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Musiega A, Tsofa B, Nyawira L, Njuguna RG, Munywoki J, Hanson K, Mulwa A, Molyneux S, Maina I, Normand C, Jemutai J, Barasa E. Examining the influence of budget execution processes on the efficiency of county health systems in Kenya. Health Policy Plan 2023; 38:351-362. [PMID: 36367746 PMCID: PMC10074769 DOI: 10.1093/heapol/czac098] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 10/06/2022] [Accepted: 11/11/2022] [Indexed: 11/13/2022] Open
Abstract
Public financial management (PFM) processes are a driver of health system efficiency. PFM happens within the budget cycle which entails budget formulation, execution and accountability. At the budget execution phase, budgets are implemented by spending as planned to generate a desired output or outcome. Understanding how the budget execution processes influence the use of inputs and the outcomes that result is important for maximizing efficiency. This study sought to explain how the budget execution processes influence the efficiency of health systems, an area that is understudied, using a case study of county health systems in Kenya. We conducted a concurrent mixed methods case study using counties classified as relatively efficient (n = 2) and relatively inefficient (n = 2). We developed a conceptual framework from a literature review to guide the development of tools and analysis. We collected qualitative data through document reviews and in-depth interviews (n = 70) with actors from health and finance sectors at the national and county level. We collected quantitative data from secondary sources, including budgets and budget reports. We analysed qualitative data using the thematic approach and carried out descriptive analyses on quantitative data. The budget execution processes within counties in Kenya were characterized by poor budget credibility, cash disbursement delays, limited provider autonomy and poor procurement practices. These challenges were linked to an inappropriate input mix that compromised the capacity of county health systems to deliver health-care services, misalignment between county health needs and the use of resources, reduced staff motivation and productivity, procurement inefficiencies and reduced county accountability for finances and performance. The efficiency of county health systems in Kenya can be enhanced by improving budget credibility, cash disbursement processes, procurement processes and provider autonomy.
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Affiliation(s)
- Anita Musiega
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, 197 Lenana Place, Lenana Road, P.O Box 43460-00100, Nairobi, Kenya
- Institute of Healthcare Management, Strathmore Business School, Strathmore University, Ole Sangale Road, P.O. Box 59857-00200, Madaraka, Nairobi, Kenya
| | - Benjamin Tsofa
- Health Systems and Research Ethics Department, KEMRI-Wellcome Trust Research Programme, P.O Box 230-8010, Kilifi, Kenya
| | - Lizah Nyawira
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, 197 Lenana Place, Lenana Road, P.O Box 43460-00100, Nairobi, Kenya
| | - Rebecca G Njuguna
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, 197 Lenana Place, Lenana Road, P.O Box 43460-00100, Nairobi, Kenya
| | - Joshua Munywoki
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, 197 Lenana Place, Lenana Road, P.O Box 43460-00100, Nairobi, Kenya
| | - Kara Hanson
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Andrew Mulwa
- Directorate of Medical Services, Preventive and Pomotive Health, Ministry of Health, Afya House, Cathedral Road, P.O. Box 30016-00100, Nairobi, Kenya
| | - Sassy Molyneux
- Health Systems and Research Ethics Department, KEMRI-Wellcome Trust Research Programme, P.O Box 230-8010, Kilifi, Kenya
| | - Isabel Maina
- Health Financing Department, Ministry of Health, Afya House, Cathedral Road, P.O. Box 30016-00100, Nairobi, Kenya
| | - Charles Normand
- Centre for Health Policy and Management, Trinity College, The University of Dublin, Dublin, Ireland
| | - Julie Jemutai
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, 197 Lenana Place, Lenana Road, P.O Box 43460-00100, Nairobi, Kenya
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, 197 Lenana Place, Lenana Road, P.O Box 43460-00100, Nairobi, Kenya
- Institute of Healthcare Management, Strathmore Business School, Strathmore University, Ole Sangale Road, P.O. Box 59857-00200, Madaraka, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, The Peter Medawar Building for Pathogen Research, South Parks Road, Oxon, Oxford OX1 3SY, UK
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Heerdegen ACS, Gerold J, Amon S, Agyemang SA, Aikins M, Wyss K. How Does District Health Management Emerge Within a Complex Health System? Insights for Capacity Strengthening in Ghana. Front Public Health 2020; 8:270. [PMID: 32733833 PMCID: PMC7360672 DOI: 10.3389/fpubh.2020.00270] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 05/26/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: District health managers (DHMs) play a pivotal role in the operation of district health systems in low-and middle income countries, including Ghana. Their capacity is determined by their competencies, but also by the organization and system in which they are embedded. The objective of this paper is to explore how district health management emerges from contextual, organizational, and individual factors in order to demonstrate that capacity strengthening efforts at district level need to transcend individual competencies to take on more systemic approaches. Methods: Semi-structured interviews (n = 21) were conducted to gain insight into aspects that affect district health management in the Eastern Region of Ghana. Interviews were conducted with DHMs (n = 15) from six different districts, as well as with their superiors at the regional level (n = 4) and peers from non-governmental organizations (n = 2). A thematic analysis was conducted by using an analytical approach based on systems theory. Results: Contextual aspects, such as priorities among elected officials, poor infrastructure and working conditions, centralized decision-making, delayed disbursement of funds and staff shortages, affect organizational processes and the way DHMs carry out their role. Enabling organizational aspects that provide DHMs with direction and a clear perception of their role, include positive team dynamics, good relations with supervisors, job descriptions, appraisals, information systems, policies and guidelines. Meanwhile, hierarchical organizational structures, agendas driven by vertical programs and limited opportunities for professional development provide DHMs with limited authority to make decisions and dampens their motivation. The DHMs ability to carry out their role effectively depends on their perception of their role and the effort they expend, in addition to their competencies. In regards to competencies, a need for more general management and leadership skills were called for by DHMs as well as by their superiors and peers. Conclusion: Systemic approaches are called for in order to strengthen district health management capacity. This study can provide national policy-makers, donors and researchers with a deeper understanding of factors that should be taken into consideration when developing, planning, implementing, and assessing capacity-building strategies targeted at strengthening district health management.
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Affiliation(s)
| | - Jana Gerold
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Samuel Amon
- School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Samuel Agyei Agyemang
- School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Moses Aikins
- School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Kaspar Wyss
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
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Kuwawenaruwa A, Borghi J, Remme M, Mtei G. An assessment of equity in the distribution of non-financial health care inputs across public primary health care facilities in Tanzania. Int J Equity Health 2017; 16:124. [PMID: 28697732 PMCID: PMC5505032 DOI: 10.1186/s12939-017-0620-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 07/04/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND There is limited evidence on how health care inputs are distributed from the sub-national level down to health facilities and their potential influence on promoting health equity. To address this gap, this paper assesses equity in the distribution of health care inputs across public primary health facilities at the district level in Tanzania. METHODS This is a quantitative assessment of equity in the distribution of health care inputs (staff, drugs, medical supplies and equipment) from district to facility level. The study was carried out in three districts (Kinondoni, Singida Rural and Manyoni district) in Tanzania. These districts were selected because they were implementing primary care reforms. We administered 729 exit surveys with patients seeking out-patient care; and health facility surveys at 69 facilities in early 2014. A total of seventeen indices of input availability were constructed with the collected data. The distribution of inputs was considered in relation to (i) the wealth of patients accessing the facilities, which was taken as a proxy for the wealth of the population in the catchment area; and (ii) facility distance from the district headquarters. We assessed equity in the distribution of inputs through the use of equity ratios, concentration indices and curves. RESULTS We found a significant pro-rich distribution of clinical staff and nurses per 1000 population. Facilities with the poorest patients (most remote facilities) have fewer staff per 1000 population than those with the least poor patients (least remote facilities): 0.6 staff per 1000 among the poorest, compared to 0.9 among the least poor; 0.7 staff per 1000 among the most remote facilities compared to 0.9 among the least remote. The negative concentration index for support staff suggests a pro-poor distribution of this cadre but the 45 degree dominated the concentration curve. The distribution of vaccines, antibiotics, anti-diarrhoeal, anti-malarials and medical supplies was approximately proportional (non dominance), whereas the distribution of oxytocics, anti-retroviral therapy (ART) and anti-hypertensive drugs was pro-rich, with the 45 degree line dominating the concentration curve for ART. CONCLUSION This study has shown there are inequities in the distribution of health care inputs across public primary care facilities. This highlights the need to ensure a better coordinated and equitable distribution of inputs through regular monitoring of the availability of health care inputs and strengthening of reporting systems.
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Affiliation(s)
- August Kuwawenaruwa
- Ifakara Health Institute, Plot 463, Kiko Avenue Mikocheni, P.O. Box 78 373, Dar es Salaam, Tanzania
| | - Josephine Borghi
- Ifakara Health Institute, Plot 463, Kiko Avenue Mikocheni, P.O. Box 78 373, Dar es Salaam, Tanzania
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Michelle Remme
- Ifakara Health Institute, Plot 463, Kiko Avenue Mikocheni, P.O. Box 78 373, Dar es Salaam, Tanzania
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Gemini Mtei
- Ifakara Health Institute, Plot 463, Kiko Avenue Mikocheni, P.O. Box 78 373, Dar es Salaam, Tanzania
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Roman TE, Cleary S, McIntyre D. Exploring the Functioning of Decision Space: A Review of the Available Health Systems Literature. Int J Health Policy Manag 2017; 6:365-376. [PMID: 28812832 PMCID: PMC5505106 DOI: 10.15171/ijhpm.2017.26] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 02/18/2017] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The concept of decision space holds appeal as an approach to disaggregating the elements that may influence decision-making in decentralized systems. This narrative review aims to explore the functioning of decision space and the factors that influence decision space. METHODS A narrative review of the literature was conducted with searches of online databases and academic journals including PubMed Central, Emerald, Wiley, Science Direct, JSTOR, and Sage. The articles were included in the review based on the criteria that they provided insight into the functioning of decision space either through the explicit application of or reference to decision space, or implicitly through discussion of decision-making related to organizational capacity or accountability mechanisms. RESULTS The articles included in the review encompass literature related to decentralisation, management and decision space. The majority of the studies utilise qualitative methodologies to assess accountability mechanisms, organisational capacities such as finance, human resources and management, and the extent of decision space. Of the 138 articles retrieved, 76 articles were included in the final review. CONCLUSION The literature supports Bossert's conceptualization of decision space as being related to organizational capacities and accountability mechanisms. These functions influence the decision space available within decentralized systems. The exact relationship between decision space and financial and human resource capacities needs to be explored in greater detail to determine the potential influence on system functioning.
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Choonara S, Goudge J, Nxumalo N, Eyles J. Significance of informal (on-the-job) learning and leadership development in health systems: lessons from a district finance team in South Africa. BMJ Glob Health 2017; 2:e000138. [PMID: 28588998 PMCID: PMC5335765 DOI: 10.1136/bmjgh-2016-000138] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 11/29/2016] [Accepted: 12/01/2016] [Indexed: 11/06/2022] Open
Abstract
Background The district health system (DHS) has a critical role to play in the delivery of primary healthcare (PHC). Effective district management, particularly leadership is considered to be crucial element of the DHS. Internationally, the debate around developing leadership competencies such as motivation or empowerment of staff, managing relationships, being solution driven as well as fostering teamwork are argued to be possible through approaches such as formal and informal training. Despite growing multidisciplinary evidence in fields such as engineering, computer sciences and health sciences there remains little empirical evidence of these approaches, especially the informal approach. Findings are based on a broader doctoral thesis which explored district financial management; although the core focus of this paper draws attention to the significance of informal learning and its practical value in developing leadership competencies. Methods A qualitative case study was conducted in one district in the Gauteng province, South Africa. Purposive and snowballing techniques yielded a sample of 18 participants, primarily based at a district level. Primary data collected through in-depth interviews and observations (participant and non-participant) were analysed using thematic analysis. Findings Results indicate the sorts of complexities, particularly financial management challenges which staff face and draws attention to the use of two informal learning strategies—learning from others (how to communicate, delegate) and fostering team-based learning. Such strategies played a role in developing a cadre of leaders at a district level who displayed essential competencies such as motivating staff, and problem solving. Conclusions It is crucial for health systems, especially those in financially constrained settings to find cost-effective ways to develop leadership competencies such as being solution driven or motivating and empowering staff. This study illustrates that it is possible to develop such competencies through creating and nurturing a learning environment (on-the-job training) which could be incorporated into everyday practice.
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Affiliation(s)
- S Choonara
- Centre for Health Policy, MRC Health Policy Research Group, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - J Goudge
- Centre for Health Policy, MRC Health Policy Research Group, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - N Nxumalo
- Centre for Health Policy, MRC Health Policy Research Group, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - J Eyles
- Centre for Health Policy, MRC Health Policy Research Group, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.,School of Geography and Earth Sciences, McMaster University, Hamilton, Ontario, Canada
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Palmer JJ, Gilbert A, Choy M, Blanchet K. Circumventing 'free care' and 'shouting louder': using a health systems approach to study eye health system sustainability in government and mission facilities of north-west Tanzania. Health Res Policy Syst 2016; 14:68. [PMID: 27612454 PMCID: PMC5017067 DOI: 10.1186/s12961-016-0137-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 08/09/2016] [Indexed: 11/21/2022] Open
Abstract
Background Little is known about the contributions of faith-based organisations (FBOs) to health systems in Africa. In the specialist area of eye health, international and domestic Christian FBOs have been important contributors as service providers and donors, but they are also commonly critiqued as having developed eye health systems parallel to government structures which are unsustainable. Methods In this study, we use a health systems approach (quarterly interviews, a participatory sustainability analysis exercise and a social network analysis) to describe the strategies used by eye care practitioners in four hospitals of north-west Tanzania to navigate the government, church mission and donor rules that govern eye services delivery there. Results Practitioners in this region felt eye care was systemically neglected by government and therefore was ‘all under the NGOs’, but support from international donors was also precarious. Practitioners therefore adopted four main strategies to improve the sustainability of their services: (1) maintain ‘sustainability funds’ to retain financial autonomy over income; (2) avoid granting government user fee exemptions to elderly patients who are the majority of service users; (3) expand or contract outreach services as financial circumstances change; and (4) access peer support for problem-solving and advocacy. Mission-based eye teams had greater freedom to increase their income from user fees by not implementing government policies for ‘free care’. Teams in all hospitals, however, found similar strategies to manage their programmes even when their management structures were unique, suggesting the importance of informal rules shared through a peer network in governing eye care in this pluralistic health system. Conclusions Health systems research can generate new evidence on the social dynamics that cross public and private sectors within a local health system. In this area of Tanzania, Christian FBOs’ investments are important, not only in terms of the population health outcomes achieved by teams they support, but also in the diversity of organisational models they contribute to in the wider eye health system, which facilitates innovation. Electronic supplementary material The online version of this article (doi:10.1186/s12961-016-0137-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jennifer J Palmer
- Department of Infectious Diseases Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT, United Kingdom.,Centre of African Studies, School of Political and Social Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Alice Gilbert
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT, United Kingdom
| | - Michelle Choy
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Pl, London, WC1H 9SH, United Kingdom
| | - Karl Blanchet
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Pl, London, WC1H 9SH, United Kingdom.
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Kwamie A, van Dijk H, Ansah EK, Agyepong IA. The path dependence of district manager decision-space in Ghana. Health Policy Plan 2016; 31:356-66. [PMID: 26318537 PMCID: PMC4779147 DOI: 10.1093/heapol/czv069] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2015] [Indexed: 11/27/2022] Open
Abstract
The district health system in Ghana today is characterized by high resource-uncertainty and narrow decision-space. This article builds a theory-driven historical case study to describe the influence of path-dependent administrative, fiscal and political decentralization processes on development of the district health system and district manager decision-space. Methods included a non-exhaustive literature review of democratic governance in Ghana, and key informant interviews with high-level health system officials integral to the development of the district health system. Through our analysis we identified four periods of district health system progression: (1) development of the district health system (1970-85); (2) Strengthening District Health Systems Initiative (1986-93); (3) health sector reform planning and creation of the Ghana Health Service (1994-96) and (4) health sector reform implementation (1997-2007). It was observed that district manager decision-space steadily widened during periods (1) and (2), due to increases in managerial profile, and concerted efforts at managerial capacity strengthening. Periods (3) and (4) saw initial augmentation of district health system financing, further widening managerial decision-space. However, the latter half of period 4 witnessed district manager decision-space contraction. Formalization of Ghana Health Service structures influenced by self-reinforcing tendencies towards centralized decision-making, national and donor shifts in health sector financing, and changes in key policy actors all worked to the detriment of the district health system, reversing early gains from bottom-up development of the district health system. Policy feedback mechanisms have been influenced by historical and contemporary sequencing of local government and health sector decentralization. An initial act of administrative decentralization, followed by incomplete political and fiscal decentralization has ensured that the balance of power has remained at national level, with strong vertical accountabilities and dependence of the district on national level. This study demonstrates that the rhetoric of decentralization does not always mirror actual implementation, nor always result in empowered local actors.
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Affiliation(s)
- Aku Kwamie
- Department of Health Policy, Planning and Management, University of Ghana, School of Public Health, PO Box LG 13 Accra, Ghana, Wageningen University, Sociology and Development of Change, Hollandseweg 1, PO Box 8130, 6700 EW, the Netherlands,
| | - Han van Dijk
- Wageningen University, Sociology and Development of Change, Hollandseweg 1, PO Box 8130, 6700 EW, the Netherlands
| | - Evelyn K Ansah
- Ghana Health Service, Research and Development Division, PO Box MB 190 Accra, Ghana and
| | - Irene Akua Agyepong
- Department of Health Policy, Planning and Management, University of Ghana, School of Public Health, PO Box LG 13 Accra, Ghana, Julius Global Health, University Medical Centre, HP STR.6.131, P.O. Box 85500, 3508 GA Utrecht, the Netherlands
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Bonenberger M, Aikins M, Akweongo P, Wyss K. Factors influencing the work efficiency of district health managers in low-resource settings: a qualitative study in Ghana. BMC Health Serv Res 2016; 16:12. [PMID: 26769344 PMCID: PMC4712591 DOI: 10.1186/s12913-016-1271-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 01/12/2016] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND There is increasing evidence that good district management practices can improve health system performance and conversely, that poor and inefficient management practices have detrimental effects. The aim of the present study was to identify factors contributing to inefficient management practices of district health managers and ways to improve their overall efficiency. METHODS Nineteen semi-structured interviews were conducted with district health managers in three districts of the Eastern Region in Ghana. The 19 interviews conducted comprised 90% of the managerial workforce in these districts in 2013. A thematic analysis was carried out using the WHO's leadership and management strengthening framework to structure the results. RESULTS Key factors for inefficient district health management practices were identified to be: human resource shortages, inadequate planning and communication skills, financial constraints, and a narrow decision space that constrains the authority of district health managers and their ability to influence decision-making. Strategies that may improve managerial efficiency at both an individual and organizational level included improvements to planning, communication, and time management skills, and ensuring the timely release of district funds. CONCLUSIONS Filling District Health Management Team vacancies, developing leadership and management skills of district health managers, ensuring a better flow of district funds, and delegating more authority to the districts seems to be a promising intervention package, which may result in better and more efficient management practices and stronger health system performance.
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Affiliation(s)
- Marc Bonenberger
- Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Socinstrasse 57, Basel, 4002 Switzerland
- University of Basel, Basel, Switzerland
| | - Moses Aikins
- School of Public Health, University of Ghana, Legon, Ghana
| | | | - Kaspar Wyss
- Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Socinstrasse 57, Basel, 4002 Switzerland
- University of Basel, Basel, Switzerland
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Mostert S, Njuguna F, Olbara G, Sindano S, Sitaresmi MN, Supriyadi E, Kaspers G. Corruption in health-care systems and its effect on cancer care in Africa. Lancet Oncol 2015; 16:e394-404. [PMID: 26248847 DOI: 10.1016/s1470-2045(15)00163-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Revised: 02/24/2015] [Accepted: 03/05/2015] [Indexed: 01/09/2023]
Abstract
At the government, hospital, and health-care provider level, corruption plays a major role in health-care systems in Africa. The returns on health investments of international financial institutions, health organisations, and donors might be very low when mismanagement and dysfunctional structures of health-care systems are not addressed. More funding might even aggravate corruption. We discuss corruption and its effects on cancer care within the African health-care system in a sociocultural context. The contribution of high-income countries in stimulating corruption is also described. Corrupt African governments cannot be expected to take the initiative to eradicate corruption. Therefore, international financial institutions, health organisations, and financial donors should use their power to demand policy reforms of health-care systems in Africa troubled by the issue of corruption. These modifications will ameliorate the access and quality of cancer care for patients across the continent, and ultimately improve the outcome of health care to all patients.
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Affiliation(s)
- Saskia Mostert
- Department of Pediatric Oncology-Hematology, VU University Medical Center, Amsterdam, Netherlands.
| | - Festus Njuguna
- Department of Child Health and Pediatrics, Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Gilbert Olbara
- Department of Child Health and Pediatrics, Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Solomon Sindano
- Department of Child Health and Pediatrics, Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Mei Neni Sitaresmi
- Department of Pediatrics, Faculty of Medicine, Gadjah Mada University, Dr Sardjito Hospital, Yogyakarta, Indonesia
| | - Eddy Supriyadi
- Pediatric Hematology-Oncology Division, Department of Pediatrics, Gadjah Mada University, Dr Sardjito Hospital, Yogyakarta, Indonesia
| | - Gertjan Kaspers
- Department of Pediatric Oncology-Hematology, VU University Medical Center, Amsterdam, Netherlands
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Kwamie A, Agyepong IA, van Dijk H. What Governs District Manager Decision Making? A Case Study of Complex Leadership in Dangme West District, Ghana. Health Syst Reform 2015; 1:167-177. [DOI: 10.1080/23288604.2015.1032475] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Affiliation(s)
- Aku Kwamie
- School of Public Health; University of Ghana; Accra, Ghana
- Sociology of Development and Change; Wageningen University; Wageningen, The Netherlands
| | - Irene Akua Agyepong
- School of Public Health; University of Ghana; Accra, Ghana
- Julius Global Health; University Medical Center; Utrecht, The Netherlands
| | - Han van Dijk
- Sociology of Development and Change; Wageningen University; Wageningen, The Netherlands
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Kwamie A, van Dijk H, Agyepong IA. Advancing the application of systems thinking in health: realist evaluation of the Leadership Development Programme for district manager decision-making in Ghana. Health Res Policy Syst 2014; 12:29. [PMID: 24935521 PMCID: PMC4073809 DOI: 10.1186/1478-4505-12-29] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 04/28/2014] [Indexed: 11/10/2022] Open
Abstract
Background Although there is widespread agreement that strong district manager decision-making improves health systems, understanding about how the design and implementation of capacity-strengthening interventions work is limited. The Ghana Health Service has adopted the Leadership Development Programme (LDP) as one intervention to support the development of management and leadership within district teams. This paper seeks to address how and why the LDP ‘works’ when it is introduced into a district health system in Ghana, and whether or not it supports systems thinking in district teams. Methods We undertook a realist evaluation to investigate the outcomes, contexts, and mechanisms of the intervention. Building on two working hypotheses developed from our earlier work, we developed an explanatory case study of one rural district in the Greater Accra Region of Ghana. Data collection included participant observation, document review, and semi-structured interviews with district managers prior to, during, and after the intervention. Working backwards from an in-depth analysis of the context and observed short- and medium-term outcomes, we drew a causal loop diagram to explain interactions between contexts, outcomes, and mechanisms. Results The LDP was a valuable experience for district managers and teams were able to attain short-term outcomes because the novel approach supported teamwork, initiative-building, and improved prioritisation. However, the LDP was not institutionalised in district teams and did not lead to increased systems thinking. This was related to the context of high uncertainty within the district, and hierarchical authority of the system, which triggered the LDP’s underlying goal of organisational control. Conclusions Consideration of organisational context is important when trying to sustain complex interventions, as it seems to influence the gap between short- and medium-term outcomes. More explicit focus on systems thinking principles that enable district managers to better cope with their contexts may strengthen the institutionalisation of the LDP in the future.
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Affiliation(s)
- Aku Kwamie
- University of Ghana, School of Public Health, P,O, Box LG 13, Accra, Ghana.
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The dependency on central government funding of decentralised health systems: experiences of the challenges and coping strategies in the Kongwa District, Tanzania. BMC Health Serv Res 2014; 14:39. [PMID: 24460781 PMCID: PMC3905930 DOI: 10.1186/1472-6963-14-39] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Accepted: 01/24/2014] [Indexed: 11/24/2022] Open
Abstract
Background Decentralised health systems in Tanzania depend largely on funding from the central government to run health services. Experience has shown that central funding in a decentralised system is not an appropriate approach to ensure the effective and efficient performance of local authorities due to several limitations. One of the limitations is that funds from the central government are not disbursed on a timely basis, which in turn, leads to the serious problem of shortage of financial resources for Council Health Management Teams (CHMT). This paper examines how dependency on central government funding in Tanzania affects health activities in Kongwa district council and the strategies used by the CHMT cope with the situation. Methods The study adopted a qualitative approach and data were collected using semi-structured interviews and focus group discussions. One district in the central region of Tanzania was strategically selected. Ten key informants involved in the management of health service delivery at the district level were interviewed and one focus group discussion was held, which consisted of members of the council health management team. The data generated were analysed for themes and patterns. Results The results showed that late disbursement of funds interrupts the implementation of health activities in the district health system. This situation delays the implementation of some activities, while a few activities may not be implemented at all. However, based on their prior knowledge of the anticipated delays in financial disbursements, the council health management team has adopted three main strategies to cope with this situation. These include obtaining supplies and other services on credit, borrowing money from other projects in the council, and using money generated from cost sharing. Conclusion Local government authorities (LGAs) face delays in the disbursement of funds from the central government. This has necessitated introduction of informal coping strategies to deal with the situation. National-level policy and decision makers should minimise the bureaucracy involved in allocating funds to the district health systems to reduce delays.
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Atinga RA, Mensah SA, Asenso-Boadi F, Adjei FXA. Migrating from user fees to social health insurance: exploring the prospects and challenges for hospital management. BMC Health Serv Res 2012; 12:174. [PMID: 22726666 PMCID: PMC3407489 DOI: 10.1186/1472-6963-12-174] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Accepted: 06/22/2012] [Indexed: 11/29/2022] Open
Abstract
Background In 2003 Ghana introduced a social health insurance scheme which resulted in the separation of purchasing of health services by the health insurance authority on the one hand and the provision of health services by hospitals at the other side of the spectrum. This separation has a lot of implications for managing accredited hospitals. This paper examines whether decoupling purchasing and service provision translate into opportunities or challenges in the management of accredited hospitals. Methods A qualitative exploratory study of 15 accredited district hospitals were selected from five of Ghana’s ten administrative regions for the study. A semi-structured interview guide was designed to solicit information from key informants, Health Service Administrators, Pharmacists, Accountants and Scheme Managers of the hospitals studied. Data was analysed thematically. Results The results showed that under the health insurance scheme, hospitals are better-off in terms of cash flow and adequate stock levels of drugs. Adequate stock of non-drugs under the scheme was reportedly intermittent. The major challenges confronting the hospitals were identified as weak purchasing power due to low tariffs, non computerisation of claims processing, unpredictable payment pattern, poor gate-keeping systems, lack of logistics and other new and emerging challenges relating to moral hazards and the use of false identity cards under pretence for medical care. Conclusion Study’s findings have a lot of policy implications for proper management of hospitals. The findings suggest rationalisation of the current tariff structure, the application of contract based payment system to inject efficiency into hospitals management and piloting facility based vetting systems to offset vetting loads of the insurance authority. Proper gate-keeping mechanisms are also needed to curtail the phenomenon of moral hazard and false documentation.
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Affiliation(s)
- Roger A Atinga
- Department of Public Administration and Health Services Management, University of Ghana Business School, Legon, Accra, Ghana.
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Nnaji GA, Oguoma C, Nnaji LI, Nwobodo E. The challenges of budgeting in a newly introduced district health system: a case study. Glob Public Health 2010; 5:87-101. [PMID: 19946811 DOI: 10.1080/17441690903371762] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Nigeria operates a three-tier political system consisting of a national government: 36 states, Federal Capital Territory and 768 local governments. There are three levels of health care: primary, secondary and tertiary levels corresponding to and funded by local, state and national governments, respectively. A budget prepared at the district level was not possible until 2006 when the 2007 annual budget was prepared. AIM The goal of this study was to identify the key challenges of budgeting in a newly introduced District Health System and to share our experience with other scholars. METHODOLOGY This study is a descriptive case study using interviews and focus group discussions of district and local health officers and the District Health Management Team as well as field notes made from participant observers and reviews of relevant documents. FINDINGS AND DISCUSSION The study showed that a bottom-up approach was used at the district level, while the concept of business planning was introduced to underscore the seriousness of health planning and efficient resource allocation. The two systems of expenditure classifications, i.e., functional and economic classification, were used in a complementary manner. The capacity for planning and budgeting was found to be lacking among the district health officers. The crosscutting contextual issues constraining budgeting included the inadequate Health Management Information System (HMIS), a non-functional Financial Management System (FMS) and an unreliable Human Resources Management System (HRMS). RECOMMENDATIONS There is a need for further study to be carried out to determine the factors that constrain the collection, analysis and dissemination of HMIS. In addition, there is a need to study the constraints to proper implementation of the FMS, HRMS and the linkage between the quality of the essential data-set with the efficiency of resource allocation in budgeting.
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Affiliation(s)
- G A Nnaji
- Department of Primary Health Care, Faculty of Medicine, Nnamdi Azikiwe University, P.M.B 5001, Nnewi, Nigeria.
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Asante AD, Zwi AB. Factors influencing resource allocation decisions and equity in the health system of Ghana. Public Health 2009; 123:371-7. [PMID: 19364613 DOI: 10.1016/j.puhe.2009.02.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2008] [Revised: 11/12/2008] [Accepted: 02/09/2009] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Allocation of financial resources in the health sector is often seen as a formula-driven activity. However, the decision to allocate a certain amount of resources to a particular health jurisdiction or facility may be based on a broader range of factors, sometimes not reflected in the existing resource allocation formula. This study explores the 'other' factors that influence the equity of resource allocation in the health system of Ghana. The extent to which these factors are, or can be, accounted for in the resource allocation process is analysed. STUDY DESIGN An exploratory design focusing on different levels of the health system and diverse stakeholders. METHODS Data were gathered through semi-structured qualitative interviews with health authorities at national, regional and district levels, and with donor representatives and local government officials in 2003 and 2004. RESULTS The availability of human resources for health, local capacity to utilize funds, donor involvement in the health sector, and commitment to promote equity have considerable influence on resource allocation decisions and affect the equity of funding allocations. However, these factors are not accounted for adequately in the resource allocation process. CONCLUSION This study highlights the need for a more transparent resource allocation system in Ghana based on needs, and takes into account key issues such as capacity constraints, the inequitable human resource distribution and donor-earmarked funding.
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Affiliation(s)
- A D Asante
- School of Public Health and Community Medicine (HRH Hub@UNSW), The University of New South Wales, Sydney NSW 2052, Australia.
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District-based malaria epidemic early warning systems in East Africa: perceptions of acceptability and usefulness among key staff at health facility, district and central levels. Soc Sci Med 2008; 67:292-300. [PMID: 18450352 DOI: 10.1016/j.socscimed.2008.03.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2007] [Indexed: 11/21/2022]
Abstract
Malaria epidemics represent a significant public health problem in the highlands of Africa. Many of these epidemics occur in low resource settings, where the development of an effective system for malaria surveillance has been a key challenge. Between 2001 and 2006, the Highland Malaria Project (HIMAL) established a programme to develop and test a district-based surveillance system for the early detection and control of malaria epidemics in four pilot districts in Kenya and Uganda. An innovative feature of the programme was the devolution of responsibility for the detection of epidemics from the central Ministry of Health to District Health Management Teams. The implementation of the programme offered the opportunity to test both the technical aspects of the system and to examine the practical issues relating to the operation of the programme in the context of the existing health system. To investigate the attitude of key staff towards the programme, and their perceptions of its impact on their working practices, interviews were carried out among 52 health staff at district level and in the Ministries of Health in Kenya and Uganda. The transfer of responsibility for the early detection of epidemics to the districts had resulted in perceptions of individual empowerment among district-based staff. This, together with improved support supervision, was a key factor in sustaining motivation and improved surveillance. The enhanced support supervision also produced capacity benefits that extended beyond improved malaria surveillance. However, these improvements occurred in the context of increased logistical support (the provision of transport, fuel and travel allowances) which the participants believed was essential to the functioning of an effective system. With this proviso, the district-based malaria early warning system was perceived to be manageable, effective and sustainable in the context of the current health system.
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