Three blogs on 'How can governance be strengthened in decentralised health systems'

Thursday, 30 Oct 2014

Blog 1:

What decision space or room for manoeuvre is available to health service managers within decentralised contexts and what key factors influence this?

Sally Theobald; ; #performconsortium

This question was interrogated during a participatory panel at health systems global hosted by the PERFORM project. PERFORM deploys participatory action research approaches to make better use of the current health workforce through supporting integrated human resource and management strategies. PERFORM is taking place in 3 decentralised African settings– Tanzania, Uganda and Ghana – where  District Health Management Teams (DHMTs) have some autonomy and decision space in certain areas  for action.

A view from Jinja: Dyogo Nantamu, the District Health Officer from Jinja, Uganda kicked off by outlining the structures and roles of the DHMT within his district. The core functions of the DHMT include planning, M&E, HRH deployment, mentorship, training, supervision and rewards and sanctions of staff. They have the autonomy to decide on staff appraisal, posting, rewards and sanctions but not recruitment, dismissal, promotion/demotion or determination of pay for staff. Within PERFORM Dyogo and team with the support of the Country Research team from Makerere School of Public Health undertook a problem analysis to identify and address the problems emerging, namely the need to improve training, mentoring and coaching and orient those in charge on the benefits of appraisal and sensitise staff on appraisal. Dyogo explained that “Most of us when we leave university - we are put in charge of others without necessarily having the training or reflection space of best ways to do this”. Innovations taken forward in Jinja District include using registers to improve availability of staff, improving appraisal and partnering with a local bank who financially backed an induction process for new starters in return for being able to market their services to them. The constraints faced included limited or late funding and the need to make more strategic changes to the traditional appraisal system. Dyogo reflected that “PERFORM has helped us to look at things differently – and think about how to use the lens of performance to improve performance. “

Maximising decision space requires strategic team work: Soraya Elloker, sub-district manager, City of Cape Town and member of the Health Systems Research: District Innovation, Action and Learning for Health System Development (DIAHLS Project ) highlighted the importance of team work, leadership and buy-in to take decisions back to the coal face, implement them and make them meaningful. She said “we have lots of decision space – what’s important is how we make these decisions and the evidence we draw on, how we engage our staff and other members of the DHMT and persuade them that this is a good decision, and how we use all our spaces for learning in this process... I’ve made many decision and few were implemented… Decisions have consequences and reflecting what went wrong or right and analysing the impact on the community we are serving is important. How do we ensure that the decision doesn’t evaporate? How do we make it meaningful? We learn through the process and the challenge is to continue to take the team with you.”

Context and power are key: Sreytouch Vong from the Cambodia Development Research Institute highlighted the importance of understanding the social cultural and political context for decision making space and how this is realised or constrained in practice.  Vathanak Khim also from Cambodia said that decentralisation  may be the official policy and written down but the reality is that this is constrained by the dictates that come from above.  Aaron Black, from the Health policy project in Kenya also highlighted the importance of context in the Kenyan transition to a devolved system of governance and their learning here. He said that politics and resources are key, arguing that politicians want to invest in hardware and that you can have “a huge decisions space but if there is no money or resources the decision space is redundant.” Dyogo agreed saying that politics within organisation play the biggest role and how we manage those determines whether you will succeed. Stefan Peters from Makerere University, Uganda and the Karolinska Institute also referred to power “as the elephant in the room, or the whale as we are in Cape Town” arguing that power and politics ultimately constrains or opens decision making space.

PERFORM will continue to document and share lessons on ways in which DHMTs can be best supported to seize decision space to support health systems strengthening at district level. Please continue to share your ideas and experiences with us  - ; #performconsortium

Blog 2

How can managers and their teams be supported through workshops and mentoring to use their management decision space?

The best ways to support managers at district level to claim and use management decision space to strengthen health systems was an area of debate during a panel hosted by the PERFORM project at the Health Systems Global Conference in Cape Town. PERFORM deploys participatory action research approaches at district level to make better use of the current health workforce through supporting integrated human resource and management strategies. PERFORM is taking place in 3 decentralised African settings– Tanzania, Uganda and Ghana and conducting a comparative analysis across districts and countries to identify strategic management strengthening interventions for integrating HR strategies and identifying unintended consequences.  

The PERFORM Ghana experience: Patricia Akweongo, University of Ghana presented on her experience of being part of the Country Research Team (CRT) that supported DMHTs to undertake a reflective action research process to improve workforce performance in 3 Ghanaian districts. She explained how the CRTs supported DHMTs to identify problems and integrate them into district plans. They prioritised the problems they wanted to address and used an iterative process to review the cause and effect of each of the problems and in many cases these related to time and staff’s ability to proactively deliver on their key tasks. For example in Upper Manya Krobo the main problem is low coverage in ANC and maternal health, women are not attending these vital services and there are problems with the roads and the community health officers tasked with service delivery were not following the protocol as they didn’t have appropriate transport. They had a contract with the local taxi office who dropped them off where they needed to be but didn’t always pick them up in time which constrained the ability of CHOs to both plan deliver on their vital work.  DHMTs also highlighted how much of their time was taken up receiving visitors or waiting to receive visitors. In both cases solution were found within the district using their own resources and initiative – in the former case the taxis were requested to be more timely and in the latter and district vehicle scheduled to drop them off  early while alternative arrangements were made to pick them up later. DHMTs where possible minimised hosting visitors and also used waiting time productively on other tasks.  Patricia highlighted the importance for sustainability and ownership of identifying and solving problems at district level and with funding available at district level.

Models for mentoring: Kaspar Wyss  from the Swiss TPH explained that most managers at district level are medically trained and don’t have exposure to HRH management skill and approaches and that these are really crucial and needs to be a focus of mentoring and support. Soraya Elloker stressed the importance of mentoring for implementers and the challenges in identifying appropriate mentors and argued that academic institutions can help with mentorship here by bringing different skills and perspectives and upgrading staff through these training and that this has worked well in the DIAHLS project. In addition to mentoring she stated there is need for further fora and mechanisms to share good practice and that there are not enough conferences for implementers.  Others also highlighted the importance of developing partnerships for mentoring and that NGOs civil society, who have experience with the wider social determinants of health can offer critical expertise to support mentoring. Other options for mentoring and management that were suggested from the audience included critical incident review and failure review.

Blog 3:

How can good practice be shared across decentralised structure to improve governance structures more widely?

The importance of supporting sustained work at the district level came out loud and clear at the Health Systems Global panel “How can governance be strengthened in decentralised health systems? Lessons from Ghana, Tanzania and Uganda”. Districts where health systems are realised.  Discussant Delanyo Dovlo from WHO, AFRO argued that the district is the point where we can move and improve the health systems, and that they are critical to how health systems work and that districts need to feel comfortable in solving their own problems. He stated that the current Ebola crisis has brought this clearly to the forefront by highlighting the frequently absent or collapsed links between districts and communities. He stated that “The challenges lie in ensuring that ongoing improvement at district level becomes part of standard practice - What are the incentives for a district to continue doing this? How do we capture and understand the wider context of governance? We are all part of a system that is interwoven so we need to move it all together for impact”.  Bruno Meessen, concurred on the importance of the district and said he was delighted to see so many people at a session on districts “which have been forgotten for a while”. He explained that the community of practice he is involved with organised a celebration last year in West Arica to recognise 25 years of action at the district level. Too often the district is understood as a bureaucratic structure and the reality of coordinating multiple players and pushing forward action is lost. Bruno said that we require partnership and leadership to move this vision forward and that  “ we have an online forum and we have a blog and we try and mobilise actors for this agenda. We must unite in this complex area”

Sharing practice within country contexts: Reinhard Huss from the University of Leeds outlined the engagement strategies take forward to date in PERFORM project . These include the appointment of multi-stakeholder Country research advisory groups in Uganda, Tanzania and Ghana to both learn from and inform good practice across the country. In each country setting all three participating districts had shared practice through joint DHMT workshops and meetings and in Uganda this has also included use of facebook and newsheets. Anthony Ofosu Armah from the Ghana Health Service highlighted the importance of immersion and learning across and between contexts within a country saying “if you can move a district team that is not doing too well into another district not doing so well – it changes how they work through seeing the work being done by their own peers – it’s a very good method to learn and better done in your own country context”.  This point was also echoed by Navy Mulou  from Papua New Guinea who reflected on the challenges of working in a country with much diversity – over 800 languages and more than 1000 tribes. They are in the process of trying to introduce facility based planning and budgeting and supporting leadership and management at the district level. They are specifically targeting districts which are not doing well and also exposing them to structures and processes which are working better.

Strategic positioning in a crowded field:  Reinhard reflected that we are working in a crowded field and like the health systems conference itself there are many options/session we may want to pursue and many competing priorities. PERFORM works within this crowded arena and through deploying action research as district strategy supports what district management teams do all the time –identify and solve problems through their own budgets and within their room for manoeuvre and through making strategic alliances as where and when appropriate.