How can governance, decision-making and health worker performance be improved in decentralised health systems?

What decision space do health service managers have, and what affects this?

How can governance, decision-making and health worker performance be improved in decentralised health systems?

By Sally Theobald, ReBUILD consortium

What decision space do health service managers have, and what affects this? How can support and mentoring help managers to better use their decision space? How can good practice be shared to improve decentralised governance structures more widely?

These are some of the questions discussed in an engaging panel session in the recent Global Symposium on Health Systems Research in Cape Town. Participants from a wide range of contexts in Africa and Asia contributed to the rich discussion. There was agreement on many key issues, both on constraints and on promising ways of addressing these constraints and improving health worker performance. Above all, there was a desire to continue to share experiences and learning, through existing and new networks, and to support District Health Management Teams and others in improved governance and decision making.

Discussing decision space Soraya Elloker, sub-district manager, City of Cape Town, and member of Health Systems Research: District Innovation, Action and Learning for Health System Development (DIAHLS) Project, explained “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 persuade them that this is a good decision….” But decision space is also shaped by politics, power and resources. Aaron Black, from the Health policy project in Kenya said that politics and resources are key, and that you can have “a huge decisions space but if there is no money or resources the decision space is redundant.” Stefan Peters from Makerere University and the Karolinska Institute summed up nicely: Power was “the elephant in the room, or the whale as we are in Cape Town!

Patricia Akweongo, University of Ghana, described her experience with the PERFORM project in supporting and mentoring DMHTs to undertake a reflective action research process to improve workforce performance. Having identified problems and linked them into district plans the problems were prioritised using an iterative process to review cause and effect. In many cases these related to time and staff’s ability to proactively deliver on key tasks. In one area, for example, poor roads and transport challenges were constraining health officers’ ability to both plan deliver on their vital work.  Time was also taken up receiving (or waiting to receive) visitors. In both cases, solutions to these problems were identified through the reflective action process, and a degree of ownership of the problem and of having solved it at district level, was engendered.

Districts are where health systems are realised and are central to good practice to support decentralised governance structures.  Delanyo Dovlo (World Health Organization Regional Office for Africa) argued that the district is the point where we can move and improve the health systems, and that districts need to feel comfortable in solving their own problems. “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? … We are all part of a system that is interwoven so we need to move it all together for impact”. The Ebola crisis has brought this to the fore, highlighting the frequently absent or collapsed links between districts and communities.

Districts “…have been forgotten for a while.Bruno Meessen, concurring on the importance of the district, was delighted to see so many people at a session on districts. A community of practice he is involved with in West Africa celebrated 25 years of action at the district level last year. Partnership and leadership would move this vision forward. With an online forum and blog, he is trying to mobilise more actors: “We must unite in this complex area.

The session was hosted by the PERFORM project which is working in three decentralised African settings (Tanzania, Uganda and Ghana) where District Health Management Teams (DHMTs) have some autonomy and decision space in certain areas  for action. PERFORM uses participatory action research approaches to make better use of the current health workforce through developing and supporting integrated human resource and management strategies.

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