Decentralization Of Health Services Research Articles

The implementation process of decentralization of health services: a qualitative perspective from Sudan

BackgroundHealth system reform initiatives have increasingly embraced decentralization as a key trend. The implementation process and its outcomes are influenced by a myriad of factors, including economic forces, political dynamics, and ideological factors. Comprehending and carefully examining the implementation phase of decentralization and its consequences to achieve desired outcomes is crucial. Notably, this phase is often considered the weakest aspect of policy reforms, especially in developing countries. Therefore, this study aimed to explore and analyze the implementation phase of decentralization and its implications as essentials for achieving intended goals. The study objectives evolved around examining the entire decentralization as a multifaceted social and political process in Khartoum State, Sudan, from its early stages of decision-making, policy formulation, and implementation process and the influencing contextual factors.MethodsThis study was an exploratory qualitative study that employed in-depth interviews to gather perspectives of healthcare providers and policymakers, semi-structured observations, and thematic analysis. The study utilized Grindle’s framework for analysis.FindingsThis study revealed a political nature of decision-making, with a top–down approach to the implementation, which also lacked stakeholder involvement. It showed a lack of transparency, official documentation, and proper handover procedures from the Ministry of Health to the devolved hospitals during the implementation process. A conflict of interest between the federal and the state level was also reported. It is important to note that this process occurred within the context of structural adjustment program (SAP) schemes, which had already empowered the private sector in Sudan.ConclusionThis study documented the implementation process of decentralization of health services and its influencing factors. The study recommended reforming the decentralization policy through consultative stakeholder involvement and by implementing a concurrent responsibility paradigm that divides authority between the federal and state levels.

Health and Nutrition Promotion Programs in Papua New Guinea: A Scoping Review.

There is a rising prevalence of non-communicable diseases (NCDs) in Papua New Guinea (PNG), adding to the disease burden from communicable infectious diseases and thus increasing the burden on the healthcare system in a low-resource setting. The aim of this review was to identify health and nutrition promotion programs conducted in PNG and the enablers and barriers to these programs. Four electronic databases and grey literature were searched. Two reviewers completed screening and data extraction. This review included 23 papers evaluating 22 health and nutrition promotion programs, which focused on the Ottawa Charter action areas of developing personal skills (12 programs), reorienting health services (12 programs) and strengthening community action (6 programs). Nineteen programs targeted communicable diseases; two addressed NCDs, and one addressed health services. Enablers of health promotion programs in PNG included community involvement, cultural appropriateness, strong leadership, and the use of mobile health technologies for the decentralisation of health services. Barriers included limited resources and funding and a lack of central leadership to drive ongoing implementation. There is an urgent need for health and nutrition promotion programs targeting NCDs and their modifiable risk factors, as well as longitudinal study designs for the evaluation of long-term impact and program sustainability.

The impact of decentralization of health services at the municipal level on health outcomes: evidence from China.

Under the system of health decentralization, there are differences in the level of expenditure decentralization at different levels of government, and their impact on residents' health may also be different. This paper is one of the first to evaluate the effect of decentralization of health services at the municipal level from a multi-dimensional health perspective. This paper uses the data of expenditure decentralization of health services at the municipal level to match the panel data from the China Household Panel Survey (CFPS) from 2010 to 2018, and uses the logit model, ordered logit model and two-way fixed effects model to empirically analyze the impact of health decentralization at the municipal level on health outcomes. Based on the perspective of multi-dimensional health, from the three aspects of physical health, depression status and cognitive ability, the six sub-indicators of self-rated health, BMI standards, depression scores (summation method), depression scores (factor method), phrase test scores and mathematics test scores are discussed separately. The results show that the decentralization of health services at the municipal level has a significant promotion effect on the multi-dimensional health of residents. The decentralization of health services at the municipal level has important theoretical significance for promoting the reasonable division of medical and health powers and expenditure responsibilities between provincial and municipal governments, improving the efficiency of health expenditure funds, and establishing a fiscal system that matches financial resources.

Does the healthcare decentralization provide better public health security capacity and health services satisfaction? An analysis of OECD countries

PurposeDecentralization has profound implications for many health systems. This study investigates the effect of health system decentralization in Organization for Economic Co-operation and Development (OECD) countries on public health security capacity and health service satisfaction.Design/methodology/approachMultiple linear regression analyses were employed for variables related to the level of health security capacity and satisfaction with the healthcare system while controlling for all socio-demographic variables from the European Social Survey, including over 44,000 respondents from 25 OECD countries. The Health Systems in Transition series of countries were used for assessing the decentralization level.FindingsThe result of multiple linear regression analyses showed that the level of decentralization in health systems was significantly associated with higher health security capacity (ß-coefficient 3.722, 95% confidence interval (CI) [3.536 3.908]; p=<0.001) and health service satisfaction (ß-coefficient 1.463, 95% CI [1.389 1.536]; p=<0.001) in the study. Countries with a higher level of decentralization in health policy tasks and areas were significantly likely to have higher health services satisfaction, whereas this satisfaction had a significant negative relation with the lower level of decentralization status of secondary/tertiary care services in OECD countries (ß-coefficient −5.250, 95% CI [−5.757–4.743]; p = 0.001).Originality/valueThis study contributes to a better understanding of the extent to which decentralization of health services affects public health safety capacity and satisfaction with health services, whereas the level of decentralization in OECD countries varies considerably. Overall, the findings highlight the importance of public health security and satisfaction with health care delivery in assessing the effects of decentralization in health services.

Glosses in health establishments under state management and consortium management, in Ceará

As part of its regionalization process, Ceará was divided into five Health Regions, which decentralized health services, actions and agreement processes between municipalities and the state. As coordinator of the Health Regions, it has invested in strengthening the internalization of health through the construction of Regional Polyclinics and Regional Dental Specialty Centres (CEOR), enabling the formation of inter-municipal consortia. This is an exploratory, quantitative and descriptive study with a retrospective approach, analyzing the provision of health care costs through a partial economic evaluation. This study aimed to analyze the disallowances and outpatient production presented/informed, the relationship between them and the value of these disallowances, carried out in the 41 establishments of the five health regions under state management and consortium management in the State of Ceará, whose value in the Unified Health System (SUS) table is different from zero, during the years 2019 and 2020. Secondary databases were used from the SUS Outpatient Information System (SIA/SUS) and the website of the Coordination of Regulation, Control, Evaluation and Audit (CORAC). The results were presented by comparing the value of what was presented to the Ministry of Health (MoH) and the value of the disallowances. It was concluded that these establishments need to be monitored in terms of feeding information into systems, in order to show the Ministry of Health that there are insufficient resources to meet the needs that are increasingly growing in quantity and diversity.

The role of community engagement toward ensuring healthy lives: a case study of COVID-19 management in two Ghanaian municipalities.

Community engagement is one of the important requirements for strengthening health delivery in communities in a bid to achieve sustainable development goal 3, target 3.3 (SDG 3.3). The World Health Organization has strongly encouraged the use the five levels of community engagement, which are informing, consulting, planning, collaborating, and empowering communities in order to build resilience and to enable them contribute to the fight against diseases and for the uptake of health interventions. This study sought to explore and describe from the view of government institutions in Ghana how they engaged communities in COVID- 19 management and vaccine acceptance and how the communities within two municipalities also perceived the engagement process as well as the lessons that can be learned in engaging communities to deal with other health challenges and interventions toward the attainment of SDG 3 target 3.3. This case study qualitative research project employed in-depth interviews among 36 respondents composed of government officials (the Ghana Health Service (GHS), the Information Services Department (ISD), the National Commission on Civic Education (NCCE) and two Municipal Assemblies), and community leaders and 10 focus group discussions among 87 men and women most of whom were natives and some migrants in two administrative municipalities in Ghana. Data were collected from June to September 2021. Audio interviews were transcribed and uploaded to Nvivo 12 to support triangulation, coding, and thematic analysis. Ethical approval was obtained from the University of Health and Allied Sciences' Research Ethics Committee and all COVID-19 restrictions were observed. The findings revealed that all the four government institutions educated and informed the communities within their municipalities on COVID-19 management and vaccine acceptance. However, the Ghana Health Service was the most effective in the engagement spectrum of the other four; consulting, involving, collaborating, and empowering communities in the process of COVID-19 management and vaccine acceptance. The GHS achieved that through its CHPS program, which ensured a decentralized health service provision system with multiple programs and leveraging on its multiple programs to reach out to the communities. Government institutions such as the NCCE and the ISD faced challenges such as limited funding and support from the government to be able to carry out their tasks. Additionally, they were not involved with the communities prior to the pandemic and for that matter, they did not have access to community systems such as committees, and existing groups to facilitate the engagement process. Using communities to support Ghana's attainment of the SDG 3 target 3.3 is possible; however, the government needs to provide funds and resources to the institutions responsible to enable them to carry out community engagement effectively. Also, promoting decentralization among institutions can strengthen community engagement processes. It is important that state institutions continue to strategize to empower communities in order to promote their participation in healthcare interventions and in the fight against infectious diseases in Ghana.

Community Health Workers in Spain: a missing strategy to tackle hepatitis in migrant populations

Abstract Community health workers (CHWs) are health care providers which live and serve in the community and are responsible for the provision of health education to their communities, promoting healthy habits and lifestyles, diagnosing common illnesses, and encouraging the use of health services by linking people to health services. CHW programmes have been formally included as part of national health systems in many low- and middle-income countries (e.g., Ethiopia or Brazil), along with some high-income countries (e.g., Canada). Despite the major contribution CHWs have proven to make in health systems globally, Spain has yet to introduce a law acknowledging their role in the health system. The introduction of CHWs allows for the decentralization of health services and their extension beyond the regular forms of health service delivery (e.g. primary health centres or hospitals) as additional strategies for equity and person-centred care. CHWs have the capacity to reach underserved and vulnerable populations, including marginalized populations, which often encounter barriers to engage with their health systems. Migrant communities in Spain are an example of communities which are often marginalized and struggle to have their health needs met through their host health system. For instance, studies have reported a significantly higher prevalence of chronic infection of Hepatitis B virus (HBV) among migrants in comparison to the general Spanish population and late presentation to care in this population has been reported. CHWs have the potential to reach these underserved communities and provide culturally and linguistically appropriate health information, emphasizing the importance of HBV prevention, management and treatment, and vaccination. Ultimately, CHWs can offer decentralized and accessible health care and lead in co-creation processes for effective viral hepatitis - including HBV vaccination- services in community spaces and facilitate linkage to higher levels of care.

Decentralization and Corruption in Public Service Delivery: Local Institutional Arrangements That Can Help Reduce Governance Risks

Abstract Decentralization reform has both advantages and risks. Bringing service delivery “closer to the people” can improve information flows and strengthen accountability, but it may also leave systems vulnerable to elite capture and corruption by municipal government officials. While past research has acknowledged the possibility of corruption under decentralization, relatively little work has connected those risks to features of these reforms or specific local institutional arrangements. To explore the conditions that can help mitigate the risks of corruption under decentralization, we study the case of health sector reform in Honduras where municipal governments, associations, and NGOs each serve as intermediary-managing organizations under a common decentralized health service delivery model. We argue that three types of institutional arrangements reflecting local accountability practices serve as checks on the authority granted through decentralization and can help guard against corruption: external supervision, civil society engagement, and public participation. Empirically, we draw on data from more than 600 street-level bureaucrats, valuable but under-utilized informants about municipal corruption, across a matched sample of 65 municipalities with contrasting forms of administration. We find that reported corruption is highest under decentralization led by municipal governments, as compared to association- or NGO-led varieties. Both external supervision and civil society engagement help attenuate the positive association between decentralization and corruption, but public participation does not. Overall, this research highlights the importance of considering reform features and local conditions when designing policies to help manage risks and support effective social sector decentralization.

De-medicalized and decentralized HIV testing: a strategy to test hard-to-reach men who have sex with men in Cameroon.

Conventional HIV testing performed by a health professional has shown its limitations in targeting marginalized and vulnerable populations. Indeed, men who have sex with men (MSM) due to social discrimination are often uncomfortable using this service at the health facilities level. In this perspective, new differentiated approaches have been thought through de-medicalized and decentralized HIV testing (DDHT). This HIV testing strategy enables overcoming the structural, legal, and social barriers that prevent these populations from quickly accessing HIV services. This article discusses the prerequisites and added value of implementing this strategy for MSM living in a criminalized context and its implication in decentralizing health services toward the community level.

Managerial Performance Improvement Strategy Based on Budget Participation

Regional autonomy has led to the decentralization of health services. The impact of the decentralization of health services is the emergence of differences between provinces and districts/cities in terms of the status of funding sources and changes in the structure of the health system in the regions. The main purpose of this study is to examine the relationship between budgetary participation and managerial performance in a public sector organization. It also attempts to examine whether organizational commitment and perception of innovation mediate the budgetary participation and performance relationship. As one of the government-owned public sector organizations in charge of health issues, Semarang City Health Office became the public spotlight regarding budget and performance. The study was conducted at Semarang City's Health Office, and all of the Public Health Centers, the sample size used is 60 echelon officers, using path analysis. The analysis results indicate that Budgetary participation affects managerial performance via the mediating variable of organizational commitment but not perception of innovation. There is a direct relationship between budgetary participation, managerial performance, organizational commitment, and perception of innovation Keywords: Budgetary, managerial performance, commitment, innovation, public sector. JEL Classification: H51, H61, R10

Long travel times from health center to hospital reduce caesarean section access: a study from Kirehe District, Rwanda.

timely access to safe cesarean section (c-section) delivery can save the lives of mothers and neonates. This paper explores how distance affects c-section access in rural sub-Saharan Africa, where women in labor present to health centers before being referred to district hospitals for surgical care. this study included all adult women delivering via c-section between April 2017 and March 2018 in Kirehe District, Rwanda. We assessed the association between travel times and village-level c-section rates. the estimated travel time from home-to-health center was 26 minutes (IQR: 13, 41) and from health center-to-hospital was 43 minutes (IQR: 2, 59). There was no significant association between travel time from home-to-health center and c-section rates (RR=1.01, p=0.42), but the association was significant for health center-to-hospital travel times (RR=0.96, p=0.01); for every 15-minute increase in travel time, there was a 4% decrease in c-sections for a health center catchment area. in the context of decentralized health services, minimizing health center to hospital referral barriers is of utmost importance for improving c-section access in rural sub-Saharan Africa.

Health System Decentralization: Creating as Many Problems Than It Solves? Comment on "The Effects of Health Sector Fiscal Decentralisation on Availability, Accessibility, and Utilisation of Healthcare Services: A Panel Data Analysis".

This comment draws on the study by Rotulo et al about the effects of fiscal decentralization on access, utilization and availability of healthcare resources across Italian regions. We start by discussing the recent trends in health system decentralization worldwide, and then reflect on the rationale and main benefits and the key complexities and challenges of this much debated reform. We address these issues with reference to the recent experience of Italy as well as that of other comparable highly decentralized countries, most notably Spain, paying particular attention to their similarities and contrasts. We conclude that decentralization of health services poses complex challenges and trade-offs which may require careful design of equalisation mechanisms, framework regulation and efficient coordination mechanisms by central and sub central governments.

Health Center Performance Post Decentralization of Health Services Policy in Makassar City

The objectives of this study are: To describe and analyze the performance of the Health center after the decentralization of health service policies in Makassar City. This type of research is viewed from the research objective, so it is included in the format of qualitative research, which describes a phenomenon of problems that occur about the performance of the Health center, then is connected to the source of the problem, by confirming the service providers and referring to the theory related to the phenomenon that occurs. The results showed that the organizational performance of the Health center after the policy of decentralization of health services in the city of Makassar was still not optimal or still lacking and there was still much that needed to be addressed to be able to realize the expectations of the community.

Multi-country case studies on planning RMNCH services using WISN methodology: Bangladesh, Ghana, Kenya, Sultanate of Oman and Papua New Guinea

BackgroundGlobally, many countries are adopting evidence-based workforce planning that facilitates progress towards achieving sustainable development goals for reproductive, maternal newborn and child health. We reviewed case studies on workforce planning for reproductive maternal newborn child health services at primary care level facilities using workload indicators of staffing need in five countries.MethodUsing available workload indicators for staffing need reports from Bangladesh, Ghana, Kenya, Sultanate of Oman and Papua New Guinea, we generated descriptive statistics to explore comparable workload components and activity standards, health service delivery models with an emphasis on the primary care levels and the specific health occupations offering interventions associated with reproductive maternal, newborn and child health services.ResultsThe health services delivery models vary from one country to another. The results showed variability in the countries, in the workload components and activity standards of each regardless of facility level or occupational groups involved. All the countries have decentralized health services with emphasis on comprehensive primary care. Reproductive, maternal and new-born child health care services include antenatal, postnatal, immunization, family planning, baby wellness clinics, delivery and management of integrated minor childhood illnesses. Only Sultanate of Oman offers fertility services at primary care. Kenya has expanded interventions in the households and communities.ConclusionSince the health care services models, health services delivery contexts and the health care worker teams vary from one country to another, the study therefore concludes that activity standards cannot be adopted or adapted from one country to another despite having similar workload components. Evidence based workforce planning must be context-specific, and therefore requires that each country develop its own workload components and activity standards aligned to their local contexts.

The Influence of HR Practices on Job Satisfaction in the Delivery of Decentralized Health Services (Case Study at Sawerigading General Hospital, Palopo City

The progress of the service sector, especially in the health sector, is dependent on how good job satisfaction is felt by employees. Good job satisfaction brings a good impact on every service that occurs. The purpose of this study is to determine how the relationship and influence of human resource practices which are categorized into job training, human resource development, work environment and competence on job satisfaction. The results showed that job training, human resource development, work environment and competence had a positive and significant effect on job satisfaction.

Competing risk of mortality on loss to follow-up outcome among patients with HIV on ART: a retrospective cohort study from the Zimbabwe national ART programme

ObjectiveTo determine the loss to follow-up (LTFU) rates at different healthcare levels after antiretroviral therapy (ART) services decentralisation among ART patients who initiated ART between 2004 and 2017 using the...

Accelerating progress towards the elimination of mother-to-child transmission of HIV: a narrative review.

IntroductionFindings from biomedical, behavioural and implementation studies provide a rich foundation to guide programmatic efforts for the prevention of mother‐to‐child HIV transmission (PMTCT).MethodsWe summarized the current evidence base to support policy makers, programme managers, funding agencies and other stakeholders in designing and optimizing PMTCT programmes. We searched the scientific literature for PMTCT interventions in the era of universal antiretroviral therapy for pregnant and breastfeeding women (i.e. 2013 onward). Where evidence was sparse, relevant studies from the general HIV treatment literature or from prior eras of PMTCT programme implementation were also considered. Studies were organized into six categories: HIV prevention services for women, timely access to HIV testing, timely access to ART, programme retention and adherence support, timely engagement in antenatal care and services for infants at highest risk of HIV acquisition. These were mapped to specific missed opportunities identified by the UNAIDS Spectrum model and embedded in UNICEF operational guidance to optimize PMTCT services.Results and discussionFrom May to November 2019, we identified numerous promising, evidence‐based strategies that, properly tailored and adopted, could contribute to population reductions in vertical HIV transmission. These spanned the HIV and maternal and child health literature, emphasizing the importance of continued alignment and integration of services. We observed overlap between several intervention domains, suggesting potential for synergies and increased downstream impact. Common themes included integration of facility‐based healthcare; decentralization of health services from facilities to communities; and engagement of partners, peers and lay workers for social support. Approaches to ensure early HIV diagnosis and treatment prior to pregnancy would strengthen care across the maternal lifespan and should be promoted in the context of PMTCT.ConclusionsA wide range of effective strategies exist to improve PMTCT access, uptake and retention. Programmes should carefully consider, prioritize and plan those that are most appropriate for the local setting and best address existing gaps in PMTCT health services.

Factors influencing delivery of intersectoral actions to address infant stunting in Bogot\xe1, Colombia \u2013 a mixed methods case study

BackgroundIntersectoral actions (ISA) are a recognized relationship between the health sector and other sectors to improve health outcomes. Although a frequent topic in public health studies, evidence for systematic evaluation of implementation of ISA is scarce. An intersectoral health intervention for infants under one-year-old with, and at risk of, stunting (low height-for-age) was developed by a public-private partnership in Bogotá, Colombia, during 2018 and 2019. Here we report a case study conducted in parallel to the intervention designed to assess factors that influenced implementation of the ISA.MethodsThe case study was developed using a concurrent mixed-methods design, with the qualitative component giving context to the quantitative results. The qualitative component was obtained from four workshops, three focus groups, and 17 semi-structured interviews with actors involved in the intersectoral intervention. The quantitative component was obtained with two questionnaires that evaluated perceptions on improvement and partnership functioning of the ISA.ResultsThis study collected information from 122 participants. The intervention demanded intersectoral collaboration. Political will, motivated human resources, and recognition that health improvement results from collaboration, were factors that facilitated intersectoral actions. Intersectoral actions were limited by difficulties in engaging the health sector, communication challenges related to local health service decentralization, and administrative barriers.ConclusionsIntersectoral actions have recently been discussed in the literature due to challenges in implementation and doubts regarding economic outcomes. The implementation of intersectoral public health interventions can be jeopardized by a lack of coordination and management skills.

Performance Appraisal Experiences and Its Implications on Human Resource Decisions in Decentralized Health Services in Shinyanga Region, Tanzania

The study investigated the Performance Appraisal Experiences and its Implications on Human Resource (HR) Decisions in the decentralized health service in Shinyanga Region, Tanzania. The region was selected because over different periods it revealed poor performance in health service delivery whose causes remained unfolded. An explanatory Survey research design with a mixed approach was employed, whereas the survey tool was used to collect data from 287 respondents. The findings revealed that even though the team performance is evaluated through the Quality Improvement Teams, the individual employee’s performance is ineffectively evaluated due to the ineffective use of the Open Performance, Review and Appraisal System (OPRAS). The ineffective use of OPRAS instrument is linked to several factors including the complexity of the instrument; inadequate availability of funds to implement the set targets; shortage of the human resources in the facilities making overwhelmed by the responsibilities; the OPRAS process being time-consuming and inadequate commitment on the use of the instrument. Thus, when the individual performance is ineffectively appraised, human resource decisions such as training and compensation for employees’ performance remain uninformed, hence affecting both their quality and human resource performance. It was thus, recommended inter alia, simplification of the OPRAS instrument and customization of it to suit the health sector settings, frequent provision of training on the application of OPRAS, and linking OPRAS results with the immediate rewards to enhance employees’ commitment to the instrument. Additionally, the establishment of the mechanism to enforce the use of OPRAS in assessing employees’ performance in health facilities and ensuring that the appraisal results are linked to the human resource decisions are of paramount importance for improving human resource decisions and for performance improvement in health facilities.

Decentralized Health Service Delivery System in Bangladesh: Evaluating Community Clinics in Promoting Healthcare for the Rural Poor

The Awami League government of Bangladesh has established community clinics as decentralized healthcare units at the village level to ensure smooth and equal access to family planning, preventive health services, and limited curative care for the local community. The primary aspiration of this study is to evaluate the dynamics of service delivery systems under decentralized community clinics in rural areas of Bangladesh. It also aims to explore the challenges of accessing healthcare services and the impacts of decentralization on the promotion of the service delivery system of the community clinics. A qualitative field study was conducted in Sylhet District in the northeastern part of Bangladesh to collect the necessary data regarding the study objectives. The respondents were sampled through a purposive sampling method. Data collection was done through in-depth interviews and focus group discussions. The study findings revealed that the aspect of services in community clinics is being questioned due to different sociocultural, political, economic, and administrative stumbling blocks. If the government ensures skilled workforce, structural and technical support, locallevel planning, adequate funding, strategic coordination, and delegation of functions to address the challenges in providing health services to community clinics, then it is believed that these community-knit clinics would be considered as the lighthouse for providing primary healthcare for the disadvantaged rural sections of Bangladesh.