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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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Witter S, van der Merwe M, Twine R, Mabetha D, Hove J, Tollman SM, D’Ambruoso L. Opening decision spaces: A case study on the opportunities and constraints in the public health sector of Mpumalanga Province, South Africa. PLoS One 2024; 19:e0304775. [PMID: 38968289 PMCID: PMC11226100 DOI: 10.1371/journal.pone.0304775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 05/19/2024] [Indexed: 07/07/2024] Open
Abstract
BACKGROUND Decentralised and evidence-informed health systems rely on managers and practitioners at all levels having sufficient 'decision space' to make timely locally informed and relevant decisions. Our objectives were to understand decision spaces in terms of constraints and enablers and outline opportunities through which to expand them in an understudied rural context in South Africa. METHODS This study examined decision spaces within Mpumalanga Province, using data and insights generated through a participatory action research process with local communities and health system stakeholders since 2015, which was combined with published documents and research team participant observation to produce findings on three core domains at three levels of the health system. RESULTS Although capacity for decision making exists in the system, accessing it is frequently made difficult due to a number of intervening factors. While lines of authority are generally well-defined, personal networks take on an important dimension in how stakeholders can act. This is expressed through a range of informal coping strategies built on local relationships. There are constraints in terms of limited formal external accountability to communities, and internal accountability which is weak in places for individuals and focused more on meeting performance targets set at higher levels and less on enabling effective local leadership. More generally, political and personal factors are clearly identified at higher levels of the system, whereas at sub-district and facility levels, the dominant theme was constrained capacity. CONCLUSIONS By examining the balance of authority, accountability and capacity across multiple levels of the provincial health system, we are able to identify emergent decision space and areas for enlargement. Creating spaces to support more constructive relationships and dialogue across system levels emerges as important, as well as reinforcing horizontal networks to problem solve, and developing the capacity of link-agents such as community health workers to increase community accountability.
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Affiliation(s)
- Sophie Witter
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, Scotland, United Kingdom
| | - Maria van der Merwe
- Independent Consultant, White River, South Africa
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Rhian Twine
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Denny Mabetha
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Jennifer Hove
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Stephen M. Tollman
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Lucia D’Ambruoso
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Scotland, United Kingdom
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Avan BI, Dubale M, Taye G, Marchant T, Persson LÅ, Schellenberg J. Data-driven decision-making for district health management: a cluster-randomised study in 24 districts of Ethiopia. BMJ Glob Health 2024; 9:e014140. [PMID: 38423549 PMCID: PMC10910485 DOI: 10.1136/bmjgh-2023-014140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 01/14/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Use of local data for health system planning and decision-making in maternal, newborn and child health services is limited in low-income and middle-income countries, despite decentralisation and advances in data gathering. An improved culture of data-sharing and collaborative planning is needed. The Data-Informed Platform for Health is a system-strengthening strategy which promotes structured decision-making by district health officials using local data. Here, we describe implementation including process evaluation at district level in Ethiopia, and evaluation through a cluster-randomised trial. METHODS We supported district health teams in 4-month cycles of data-driven decision-making by: (a) defining problems using a health system framework; (b) reviewing data; (c) considering possible solutions; (d) value-based prioritising; and (e) a consultative process to develop, commit to and follow up on action plans. 12 districts were randomly selected from 24 in the North Shewa zone of Ethiopia between October 2020 and June 2022. The remaining districts formed the trial's comparison arm. Outcomes included health information system performance and governance of data-driven decision-making. Analysis was conducted using difference-in-differences. RESULTS 58 4-month cycles were implemented, four or five in each district. Each focused on a health service delivery challenge at district level. Administrators' practice of, and competence in, data-driven decision-making showed a net increase of 77% (95% CI: 40%, 114%) in the regularity of monthly reviews of service performance, and 48% (95% CI: 9%, 87%) in data-based feedback to health facilities. Statistically significant improvement was also found in administrators' use of information to appraise services. Qualitative findings also suggested that district health staff reported enhanced data use and collaborative decision-making. CONCLUSIONS This study generated robust evidence that 20 months' implementation of the Data-Informed Platform for Health strengthened health management through better data use and appraisal practices, systemised problem analysis to follow up on action points and improved stakeholder engagement. TRIAL REGISTRATION NUMBER NCT05310682.
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Affiliation(s)
- Bilal Iqbal Avan
- Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Mehret Dubale
- London School of Hygiene & Tropical Medicine, London, UK
| | - Girum Taye
- Health System and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Tanya Marchant
- Disease Control, London School of Hygiene & Tropical Medicine, London, UK
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D'Ambruoso L, Abruquah NA, Mabetha D, van der Merwe M, Goosen G, Sigudla J, Witter S. Expanding Community Health Worker decision space: learning from a Participatory Action Research training intervention in a rural South African district. HUMAN RESOURCES FOR HEALTH 2023; 21:66. [PMID: 37596628 PMCID: PMC10439531 DOI: 10.1186/s12960-023-00853-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 08/08/2023] [Indexed: 08/20/2023]
Abstract
BACKGROUND While integral to decentralising health reforms, Community Health Workers (CHWs) in South Africa experience many challenges. During COVID-19, CHW roles changed rapidly, shifting from communities to clinics. In the contexts of new roles and re-engineered primary healthcare (PHC), the objectives were to: (a) implement a training intervention to support local decision-making capability of CHWs; and (b) assess learning and impacts from the perspectives of CHWs. METHODS CHWs from three rural villages (n = 9) were trained in rapid Participatory Action Research (PAR) with peers and community stakeholders (n = 33). Training equipped CHWs with tools and techniques to convene community groups, raise and/or respond to local health concerns, understand concerns from different perspectives, and facilitate action in communities and public services. CHWs' perspectives before and after the intervention were gained through semi-structured interviews. Data were collected and analysed using the decision space framework to understand local actors' power to affect devolved decision-making. RESULTS CHWs demonstrated significant resilience and commitment in the face of COVID-19. They experienced multiple, intersecting challenges including: limited financial, logistical and health systems support, poor role clarity, precarious employment, low and no pay, unstable organisational capacity, fragile accountability mechanisms and belittling treatment in clinics. Together, these restricted decision space and were seen to reflect a low valuing of the cadre in the system. CHWs saw the training as a welcome opportunity to assert themselves as a recognised cadre. Regular, spaces for dialogue and mutual learning supported CHWs to gain tools and skills to rework their agency in more empowered ways. The training improved management capacity, capabilities for dialogue, which expanded role clarity, and strengthened community mobilisation, facilitation and analysis skills. Development of public speaking skills was especially valued. CHWs reported an overall 'tripe-benefit' from the training: community-acceptance; peer support; and dialogue with and recognition by the system. The training intervention was recommended for scale-up by the health authority as an implementation support strategy for PHC. CONCLUSIONS Lack of recognition of CHWs is coupled with limited opportunities for communication and trust-building. The training supported CHWs to find and amplify their voices in strategic partnerships, and helped build functionality for local decision-making.
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Affiliation(s)
- Lucia D'Ambruoso
- Aberdeen Centre for Health Data Science, School of Medicine, Medical Sciences and Nutrition, and Centre for Global Development, School of Education, University of Aberdeen, Aberdeen, Scotland, UK.
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden.
- Public Health, National Health Service (NHS) Grampian, Aberdeen, Scotland, UK.
- Department of Global Health, Stellenbosch University, Stellenbosch, South Africa.
| | - Nana Akua Abruquah
- The University Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Denny Mabetha
- Aberdeen Centre for Health Data Science, School of Medicine, Medical Sciences and Nutrition, and Centre for Global Development, School of Education, University of Aberdeen, Aberdeen, Scotland, UK
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Cochrane South Africa, South African Medical Research Council (MRC), Cape Town, South Africa
| | - Maria van der Merwe
- Aberdeen Centre for Health Data Science, School of Medicine, Medical Sciences and Nutrition, and Centre for Global Development, School of Education, University of Aberdeen, Aberdeen, Scotland, UK
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Maria Van Der Merwe Consulting, White River, South Africa
| | | | - Jerry Sigudla
- Mpumalanga Department of Health, Mbombela, South Africa
| | - Sophie Witter
- Institute for Global Health and Development, Queen Margaret University, Musselburgh, Scotland, UK
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Denis JL, Usher S, Préval J. Health reforms and policy capacity: the Canadian experience. POLICY & SOCIETY 2023; 42:64-89. [PMID: 36798673 PMCID: PMC9923719 DOI: 10.1093/polsoc/puac010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 09/30/2021] [Accepted: 03/16/2022] [Indexed: 06/18/2023]
Abstract
Recent work on health system strengthening suggests that a combination of leadership and policy capacity is essential to achieve transformation and improvement. Policy capacity and leadership are mutually constitutive but difficult to assemble in a coherent and consistent way. Our paper relies on the nested model of policy capacity to empirically explore how health reformers in seven Canadian provinces address the question of policy capacity. More specifically, we look at emerging representations of policy capacity within the context of health reforms between 1990 and 2020. Based on the exploration of the scientific and grey literature (legislation, annual reports of Ministries, agencies and organizations, meeting minutes, press, etc.) and interviews with key informants (n = 54), we identify how policy capacity is considered and framed within health reforms A series of core dilemmas emerge from attempts by each province to develop policy capacity for and through health reforms.
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Affiliation(s)
- Jean-Louis Denis
- Corresponding author: J.-L. Denis, Département de gestion, d’évaluation et de politique de santé, École de santé publique, Université de Montréal, 7101 ave du Parc, Montréal, Québec, H3N 1X9, Canada.
| | - Susan Usher
- École nationale d’administration publique, Montreal, Canada; Centre de recherche Charles-le-Moyne, Université de Sherbrooke, Longueuil, Canada
| | - Johanne Préval
- École nationale d’administration publique, Montreal, Canada; Centre de recherche du Centre hospitalier de l’Université de Montréal, Montreal, Canada
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Kesale AM, Mahonge C, Muhanga M. Effects of decentralization on the functionality of health facility governing committees in lower and middle-income countries: a systematic literature review. Glob Health Action 2022; 15:2074662. [PMID: 35960165 PMCID: PMC9377249 DOI: 10.1080/16549716.2022.2074662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 05/02/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Health facility governing committees (HFGCs) were established by lower and middle-income countries (LMICs) to facilitate community participation at the primary facility level to improve health system performance. However, empirical evidence on their effects under decentralization reform on the functionality of HFGCs is scant and inconclusive. OBJECTIVE This article reviews the effects of decentralization on the functionality of HFGCs in LMICs. METHODS A systematic literature review was conducted using various search engines to obtain a total number of 24 relevant articles from 14 countries published between 2000 and 2020. Inclusion criteria include studies must be on community health committees, carried out under decentralization, HFGCs operating at the individual facility, effects of HFGCs on health performance or health outcomes and peer-reviewed empirical studies conducted in LMICs. RESULTS The study has found varied functionality of HFGCs under a decentralization context. The study has found many HFGCs to have very low functionality, while a few HFGCs in other LMICs countries are performing very well. The context and decentralization type, members' awareness of their roles, membership allowance and availability of resource to the facility in which HFGCs operate to produce the desired outcomes play a significant role in facilitating/limiting them to effectively carry out the devolved duties and responsibilities. CONCLUSION Fiscal decentralization has largely been seen as important in making health committees more autonomous, even though it does not guarantee the performance of HFGCs.
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Affiliation(s)
- Anosisye M Kesale
- Department of Local Government Management, School of Public Administration and Management, Mzumbe University, Morogoro, Tanzania
| | - Christopher Mahonge
- Department of Policy Planning and Management, College of Social Sciences and Humanities, Sokoine University of Agriculture, Morogoro, Tanzania
| | - Mikidadi Muhanga
- Department of Development Studies, College of Social Sciences and Humanities, Sokoine University of Agriculture, Morogoro, Tanzania
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Witter S, Sheikh K, Schleiff M. Learning health systems in low-income and middle-income countries: exploring evidence and expert insights. BMJ Glob Health 2022; 7:bmjgh-2021-008115. [PMID: 36130793 PMCID: PMC9490579 DOI: 10.1136/bmjgh-2021-008115] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 02/16/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction Learning health systems (LHS) is a multifaceted subject. This paper reviewed current concepts as well as real-world experiences of LHS, drawing on published and unpublished knowledge in order to identify and describe important principles and practices that characterise LHS in low/middle-income country (LMIC) settings. Methods We adopted an exploratory approach to the literature review, recognising there are limited studies that focus specifically on system-wide learning in LMICs, but a vast set of connected bodies of literature. 116 studies were included, drawn from an electronic literature search of published and grey literature. In addition, 17 interviews were conducted with health policy and research experts to gain experiential knowledge. Results The findings were structured by eight domains on learning enablers. All of these interact with one another and influence actors from community to international levels. We found that learning comes from the connection between information, deliberation, and action. Moreover, these processes occur at different levels. It is therefore important to consider experiential knowledge from multiple levels and experiences. Creating spaces and providing resources for communities, staff and managers to deliberate on their challenges and find solutions has political implications, however, and is challenging, particularly when resources are constrained, funding and accountability are fragmented and the focus is short-term and narrow. Nevertheless, we can learn from countries that have managed to develop institutional mechanisms and human capacities which help health systems respond to changing environments with ‘best fit’ solutions. Conclusion Health systems are knowledge producers, but learning is not automatic. It needs to be valued and facilitated. Everyday governance of health systems can create spaces for reflective practice and learning within routine processes at different levels. This article highlights important enablers, but there remains much work to be done on developing this field of knowledge.
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Affiliation(s)
- Sophie Witter
- Institute for Global Health and Development & ReBUILD Consortium, Queen Margaret University Edinburgh, Edinburgh, UK
| | - Kabir Sheikh
- Alliance For Health Policy and System Research, Geneva, Switzerland
| | - Meike Schleiff
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
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Koduah A, Baatiema L, Kretchy IA, Agyepong IA, Danso-Appiah A, de Chavez AC, Ensor T, Mirzoev T. Powers, engagements and resultant influences over the design and implementation of medicine pricing policies in Ghana. BMJ Glob Health 2022; 7:bmjgh-2021-008225. [PMID: 35589156 PMCID: PMC9121428 DOI: 10.1136/bmjgh-2021-008225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 04/19/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction Universal availability and affordability of essential medicines are determined by effective design and implementation of relevant policies, typically involving multiple stakeholders. This paper examined stakeholder engagements, powers and resultant influences over design and implementation of four medicines pricing policies in Ghana: Health Commodity Supply Chain Master Plan, framework contracting for high demand medicines, Value Added Tax (VAT) exemptions for selected essential medicines, and ring-fencing medicines for local manufacturing. Methods Data were collected using reviews of policy documentation (n=16), consultative meetings with key policy actors (n=5) and in-depth interviews (n=29) with purposefully identified national-level policymakers, public and private health professionals including members of the National Medicine Pricing Committee, pharmaceutical wholesalers and importers. Data were analysed using thematic framework. Results A total of 46 stakeholders were identified, including representatives from the Ministry of Health, other government agencies, development partners, pharmaceutical industry and professional bodies. The Ministry of Health coordinated policy processes, utilising its bureaucratic mandate and exerted high influences over each policy. Most stakeholders were highly engaged in policy processes. Whereas some led or coproduced the policies in the design stage and participated in policy implementation, others were consulted for their inputs, views and opinions. Stakeholder powers reflected their expertise, bureaucratic mandates and through participation in national level consultation meetings, influences policy contents and implementation. A wider range of stakeholders were involved in the VAT exemption policies, reflecting their multisectoral nature. A minority of stakeholders, such as service providers were not engaged despite their interest in medicines pricing, and consequently did not influence policies. Conclusions Stakeholder powers were central to their engagements in, and resultant influences over medicine pricing policy processes. Effective leadership is important for inclusive and participatory policymaking, and one should be cognisant of the nature of policy issues and approaches to policy design and implementation.
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Affiliation(s)
- Augustina Koduah
- Pharmacy Practice and Clinical Pharmacy, University of Ghana School of Pharmacy, Legon, Accra, Ghana
| | - Leonard Baatiema
- Health Policy, Planning & Management, University of Ghana School of Public Health, Legon, Accra, Ghana
| | - Irene A Kretchy
- Pharmacy Practice and Clinical Pharmacy, University of Ghana School of Pharmacy, Legon, Accra, Ghana
| | - Irene Akua Agyepong
- Dodowa Health Research Centre, Ghana Health Service, Accra, Greater Accra, Ghana.,Faculty of Public Health, Ghana College of Physicians and Surgeons, Accra, Greater Accra, Ghana
| | - Anthony Danso-Appiah
- Epidemiology and Disease Control, University of Ghana School of Public Health, Legon, Accra, Ghana
| | - Anna Cronin de Chavez
- Global Health and Development, London School of Hygiene & Tropical Medicine, London, London, UK
| | - Timothy Ensor
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Tolib Mirzoev
- Global Health and Development, London School of Hygiene & Tropical Medicine, London, London, UK
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Kesale AM, Mahonge C, Muhanga M. The quest for accountability of Health Facility Governing Committees implementing Direct Health Facility Financing in Tanzania: A supply-side experience. PLoS One 2022; 17:e0267708. [PMID: 35482793 PMCID: PMC9049541 DOI: 10.1371/journal.pone.0267708] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 04/13/2022] [Indexed: 12/02/2022] Open
Abstract
User committees, such as Health Facility Governing Committees, are popular platforms for representing communities and civil society in holding service providers accountable. Fiscal decentralization via various arrangements such as Direct Health Facility Financing is thought to strengthen Health Facility Governing Committees in improving accountability in carrying out the devolved tasks and mandates. The purpose of this study was to analyze the status of accountability of Health Facility Governing Committees in Tanzania under the Direct Health Facility Financing setting as perceived by the supply side. In 32 different health institutions, a cross-sectional design was used to collect both qualitative and quantitative data at one point in time. Data was collected through a closed-ended questionnaire, an in-depth interview, and a Focus Group Discussion. Descriptive statistics, multiple logistic regression, and theme analysis were used to analyze the data. According to the findings, Health Facility Governing Committees' accountability is 78%. Committees have a high level of accountability in terms of encouraging the community to join community health funds (91.71%), receiving medicines and medical commodities (88.57%), and providing timely health services (84.29%). The health facility governance committee's responsibility was shown to be substantially connected with the health planning component (p = 0.0048) and the financial management aspect (p = 0.0045). This study found that the fiscal decentralization setting permits Committees to be accountable for carrying out their obligations, resulting in improved health service delivery in developing nations.
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Affiliation(s)
- Anosisye Mwandulusya Kesale
- Department Local Government Management, School of Public Administration and Management, Mzumbe University, Mzumbe University-Morogoro, Morogoro, Tanzania
| | - Christopher Mahonge
- Department of Policy Planning and Management, Sokoine University of Agriculture, College of Social Sciences and Humanities, Morogoro, Tanzania
| | - Mikidadi Muhanga
- Department of the Development Studies-Sokoine University of Agriculture, College of Social Sciences and Humanities, Morogoro, Tanzania
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Kesale AM, Mahonge CP, Muhanga M. The functionality of health facility governing committees and their associated factors in selected primary health facilities implementing direct health facility financing in Tanzania: A mixed‐method study. Health Sci Rep 2022; 5:e611. [PMID: 35509407 PMCID: PMC9059188 DOI: 10.1002/hsr2.611] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 03/20/2022] [Accepted: 03/22/2022] [Indexed: 11/13/2022] Open
Abstract
Background In Lower and Middle‐Income Countries (LMICs), decentralization has dominated the agenda for reforming the organization of service delivery (LMICs). The fiscal decentralization challenge is a hard one for decentralization. As they strive to make decisions and use health facility funding, primary healthcare facilities encounter the obstacles of fiscal decentralization. LMICs are currently implementing fiscal decentralization reforms to empower health facilities and their Health Facility Governing Committees (HFGCs) to improve service delivery. Given the scarcity of systematic evidence on the impact of fiscal decentralization, this study examined the functionality of HFGCs and their associated factors in primary healthcare facilities in Tanzania that were implementing fiscal decentralization through Direct Health Facility Financing (DHFF). Methods To collect both qualitative and quantitative data, a cross‐sectional approach was used. The research was carried out in 32 primary healthcare facilities in Tanzania that were implementing the DHFF. A multistage sample approach was utilized to pick 280 respondents, using both probability and nonprobability sampling procedures. A structured questionnaire, in‐depth interviews, and focus group discussions were used to gather data. The functionality of HFGCs was determined using descriptive analysis, and associated factors for the functioning of HFGCs were determined using binary logistic regression. Thematic analysis was used to do qualitative research. Result HFGC functionality under DHFF has been found to be good by 78.57%. Specifically, HFGCs have been found to have good functionality in mobilizing communities to join Community Health Funds 87.14%, participating in the procurement process 85%, discussing community health challenges 81.43% and planning and budgeting 80%. The functionality of HFGCs has been found to be associated with the planning and budgeting aspects p value of 0.0011, procurement aspects p value 0.0331, availability of information reports p value 0.0007 and Contesting for HFGC position p value 0.0187. Conclusion The study found that fiscal decentralization via DHFF increases the functionality of HFGCs significantly. As a result, the report proposes that more effort be placed into making financial resources available to health facilities.
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Affiliation(s)
- Anosisye Mwandulusya Kesale
- Department of Local Government Management, School of Public Administration and Management Mzumbe University Morogoro Tanzania
| | - Christopher Paul Mahonge
- Department of Policy Planning and Management, College of Social Sciences and Humanities Sokoine University of Agriculture Morogoro Tanzania
| | - Mikidadi Muhanga
- Department of the Development Studies Sokoine University of Agriculture Morogoro Tanzania
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Hospital physicians' experiences and reflections on their work and role in relation to older patients' pathways - a qualitative study in two Norwegian hospitals. BMC Health Serv Res 2022; 22:443. [PMID: 35382820 PMCID: PMC8981867 DOI: 10.1186/s12913-022-07846-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 03/24/2022] [Indexed: 11/25/2022] Open
Abstract
Background Older patients are the most frequent users of initial hospital admissions and readmissions. Both hospital admission and discharge require communication and coordination between healthcare professionals within the hospital, and between professionals in hospitals and primary healthcare. We have identified few studies exploring hospital physicians’ perspectives on older patients’ pathways in the interface between hospital and primary healthcare services. The aim of this study was to explore hospital physicians’ experiences and reflections on their work and role in relation to older patients’ pathways between hospital and primary healthcare. Specifically, we focused on the challenges they faced and how they dealt with these in relation to admission and discharge, and their suggestions for service improvements that could facilitate older patients’ pathway. Methods We used a qualitative approach, conducting individual in-depth interviews with 18 hospital physicians from two hospitals in eastern Norway. Data were analyzed using systematic text condensation, in line with a four-step prosedure developed by Malterud. Results The participants emphasized challenges in the communication about patients across the two service levels. Moreover, they described being in a squeeze between prioritizing patients and trying to ensure a proper flow of patients through the hospital wards, but with restricted possibilities to influence on the admissions. They also described a frustration regarding the lack of influence on the healthcare delivery after discharge. The participants had various suggestions for service improvements which might be beneficial to older patients. Conclusions The results demonstrate that the hospital physicians perceived being squeezed between professional autonomy and limited capacity at the hospital, and between their medical judgement as a specialist and their power to decide on hospital admissions for old patients and also on the delivery of health care services to patients after discharge. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07846-1.
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Madon S, Krishna S. Theorizing Community Health Governance for Strengthening Primary Healthcare in LMICs. Health Policy Plan 2022; 37:706-716. [PMID: 35077543 PMCID: PMC9189612 DOI: 10.1093/heapol/czac002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 01/10/2022] [Accepted: 01/24/2022] [Indexed: 11/17/2022] Open
Abstract
In recent years, community health governance structures have been established in many low and middle-income countries (LMICs) as part of decentralization policies aimed at strengthening primary healthcare systems. So far, most studies on these local structures either focus on measuring their impact on health outcome or on identifying the factors that affect their performance. In this paper we offer an alternative contribution that draws on a sociological interpretation of community health governance to improve understanding of how the government’s policy vision and instrumentation translate to interactions that take place within local spaces at field level. We study 13 Village Health Sanitation and Nutrition Committees (VHSNCs) in Karnataka, India, from 2016 to 2018 focusing on sanitation, nutrition and hygiene which remain impediments to improving primary healthcare amongst poor and marginalized communities. Three local governance mechanisms of horizontal coordination, demand for accountability and self-help help to explain improvements that have taken place at village level and contribute to the creation of a new theory of community health governance as evolving phenomenon that requires a constant process of learning from the field to strengthen policymaking.
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Affiliation(s)
- Shirin Madon
- *Corresponding author. Department of International Development/Department of Management, London School of Economics & Political Science, London WC2A 2AE, UK. E-mail:
| | - S Krishna
- Foundation for Research in Health Systems and Indian Institute of Management, Bangalore, India
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Vasudevan H. Management and Leadership in the Klang Valley IT Sector: Conceptual Approach. MARKETING AND MANAGEMENT OF INNOVATIONS 2022. [DOI: 10.21272/mmi.2022.3-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The aim is to conceptualize what makes for effective leadership in the Klang Valley IT sector. All industries need effective leadership; it ought to be brought up in the workplace. Employee motivation and performance could be improved through effective leadership. Additionally, employees are more committed to the organization, while lowers the turnover rate. Under successful leadership, an organization’s output and revenue can increase. The unethical behaviour by leaders who lack drive, confidence, foresight, and communication skills affects most industries. Perhaps these traits (ethics, motivation, trustworthiness, vision, and good communication) put things in perspective and provide direction as the author takes this challenging journey through a setting that only gets trickier as the person rises to the leadership level within the firm. This study will be able to improve leadership effectiveness through the issues’ goals. About 225 thousand people were working in the Malaysian IT sector. Each hypothesis has been observed and demonstrated. The substantial result was supported for each hypothesis from the previous study. In this instance, the conceptualized study has assessed and carried out fundamental analyses like descriptive, reliability, and validity analysis to determine how dependable the variables are for future research. The findings show that these dimensions (ethics, motivation, trust, vision, and good communication skills) are the essential elements of effective leadership. This study gave organizations and sectors reasons to raise employee levels of effective leadership to meet organizational goals and improve the attitudes and behaviours of leaders. Although there are many opportunities for exciting theoretical advancement and significant policy ramifications in this field of study, strict ethical guidelines must follow to have effective leadership quality in the IT sector. The novel aspect of this study is vision, which is a crucial element of the new leadership strategy. Followers and changes are prepared for their vision and are always necessary for this method.
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Clifford KR, Cravens AE, Knapp CN. Responding to Ecological Transformation: Mental Models, External Constraints, and Manager Decision-Making. Bioscience 2021. [DOI: 10.1093/biosci/biab086] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Ecological transformation creates many challenges for public natural resource management and requires managers to grapple with new relationships to change and new ways to manage it. In the context of unfamiliar trajectories of ecological change, a manager can resist, accept, or direct change, choices that make up the resist-accept-direct (RAD) framework. In this article, we provide a conceptual framework for how to think about this new decision space that managers must navigate. We identify internal factors (mental models) and external factors (social feasibility, institutional context, and scientific uncertainty) that shape management decisions. We then apply this conceptual framework to the RAD strategies (resist, accept, direct) to illuminate how internal and external factors shape those decisions. Finally, we conclude with a discussion of how this conceptual framework shapes our understanding of management decisions, especially how these decisions are not just ecological but also social, and the implications for research and management.
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Affiliation(s)
- Katherine R Clifford
- Postdoctoral social science research fellow, Fort Collins, Colorado, United States
| | - Amanda E Cravens
- US Geological Survey's Social and Economic Analysis Branch, Fort Collins, Colorado, United States
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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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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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Martinussen PE, Rydland HT. Is a Decentralised Health Policy Associated With Better Self-rated Health and Health Services Evaluation? A Comparative Study of European Countries. Int J Health Policy Manag 2021; 10:55-66. [PMID: 32610745 PMCID: PMC7947669 DOI: 10.34172/ijhpm.2020.13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 01/25/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND While decentralisation has come to be a major policy strategy in many healthcare systems, there is still insufficient evidence about its impact. Most studies have been of developing countries, and they have provided mixed results. This study is the first to test the relevance of political decentralisation across European countries, thus meeting the demand for more studies of decentralisation in developed countries, and building on an indicator of decentralisation reflecting the allocation of authority for both health policy tasks and health policy areas. METHODS As indicators of health system outcome, we employed 2 measures that have not previously been investigated in the context of decentralisation: self-rated health and satisfaction with healthcare system. Using multilevel modelling and controlling for individual-level demographic and socioeconomic variables, the paper utilised the 2014 (7th) and 2016 (8th) round of the European Social Survey (ESS), including more than 70 000 individuals from 20 countries. RESULTS The results suggest that decentralisation has a positive and significant association with health system satisfaction, but not with self-rated health. Of the different operationalisations, decentralised healthcare provision had the strongest association with health system satisfaction. CONCLUSIONs Our study fails to provide clear support for decentralised health systems. There is a need for more research on the impact of such reforms in order to provide policy-makers with knowledge of desirable governance, organisational designs, management and incentives in healthcare.
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Affiliation(s)
- Pål E. Martinussen
- Department of Sociology and Political Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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18
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Bhattacharyya S, Issac A, Girase B, Guha M, Schellenberg J, Iqbal Avan B. "There Is No Link Between Resource Allocation and Use of Local Data": A Qualitative Study of District-Based Health Decision-Making in West Bengal, India. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17218283. [PMID: 33182464 PMCID: PMC7665146 DOI: 10.3390/ijerph17218283] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/28/2020] [Accepted: 10/28/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Effective coordination among multiple departments, including data-sharing, is needed for sound decision-making for health services. India has a district planning process involving departments for local resource-allocation based on shared data. This study assesses the decision-making process at the district level, with a focus on the extent of local data-use for resource allocation for maternal and child health. METHODS Direct observations of key decision-making meetings and qualitative interviews with key informants were conducted in two districts in the State of West Bengal, India. Content analysis of the data maintained within the district health system was done to understand the types of data available and sharing mechanisms. This information was triangulated thematically based on WHO health system blocks. RESULTS There was no structured decision-making process and only limited inter-departmental data-sharing. Data on all 21 issues discussed in the district decision-making meetings observed were available within the information systems. Yet indicators for only nine issues-such as institutional delivery and immunisation services were discussed. Discussions about infrastructure and supplies were not supported by data, and planning targets were not linked to health outcomes. CONCLUSION Existing local data is highly under-used for decision-making at the district level. There is strong potential for better interaction between departments and better use of data for priority-setting, planning and follow-up.
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Affiliation(s)
- Sanghita Bhattacharyya
- Public Health Foundation of India, Gurgaon, Haryana 122002, India; (S.B.); (A.I.); (B.G.); (M.G.)
| | - Anns Issac
- Public Health Foundation of India, Gurgaon, Haryana 122002, India; (S.B.); (A.I.); (B.G.); (M.G.)
| | - Bhushan Girase
- Public Health Foundation of India, Gurgaon, Haryana 122002, India; (S.B.); (A.I.); (B.G.); (M.G.)
| | - Mayukhmala Guha
- Public Health Foundation of India, Gurgaon, Haryana 122002, India; (S.B.); (A.I.); (B.G.); (M.G.)
| | - Joanna Schellenberg
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK;
| | - Bilal Iqbal Avan
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK;
- Correspondence:
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Gilson L, Ellokor S, Lehmann U, Brady L. Organizational change and everyday health system resilience: Lessons from Cape Town, South Africa. Soc Sci Med 2020; 266:113407. [PMID: 33068870 PMCID: PMC7538378 DOI: 10.1016/j.socscimed.2020.113407] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 09/26/2020] [Accepted: 09/28/2020] [Indexed: 02/04/2023]
Abstract
This paper reports a study from Cape Town, South Africa, that tested an existing framework of everyday health system resilience (EHSR) in examining how a local health system responded to the chronic stress of large-scale organizational change. Over two years (2017–18), through cycles of action-learning involving local managers and researchers, the authorial team tracked the stress experienced, the response strategies implemented and their consequences. The paper considers how a set of micro-governance interventions and mid-level leadership practices supported responses to stress whilst nurturing organizational resilience capacities. Data collection involved observation, in-depth interviews and analysis of meeting minutes and secondary data. Data analysis included iterative synthesis and validation processes. The paper offers five sets of insights that add to the limited empirical health system resilience literature: 1) resilience is a process not an end-state; 2) resilience strategies are deployed in combination rather than linearly, after each other; 3) three sets of organizational resilience capacities work together to support collective problem-solving and action entailed in EHSR; 4) these capacities can be nurtured by mid-level managers’ leadership practices and simple adaptations of routine organizational processes, such as meetings; 5) central level actions must nurture EHSR by enabling the leadership practices and micro-governance processes entailed in everyday decision-making. Resilience to chronic stress will prepare health systems to face acute shocks. Collective problem-solving and sensemaking enable everyday resilience. Distributed leadership, feeling safe and reflective practice are key processes. New forms of health system strengthening are needed to nurture resilience.
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Affiliation(s)
- Lucy Gilson
- Health Policy and Systems Division, School of Public Health, University of Cape Town, South Africa; Department of Global Health and Development, London School of Hygiene and Tropical Medicine, UK.
| | - Soraya Ellokor
- CityHealth, City of Cape Town Metropolitan Municipality, South Africa
| | - Uta Lehmann
- School of Public Health, University of the Western Cape, South Africa
| | - Leanne Brady
- Health Policy and Systems Division, School of Public Health, University of Cape Town, South Africa; Emergency Medical Services, Western Cape Government: Health, South Africa
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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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Abimbola S, Baatiema L, Bigdeli M. The impacts of decentralization on health system equity, efficiency and resilience: a realist synthesis of the evidence. Health Policy Plan 2019; 34:605-617. [PMID: 31378811 PMCID: PMC6794566 DOI: 10.1093/heapol/czz055] [Citation(s) in RCA: 96] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2019] [Indexed: 10/28/2022] Open
Abstract
One constant refrain in evaluations and reviews of decentralization is that the results are mixed. But given that decentralization is a complex intervention or phenomenon, what is more important is to generate evidence to inform implementation strategies. We therefore synthesized evidence from the literature to understand why, how and under what circumstances decentralization influences health system equity, efficiency and resilience. In doing this, we adopted the realist approach to evidence synthesis and included quantitative and qualitative studies in high-, low- and middle-income countries that assessed the the impact of decentralization on health systems. We searched the Medline and Embase databases via Ovid, and the Cochrane library of systematic reviews and included 51 studies with data from 25 countries. We identified three mechanisms through which decentralization impacts on health system equity, efficiency and resilience: 'Voting with feet' (reflecting how decentralization either exacerbates or assuages the existing patterns of inequities in the distribution of people, resources and outcomes in a jurisdiction); 'Close to ground' (reflecting how bringing governance closer to the people allows for use of local initiative, information, feedback, input and control); and 'Watching the watchers' (reflecting mutual accountability and support relations between multiple centres of governance which are multiplied by decentralization, involving governments at different levels and also community health committees and health boards). We also identified institutional, socio-economic and geographic contextual factors that influence each of these mechanisms. By moving beyond findings that the effects of decentralization on health systems and outcomes are mixed, this review presents mechanisms and contextual factors to which policymakers and implementers need to pay attention in their efforts to maximize the positive and minimize the negative impact of decentralized governance.
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Affiliation(s)
- Seye Abimbola
- School of Public Health, Faculty of Medicine and Health, University of Sydney, NSW, Australia
- National Primary Health Care Development Agency, Abuja, FCT, Nigeria
- The George Institute for Global Health, Sydney, NSW, Australia
- Health Systems Governance Collaborative, Department of Health Systems Governance and Financing, World Health Organization, Avenue Appia 20, Geneva, Switzerland
| | - Leonard Baatiema
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Accra, Ghana
| | - Maryam Bigdeli
- Health Systems Governance Collaborative, Department of Health Systems Governance and Financing, World Health Organization, Avenue Appia 20, Geneva, Switzerland
- World Health Organization, 3 Avenue S.A.R. Sidi Mohamed, Rabat, Morocco
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Kigume R, Maluka S. Health sector decentralisation in Tanzania: Analysis of decision space in human resources for health management. Int J Health Plann Manage 2019; 34:1265-1276. [DOI: 10.1002/hpm.2792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 03/29/2019] [Accepted: 04/01/2019] [Indexed: 11/08/2022] Open
Affiliation(s)
- Ramadhani Kigume
- Department of History, Political Science and Development Studies Dar es Salaam University College of Education Dar es Salaam Tanzania
| | - Stephen Maluka
- Institute of Development Studies University of Dar es Salaam Dar es Salaam Tanzania
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Kigume R, Maluka S. Decentralisation and Health Services Delivery in 4 Districts in Tanzania: How and Why Does the Use of Decision Space Vary Across Districts? Int J Health Policy Manag 2019; 8:90-100. [PMID: 30980622 PMCID: PMC6462210 DOI: 10.15171/ijhpm.2018.97] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 09/29/2018] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Decentralisation in the health sector has been promoted in low- and middle-income countries (LMICs) for many years. Inherently, decentralisation grants decision-making space to local level authorities over different functions such as: finance, human resources, service organization, and governance. However, there is paucity of studies which have assessed the actual use of decision-making space by local government officials within the decentralised health system. The objective of this study was to analyse the exercise of decision space across 4 districts in Tanzania and explore why variations exist amongst them. METHODS The study was guided by the decision space framework and relied on interviews and documentary reviews. Interviews were conducted with the national, regional and district level officials; and data were analysed using thematic approach. RESULTS Decentralisation has provided moderate decision space on the Community Health Fund (CHF), accounting for supplies of medicine, motivation of health workers, additional management techniques and rewarding the formally established health committees as a more effective means of community participation and management. While some districts innovated within a moderate range of choice, others were unaware of the range of choices they could utilise. Leadership skills of key district health managers and local government officials as well as horizontal relationships at the district and local levels were the key factors that accounted for the variations in the use of the decision space across districts. CONCLUSION This study concludes that more horizontal sharing of innovations among districts may contribute to more effective service delivery in the districts that did not have active leadership. Additionally, the innovations applied by the best performing districts should be incorporated in the national guidelines. Furthermore, targeted capacity building activities for the district health managers may improve decision-making abilities and in turn improve health system performance.
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Affiliation(s)
- Ramadhani Kigume
- Department of History, Political Science & Development Studies, Dar es Salaam University College of Education, Dar es Salaam, Tanzania
| | - Stephen Maluka
- Institute of Development Studies, University of Dar es Salaam, Dar es Salaam, Tanzania
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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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Kigume R, Maluka S. Health sector decentralisation in Tanzania: How do institutional capacities influence use of decision space? Int J Health Plann Manage 2018; 33:e1050-e1066. [PMID: 30052278 DOI: 10.1002/hpm.2587] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 06/29/2018] [Indexed: 11/11/2022] Open
Abstract
While decentralisation of health systems has dominated political arena in the low-income and middle-income countries since the 1970s, there is scarcity of studies on how organisational capacities influence the ability of the decentralised local-level officials to use the available decision space. Using qualitative approach through in-depth interviews and focus group discussions in 4 districts in Tanzania, this study explored how organisational capacities influence the use of decision space available in the 5 broad categories namely planning, finance, human resources, service organisation, and governance. The findings of the study indicated that while the district health managers had authority in many health system functional areas, limited capacity of the local government in financial resources highly affected their capacity to make use of the available decision space. In addition, while the district health managers had skills, knowledge, and experiences in preparing district health plans, health facilities and community representatives had limited capacity. Most of the health facilities had critical shortage of skilled health providers. Similarly, health committees had limited capacity in knowledge and skills. This study concludes that decentralisation will only improve delivery of health services when an appropriate degree of discretion is combined with adequate institutional capacities to enable exercise of those authorities. The district councils and the Ministry of Health should strengthen the capacities of health service providers and members of health committees and boards.
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Affiliation(s)
- Ramadhani Kigume
- Department of History, Political Science and Development Studies, Dar es Salaam University College of Education, Dar es Salaam, Tanzania
| | - Stephen Maluka
- Institute of Development Studies, University of Dar es Salaam, Dar es Salaam, Tanzania
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Kigume R, Maluka S, Kamuzora P. Decentralisation and health services delivery in Tanzania: Analysis of decision space in planning, allocation, and use of financial resources. Int J Health Plann Manage 2018. [DOI: 10.1002/hpm.2511] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Ramadhani Kigume
- Department of History, Political Science and Development StudiesDar es Salaam University College of Education Dar es Salaam Tanzania
| | - Stephen Maluka
- Institute of Development StudiesUniversity of Dar es Salaam Dar es Salaam Tanzania
| | - Peter Kamuzora
- Institute of Development StudiesUniversity of Dar es Salaam Dar es Salaam Tanzania
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Kwamie A, Asiamah M, Schaaf M, Agyepong IA. Postings and transfers in the Ghanaian health system: a study of health workforce governance. Int J Equity Health 2017; 16:85. [PMID: 28911337 PMCID: PMC5599893 DOI: 10.1186/s12939-017-0583-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 05/12/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Decision-making on postings and transfers - that is, the geographic deployment of the health workforce - is a key element of health workforce governance. When poorly managed, postings and transfers result in maldistribution, absenteeism, and low morale. At stake is managing the balance between organisational (i.e., health system) and individual (i.e., staff preference) needs. The negotiation of this potential convergence or divergence of interests provides a window on practices of postings and transfers, and on the micro-practices of governance in health systems more generally. This article explores the policies and processes, and the interplay between formal and informal rules and norms which underpin postings and transfers practice in two rural districts in the Greater Accra Region of Ghana. METHODS Semi-structured interviews were conducted with eight district managers and 87 frontline staff from the district health administration, district hospital, polyclinic, health centres and community outreach compounds across two districts. Interviews sought to understand how the postings and transfers process works in practice, factors in frontline staff and district manager decision-making, personal experiences in being posted, and study leave as a common strategy for obtaining transfers. RESULTS Differential negotiation-spaces at regional and district level exist and inform postings and transfers in practice. This is in contrast to the formal cascaded rules set to govern decision-making authority for postings and transfers. Many frontline staff lack policy clarity of postings and transfers processes and thus 'test' the system through informal staff lobbying, compounding staff perception of the postings and transfers process as being unfair. District managers are also challenged with limited decision-space embedded in broader policy contexts of systemic hierarchy and resource dependence. This underscores the negotiation process as ongoing, rather than static. CONCLUSIONS These findings point to tensions between individual and organisational goals. This article contributes to a burgeoning literature on postings and transfers as a distinct dynamic which bridges the interactions between health systems governance and health workforce development. Importantly, this article helps to expand the notion of health systems governance beyond 'good' governance towards understanding governance as a process of negotiation.
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Affiliation(s)
- Aku Kwamie
- Ghana Health Service, Research and Development Division, Ministries, P.O. Box MB190, Accra, Ghana
| | | | - Marta Schaaf
- Averting Maternal Death & Disability Program (AMDD) Heilbrunn Department of Population and Family Health Mailman School of Public Health, Columbia University, New York, USA
| | - Irene Akua Agyepong
- Ghana Health Service, Research and Development Division, Ministries, P.O. Box MB190, Accra, Ghana
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