Society, Centre for Health Economics and Policy Analysis, McMaster University, 1280 Main St. West, Hamilton, ON, Canada
| | - Julia Abelson
- Department of Health Research Methods, Evidence, and Impact (HEI), Centre for Health Economics and Policy Analysis, McMaster University, 1280 Main St. West, Hamilton, ON, Canada
| | - Michael Wilson
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster Health Forum, Centre for Health Economics and Policy Analysis, McMaster University, 1280 Main St. West, Hamilton, ON, Canada
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21
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Liwanag HJ, Wyss K. Who should decide for local health services? A mixed methods study of preferences for decision-making in the decentralized Philippine health system. BMC Health Serv Res 2020; 20:305. [PMID: 32293432 PMCID: PMC7158124 DOI: 10.1186/s12913-020-05174-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 03/31/2020] [Indexed: 11/29/2022] Open
Abstract
Background The Philippines decentralized government health services through devolution to local governments in 1992. Over the years, opinions varied on the impact of devolved governance to decision-making for local health services. The objective of this study was to analyze decision-makers’ perspectives on who should be making decisions for local health services and on their preferred structure of health service governance should they be able to change the situation. Methods We employed a mixed methods approach that included an online survey in one region and in-depth interviews with purposively-selected decision-makers in the Philippine health system. Study participants were asked about their perspectives on decision-making in the functions of planning, health financing, resource management, human resources for health, health service delivery, and data management and monitoring. Analysis of survey results through visualization of data on charts was complemented by the themes that emerged from the qualitative analysis of in-depth interviews based on the Framework Method. Results We received 24 online survey responses and interviewed 27 other decision-makers. Survey respondents expressed a preference to shift decision-making away from the local politician in favor of the local health officer in five functions. Most survey participants also preferred re-centralization. Analysis of the interviews suggested that the preferences expressed were likely driven by an expectation that re-centralization would provide a solution to the perceived politicization in decision-making and the reliance of local governments on central support. Conclusions Rather than re-centralize the health system, one policy option for consideration for the Philippines would be to maintain devolution but with a revitalized role for the central level to maintain oversight over local governments and regulate their decision-making for the functions. Decentralization, whether in the Philippines or elsewhere, must not only transfer decision-making responsibility to local levels but also ensure that those granted with the decision space could perform decision-making with adequate capacities and could grasp the importance of health services.
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Affiliation(s)
- Harvy Joy Liwanag
- Swiss Tropical and Public Health Institute, Basel, Switzerland. .,Balik Scientist Program, Department of Science and Technology Philippine Council for Health Research and Development (DOST PCHRD), Metro Manila, Philippines. .,Ateneo de Manila University School of Medicine and Public Health, Metro Manila, Philippines.
| | - Kaspar Wyss
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
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Muthathi IS, Levin J, Rispel LC. Decision space and participation of primary healthcare facility managers in the Ideal Clinic Realisation and Maintenance programme in two South African provinces. Health Policy Plan 2020; 35:302-312. [PMID: 31872256 PMCID: PMC7152727 DOI: 10.1093/heapol/czz166] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2019] [Indexed: 02/05/2023] Open
Abstract
In South Africa, the introduction of a national health insurance (NHI) system is the most prominent health sector reform planned to achieve universal health coverage in the country. Primary health care (PHC) is the foundation of the proposed NHI system. This study draws on policy implementation theory and Bossert's notion of decision space to analyse PHC facility managers' decision space and their participation in the implementation of the Ideal Clinic Realisation and Maintenance (ICRM) programme. We conducted a cross-sectional survey among 127 PHC facility managers in two districts in Gauteng and Mpumalanga provinces. A self-administered questionnaire elicited socio-demographic information, the PHC managers' participation in the conceptualization and implementation of the ICRM programme, their decision space and an optional open-ended question for further comments. We obtained a 100% response rate. The study found that PHC facility managers reported lack of involvement in the conceptualization of the ICRM programme, high levels of participation in implementation [mean score 5.77 (SD ±0.90), and overall decision space mean score of 2.54 (SD ±0.34)]. However, 17 and 21% of participants reported narrow decision space on the critical areas of the availability of essential medicines and on basic resuscitation equipment respectively. The qualitative data revealed the unintended negative consequences of striving for 'ideal clinic status', namely that of creating an illusion of compliance with the ICRM standards. The study findings suggest the need for greater investment in the health workforce, special efforts to involve frontline managers and staff in health reforms, as well as provision of adequate resources, and an enabling practice environment.
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Affiliation(s)
- Immaculate Sabelile Muthathi
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 27 St Andrews Road, Johannesburg 2193, South Africa
| | - Jonathan Levin
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 27 St Andrews Road, Johannesburg 2193, South Africa
| | - Laetitia C Rispel
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 27 St Andrews Road, Johannesburg 2193, South Africa
- Centre for Health Policy & Department of Science and Innovation/National Research Foundation Research Chair, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 27 St Andrews Road, Johannesburg 2193, South Africa
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The Role of Quality Improvement Process in Improving the Culture of Information among Health Staff in Ghana. ADVANCES IN PUBLIC HEALTH 2019. [DOI: 10.1155/2019/7579569] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background. Over the past decades, knowledge and understanding have grown regarding the role that health information systems play in improving global health. Even so, using data to make evidence-informed decisions is still weak in most low- and middle-income countries. People do not always act on what they are told to do but act on sharing what is important and valued in an organization. Shared principles related to information systems are alluded to as a pre-existing culture of data collection or “culture of information” without specifying how these values originate and sustain themselves. They work in an organizational environment, which ultimately impacts them through organizational directives, principles, and practices. The objective of the study was to determines the role of quality improvement process in improving culture of information among health staff in Ghana, particularly in the Ejisu Juaben Health Service over time. Methods. A quasi-non-experimental pre- and post-intervention study was conducted in 26 health facilities in the Ejisu Juaben municipal health service of Ghana. The study involved assessment of perceived culture of information of staff coupled with training of 141 core staff selected from 26 facilities who were involved in data collection and use of information through application of data quality improvement training module over a twelve-month period. Results. Overall perceived promotion of culture of information improved from 71 percent in the baseline to 81 percent in the endline. Test-retest analysis suggested that the mean levels of the indices measuring promotion of a perceived culture of information, was significantly higher in endline compared to the situation in baseline. Conclusions. The study concluded that the improvement in staff perceived culture of information improved significantly overtime and this might have been contributed by the application and adoption of quality improvement training.
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Taderera BH. Do national human resources for health policy interventions impact successfully on local human resources for health systems: a case study of Epworth, Zimbabwe. Glob Health Action 2019; 12:1646037. [PMID: 31368413 PMCID: PMC6711195 DOI: 10.1080/16549716.2019.1646037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: The global health workforce crisis remains a challenge undermining health system strengthening in low-income peri-urban areas. Whilst the 2018 Astana Declaration and the 2030 Global Health Workforce Strategy are helping guide effort to address this challenge, the Decision Space Approach presents an opportunity through which to further understand decision space and its impact on innovation and performance, and what it can contribute towards the goal of health-care worker reform. Objective: To use the Decision Space Approach to understand how national policy interventions on health workers impact local health-care worker systems in Epworth, Zimbabwe. Methods: A case study design, within which cross-sectional studies were carried out at the principal and agent level, was used. At the principal level, data were collected through a documentary search and key informant interviews and generated a Human Resource for Health Policy Decision Space Mapping Analysis Conceptual Tool. The Conceptual Tool guided data collection at the agent level, where a documentary search, in-depth interviews and focus group discussions were carried out. The Tool facilitated discussion of findings and was complemented by interpretive thematic analysis and descriptive statistics. Results: Intervention by the health ministry resulted in moderate decision space within which functional innovation, in partnership with the local board and church mission, revived financial budgeting, human resources planning, deployment, and retention. However, low capacity of the principal undermined the implementation of choices generated from narrow decision space in training, performance management, labor relations, safety, and information and research. Conclusions: Whilst collaborative intervention by the principal may help revive health-care worker systems in low-income peri-urban areas, financial and technical incapacity of the principal and agent may undermine performance. Narrow decision space brings health-care worker reform policy direction but incapacity undermines progression towards universal health coverage and the Sustainable Development Goals in low-income peri-urban areas.
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Affiliation(s)
- Bernard Hope Taderera
- a Department of Environmental Health, University of Johannesburg , Johannesburg , South Africa
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Heerdegen ACS, Bonenberger M, Aikins M, Schandorf P, Akweongo P, Wyss K. Health worker transfer processes within the public health sector in Ghana: a study of three districts in the Eastern Region. HUMAN RESOURCES FOR HEALTH 2019; 17:45. [PMID: 31234893 PMCID: PMC6591950 DOI: 10.1186/s12960-019-0379-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 05/23/2019] [Indexed: 06/09/2023]
Abstract
INTRODUCTION The lack of appropriate policies and procedures to ensure transparent transfer practices is an important source of dissatisfaction among health workers in low- and middle-income countries. In order to alter and improve current practices, a more in-depth and context-specific understanding is needed. This study aims to (1) identify rationales behind transfer decisions in Ghana and (2) examine how transfers are managed in practice versus in policies. METHODS The study took place in 2014 in three districts in Eastern Ghana. The study population included (1) national, regional, and district health administrators with decision-making authority in terms of transfer decisions and (2) health workers who had transferred between 2011 and 2014. Data was collected through semi-structured and structured face-to-face interviews focusing on rationales behind transfer decisions, health administrators' role in managing transfers, and health workers' experience of transfers. A data triangulation approach was applied to compare identified practices with national policies and procedures. RESULTS A total of 44 health workers and 21 administrators participated in the study. Transfers initiated by health workers were mostly based on family conditions and preferences to move away from rural areas, while transfers initiated by administrators were based on service requirements, productivity, and performance. The management of transfers was not guided by clear and explicit procedures and thus often depended on the discretion of decision-makers. Moreover, health workers frequently reported not being involved in transfer decision-making processes. We found existing staff perceptions of a non-transparent system. CONCLUSION Our findings suggest a need to foster incentives to attract and retain health workers in rural areas. Moreover, health worker-centered procedures and systems that effectively guide and monitor transfer practices must be developed to ensure that transfers are carried out in a timely, fair, and transparent way.
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Affiliation(s)
- A. C. S. Heerdegen
- Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Socinstrasse 57, P.O. Box, CH-4002, Basel, Switzerland
- University of Basel, Petersplatz 1, P.O. Box, CH-4001, Basel, Switzerland
| | - M. Bonenberger
- FAIRMED, Aarbergergasse 29, P.O. Box, 3001, Bern, Switzerland
| | - M. Aikins
- School of Public Health, College of Health Sciences, University of Ghana, P. O. Box LG13, Accra, Legon Ghana
| | - P. Schandorf
- Nursing and Midwifery Training College, P. O. Box KF 142, Koforidua, Eastern Region Ghana
| | - P. Akweongo
- School of Public Health, College of Health Sciences, University of Ghana, P. O. Box LG13, Accra, Legon Ghana
| | - K. Wyss
- Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Socinstrasse 57, P.O. Box, CH-4002, Basel, Switzerland
- University of Basel, Petersplatz 1, P.O. Box, CH-4001, Basel, Switzerland
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Mashange W, Martineau T, Chandiwana P, Chirwa Y, Pepukai VM, Munyati S, Alonso-Garbayo A. Flexibility of deployment: challenges and policy options for retaining health workers during crisis in Zimbabwe. HUMAN RESOURCES FOR HEALTH 2019; 17:39. [PMID: 31151396 PMCID: PMC6544946 DOI: 10.1186/s12960-019-0369-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 04/30/2019] [Indexed: 06/01/2023]
Abstract
BACKGROUND Zimbabwe experienced a socio-economic crisis from 1997 to 2008 which heavily impacted all sectors. In this context, human resource managers were confronted with the challenge of health worker shortage in rural areas and, at the same time, had to operate under a highly centralised, government-centred system which defined health worker deployment policies. This study examines the implementation of deployment policies in Zimbabwe before, during and after the crisis in order to analyse how the official policy environment evolved over time, present the actual practices used by managers to cope with the crisis and draw lessons. 'Deployment' here was considered to include all the human resource management functions for getting staff into posts and managing subsequent movements: recruitment, bonding, transfer and secondment. The study contributes to address the existing paucity of evidence on flexibility on implementation of policies in crisis/conflict settings. METHODS This retrospective study investigates deployment policies in government and faith-based organisation health facilities in Zimbabwe before, during and after the crisis. A document review was done to understand the policy environment. In-depth interviews with key informant including policy makers, managers and health workers in selected facilities in three mainly rural districts in the Midlands province were conducted. Data generated was analysed using a framework approach. RESULTS Before the crisis, health workers were allowed to look for jobs on their own, while during the crisis, they were given three choices and after the crisis the preference choice was withdrawn. The government froze recruitment in all sectors during the crisis which severely affected health workers' deployment. In practice, the implementation of the deployment policies was relatively flexible. In some cases, health workers were transferred to retain them, the recruitment freeze was temporarily lifted to fill priority vacancies, the length of the bonding period was reduced including relaxation of withholding certificates, and managers used secondment to relocate workers to priority areas. CONCLUSION Flexibility in the implementation of deployment policies during crises may increase the resilience of the system and contribute to the retention of health workers. This, in turn, may assist in ensuring coverage of health services in hard-to-reach areas.
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Affiliation(s)
- Wilson Mashange
- ReBUILD Consortium and Biomedical Research and Training Institute, 10 Seagrave Road, Corner Seagrave and Sam Nujoma Street, Avondale, P.O. Box. CY 1753, Causeway, Harare, Zimbabwe.
| | - Tim Martineau
- ReBUILD Consortium and Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, United Kingdom
| | - Pamela Chandiwana
- ReBUILD Consortium and Biomedical Research and Training Institute, 10 Seagrave Road, Corner Seagrave and Sam Nujoma Street, Avondale, P.O. Box. CY 1753, Causeway, Harare, Zimbabwe
| | - Yotamu Chirwa
- ReBUILD Consortium and Biomedical Research and Training Institute, 10 Seagrave Road, Corner Seagrave and Sam Nujoma Street, Avondale, P.O. Box. CY 1753, Causeway, Harare, Zimbabwe
| | - Vongai Mildred Pepukai
- ReBUILD Consortium and Biomedical Research and Training Institute, 10 Seagrave Road, Corner Seagrave and Sam Nujoma Street, Avondale, P.O. Box. CY 1753, Causeway, Harare, Zimbabwe
| | - Shungu Munyati
- ReBUILD Consortium and Biomedical Research and Training Institute, 10 Seagrave Road, Corner Seagrave and Sam Nujoma Street, Avondale, P.O. Box. CY 1753, Causeway, Harare, Zimbabwe
| | - Alvaro Alonso-Garbayo
- ReBUILD Consortium and Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, United Kingdom
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Liwanag HJ, Wyss K. Optimising decentralisation for the health sector by exploring the synergy of decision space, capacity and accountability: insights from the Philippines. Health Res Policy Syst 2019; 17:4. [PMID: 30630469 PMCID: PMC6327786 DOI: 10.1186/s12961-018-0402-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 12/05/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Several studies on decentralisation have used the 'decision space' approach to assess the breadth of space made available to decision-makers at lower levels of the health system. However, in order to better understand how decentralisation becomes effective for the health sector, analysis should go beyond assessing decision space and include the dimensions of capacity and accountability. Building on Bossert's earlier work on the synergy of these dimensions, we analysed decision-making in the Philippines where governmental health services have been devolved to local governments since 1992. METHODS Using a qualitative research design, we interviewed 27 key decision-makers at different levels of the Philippine health system and representing various local settings. We explored their perspectives on decision space, capacities and accountability in the health sector functions of planning, financing and budget allocation, programme implementation and service delivery, management of facilities, equipment and supplies, health workforce management, and data monitoring and utilisation. Analysis followed the Framework Method. RESULTS Across all functions, decision space for local decision-makers was assessed to be moderate or narrow despite 25 years of devolution. To improve decision-making in these functions, adjustments in local capacities should include, at the individual level, skills for strategic planning, management, priority-setting, evidence-informed policy-making and innovation in service delivery. At institutional levels, these desired capacities should include having a multi-stakeholder approach, generating revenues from local sources, partnering with the private sector and facilitating cooperation between local health facilities. On the other hand, adjustments in accountability should focus on the various mechanisms that can be enforced by the central level, not only to build the desired capacities and augment the inadequacies at local levels, but also to incentivise success and regulate failure by the local governments in performing the functions transferred to them. CONCLUSION To optimise decentralisation for the health sector, widening decision spaces for local decision-makers must be accompanied by the corresponding adjustments in capacities and accountability for promoting good decision-making at lower levels in the decentralised functions. Analysing the health system through the lens of this synergy is useful for exploring concrete policy adjustments in the Philippines as well as in other settings.
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Affiliation(s)
- Harvy Joy Liwanag
- Swiss Tropical and Public Health Institute, Basel, Switzerland.
- University of Basel, Basel, Switzerland.
- Ateneo de Manila University School of Medicine and Public Health, Metro Manila, Philippines.
| | - Kaspar Wyss
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
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Liwanag HJ, Wyss K. What conditions enable decentralization to improve the health system? Qualitative analysis of perspectives on decision space after 25 years of devolution in the Philippines. PLoS One 2018; 13:e0206809. [PMID: 30395625 PMCID: PMC6218067 DOI: 10.1371/journal.pone.0206809] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 10/21/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Decentralization is promoted as a strategy to improve health system performance by bringing decision-making closer to service delivery. Some studies have investigated if decentralization actually improves the health system. However, few have explored the conditions that enable it to be effective. To determine these conditions, we have analyzed the perspectives of decision-makers in the Philippines where devolution, one form of decentralization, was introduced 25 years ago. METHODS Drawing from the "decision space" approach, we interviewed 27 decision-makers with an average of 23.6 years of working across different levels of the Philippine government health sector and representing various local settings. Qualitative analysis followed the "Framework Method." Conditions that either enable or hinder the effectiveness of decentralization were identified by exploring decision-making in five health sector functions. RESULTS These conditions include: for planning, having a multi-stakeholder approach and monitoring implementation; for financing and budget allocation, capacities to raise revenues at local levels and pooling of funds at central level; for resource management, having a central level capable of augmenting resource needs at local levels and a good working relationship between the local health officer and the elected local official; for program implementation and service delivery, promoting innovation at local levels while maintaining fidelity to national objectives; and for monitoring and data management, a central level capable of ensuring that data collection from local levels is performed in a timely and accurate manner. CONCLUSIONS The Philippine experience suggests that decentralization is a long and complex journey and not an automatic solution for enhancing service delivery. The role of the central decision-maker (e.g. Ministry of Health) remains important to assist local levels unable to perform their functions well. It is policy-relevant to analyze the conditions that make decentralization work and the optimal combination of decentralized and centralized functions that enhance the health system.
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Affiliation(s)
- Harvy Joy Liwanag
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Ateneo School of Medicine and Public Health, Ateneo de Manila University, Metro Manila, Philippines
| | - Kaspar Wyss
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
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