Decentralized Health System Research Articles

Decision-making in district health planning in Uganda: does use of district-specific evidence matter?

BackgroundIn a decentralised health system, district health managers are tasked with planning for health service delivery, which should be evidence based. However, planning in low-income countries such as Uganda has been described as ad hoc. A systematic approach to the planning process using district-specific evidence was introduced to district health managers in Uganda. However, little is known about how the use of district-specific evidence informs the planning process. In this study, we investigate how the use of this evidence affects decision-making in the planning process and how stakeholders in the planning process perceived the use of evidence.MethodsA convergent parallel mixed-methods study design was used, where quantitative data was collected from district health annual work plans for the financial years 2012/2013, 2013/2014, 2014/2015 and 2015/2016 as well as from bottleneck analysis reports for 2012, 2013, 2014 and 2015. Qualitative data was collected through semi-structured interviews with key informants from the two study districts.ResultsDistrict managers reported that they were able to produce more robust district annual work plans when they used the systematic approach of using district-specific evidence. Approximately half of the prioritised activities in the annual work plans were evidence based. Procurement and logistics, training, and support supervision activities were the most prioritised activities. Between 4% and 5.5% of the total planned expenditure was for child survival, of which 47% to 94% was from donor and other partner contributions.ConclusionDistrict-specific evidence and a structured process for its use to prioritise activities and make decisions in the planning process at the district level helped systematise the planning process. However, the reported limited decision and fiscal space, inadequate funding and high dependency on donor funding did not always allow for the use of district-specific evidence in the planning process.

Public hospitals’ finance management systems, and accountability mechanisms in the context of decentralized health systems in low- and middle-income countries – A thematic review

Background: Health sector decentralization, defined as the transfer of decision making over health sector resources from a central to a peripheral entity; has been and continues to be a widely adopted health system reforms in many low and middle-income countries (LMICs). However, its reported effects have been varied. Nevertheless, decentralization reforms aimed at providing public hospital management autonomy are increasing in prevalence in many LMICs. The range and form of this autonomy because of these reforms has often produced mixed effects. We set out to understand the range of financial management autonomy that has been granted to public hospitals in decentralized health systems in LMICs, and what forms of accountability arrangements have been used to facilitate this autonomy. Methods: We systematically searched PubMed, Google Scholar, Web of Science and CINAHL databases for published articles on this subject. We only included articles that reported empirical findings on hospital level financing and financial management in the context of decentralization in LMICs and/or those that included findings on hospital level finance management accountability arrangements. After a systematic search we found four articles that met our inclusion criteria. We undertook a thematic synthesis of the data and narrative reporting of our findings. Results: From the review – we find that decentralization reforms did not result in improved funding flows, finance management autonomy or accountability mechanisms and for public hospitals. These outcomes were irrespective of the mode and form of decentralization reform adopted. Conclusion: From our review, it is evident that though health sector decentralization reforms have been widely promoted and adopted in the past few decades across LMICs, there is minimal evidence that these reforms have improved funding flows to public hospitals, improved financial management autonomy or accountability mechanisms; so as to enhance the performance of these hospitals at sub-national level.

An overview of advances in global maternal health: From broad to specific improvements.

After the declaration of the Millennium Development Goals in 2000 by the United Nations, many stakeholders allocated financial resources to "global maternal health." Research to expand care and improve delivery of maternal health services has exponentially increased. The present article highlights an overview, namely 10 of the health system, clinical, and technology-based advancements that have occurred in the past three decades in the field of global maternal health. The list of topics has been selected through the cumulative clinical and public health expertise of the authors and is certainly not exhaustive. Rather, the list is intended to provide a mapping of key topics arranged from broad to specific that span from the global policy level to the level of individual care. The list of health system, clinical, and technology-based advancements include: (10) Millennium Development Goals and Sustainable Development Goals; (9) Development of clinical training programs, including the potential for subspecialty development; (8) Prenatal care expansion and potential; (7) Decentralized health systems, including the use of skilled birth attendants; (6) Antiretroviral therapy for HIV; (5) Essential medicines; (4) Vaccines; (3) mHealth/eHealth; (2) Ultrasonography; and (1) Obstetric hemorrhage management. With the Sustainable Development Goals now underway, the field must build upon past successes to sustain maternal and neonatal well-being in the future global health agenda.

Health sector decentralisation in Tanzania: Analysis of decision space in human resources for health management.

While decentralisation of health systems has dominated the political arena in the low- and middle-income countries since the 1970s, many studies on decentralisation have focused on understanding who is given more decision-making authority, but less attention is paid to understanding what that authority involves. This paper assesses the range of decision-making authority transferred from the central government to subnational levels in the area of human resources for health management in Tanzania. This analysis was guided by the decision space framework and relied on interviews, focused group discussions, and analysis of documents. Data were analysed using thematic approach. While districts had narrow decision space on recruitment and promotion of health service providers, they had wide decision space on distributing health providers within districts and providing incentives. Centrally managed recruitments resulted in frequent delays, thereby intensifying shortages of skilled health service providers. This analysis concludes that decentralisation of human resources for health planning and deployment role to lower levels of the administrative hierarchy in Tanzania is limited. This suggests the need for the central government to increase decision space to districts in the area of recruitment. In order for the Ministry of Health to perform its functions better in the area of human resources for health management, there is a need to strengthen the capacity of the department dealing with recruitment of skilled health staff at the Ministry of Health.

HEALTH SECTOR DECENTRALIZATION AND ITS IMPLICATION TO HEALTH SERVICES IN INDONESIA

Background: After more than a decade, in what way decentralization has affected health service and population health status in Indonesia, is still partly known. This paper aims to review about to what extent the health sector decentralization has affected health services in Indonesia, especially in access and health systems management. 
 Methods: We conducted systematic search studies using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We search for relevant studies using keywords ‘decentralization’ OR ‘decentralisation’ AND ‘(public health)’ AND ‘effect’ OR ‘impact’ AND ‘reform’ AND ‘(health inequalities)’ AND ‘Indonesia’ on electronic sources Proquest, Science Direct, and EBSCOHost. The articles then filtered using pre determined criterias and duplication removal.
 Results: Database search resulting on 628 articles in Proquest, 0 articles in Science Direct, and 13 articles in EBSCOHost. The screening result were 5 eligible articles. We found equality of access in health services were jeopardized by fragmented health services and worsen health disparities among districts that occured after decentralization. This worsen gap between the most developed provinces of Java-Bali and those of other island groupings affected the community’s health status. Low local government’s capacity in planning, managing and utilizing health resources were the most reported evidence in decentralized health system.
 Conclusion: This study concludes that good capacity of local government, coordination and monitoring system between central and local government, partnership with private sectors and community empowerment are essential to achieve better health outcome result in decentralized Indonesia.
 Keywords: Decentralization, Health Services, Health Policy, Indonesia

District-level impacts of health system decentralization in Indonesia: A systematic review.

The local-level impacts of decentralizing national health systems are significant yet infrequently examined. This review aims to assess whether localized health services delivery in Indonesia, which commenced a health system decentralization process in 2001, achieved its objectives or could be enhanced. A systematic review was undertaken to collate published evidence regarding this topic and synthesize key findings holistically using the six building blocks framework of the World Health Organization (WHO) to categorize health system performance. Four research databases were searched in 2016 for relevant evidence published between 2001 and 2015. The inclusion criteria were relevance to the topic of decentralization impacts at the district level, original research, and published in English. Included articles were appraised for quality using a standardized tool, with key findings synthesized using the WHO building blocks. Twenty-nine articles met the inclusion criteria and categorized under the WHO building blocks categories. The findings highlight problematic impacts of decentralization related to three building blocks: service delivery, health financing, and workforce. In the 15years of post-decentralization in Indonesia, the service delivery, health workforce, and health financing blocks should be prioritized for further research and policy evaluation to improve the overall health system performance at the district level.

Implementation and effectiveness of free health insurance for the poor pregnant women in Tanzania: A mixed methods evaluation

Demand side financing strategies have been a popular means of increasing coverage and availability of effective maternal and child health services in low and middle income countries (LMIC). However, most research to date has focused on the effects of demand side financing on the use and costs of care with less attention being paid to how they work to achieve outcomes. This study used a mixed methods evaluation to determine the effect of a targeted health insurance scheme on access to affordable quality maternal and child care, and assess implementation fidelity and how this affected programme outcomes.Programme effects on service access, affordability and quality were evaluated using difference in difference regression analysis, with outcomes being measured through facility, patient and household surveys and observations of care before the intervention started and eighteen months later. A simultaneous process evaluation was designed as a case study of the implementation experience. A total of 90 in-depth interviews (IDIs) and five focus group discussions were conducted during three rounds of data collection among respondents from management, facility and community. The scheme achieved high coverage among the target population and reduced the amount paid for antenatal and delivery care; however, there was no effect on service coverage and limited effects on quality of care. The lack of programme effects was partly due to the late timing of first antenatal care visits and registration for the scheme together with limited understanding of entitlements among beneficiaries and providers.Better communication of programme benefits is needed to enhance effects together with integration of such schemes within existing purchasing mechanisms and in financially decentralised health systems.

Understanding the implementation of Direct Health Facility Financing and its effect on health system performance in Tanzania: a non-controlled before and after mixed method study protocol

BackgroundGlobally, good health system performance has resulted from continuous reform, including adaptation of Decentralisation by Devolution policies, for example, the Direct Health Facility Financing (DHFF). Generally, the role of decentralisation in the health sector is to improve efficiency, to foster innovations and to improve quality, patient experience and accountability. However, such improvements have not been well realised in most low- and middle-income countries, with the main reason cited being the poor mechanism for disbursement of funds, which remain largely centralised. The introduction of the DHFF programme in Tanzania is expected to help improve the quality of health service delivery and increase service utilisation resulting in improved health system performance. This paper describes the protocol, which aims to evaluate the effects of DHFF on health system performance in Tanzania.MethodsAn evaluation of the effect of the DHFF programme will be carried out as part of a nationwide programme rollout. A before and after non-controlled concurrent mixed methods design study will be employed to examine the effect of the DHFF programme implementation on the structural quality of maternal health, health facility governing committee governance and accountability, and health system responsiveness as perceived by the patients’ experiences. Data will be collected from a nationally representative sample involving 42 health facilities, 422 patient consultations, 54 health workers, and 42 health facility governing committees in seven regions from the seven zones of the Tanzanian mainland. The study is grounded in a conceptual framework centered on the Theory of Change and the Implementation Fidelity Framework. The study will utilise a mixture of quantitative and qualitative data collection tools (questionnaires, focus group discussions, in-depth interviews and documentary review). The study will collect information related to knowledge, acceptability and practice of the programme, fidelity of implementation, structural qualities of maternal and child health services, accountability, governance, and patient perception of health system responsiveness.DiscussionThis evaluation study will generate evidence on both the process and impact of the DHFF programme implementation, and help to inform policy improvement. The study is expected to inform policy on the implementation of DHFF within decentralised health system government machinery, with particular regard to health system strengthening through quality healthcare delivery. Health system responsiveness assessment, accountability and governance of Health Facility Government Committee should bring autonomy to lower levels and improve patient experiences. A major strength of the proposed study is the use of a mixed methods approach to obtain a more in-depth understanding of factors that may influence the implementation of the DHFF programme. This evaluation has the potential to generate robust data for evidence-based policy decisions in a low-income setting.

Trends and geographic pattern of stomach cancer mortality in Peru

BackgroundStomach cancer mortality rates in South America are among the highest in the world. In Peru, stomach cancer has the highest absolute number of cancer deaths in both sexes combined. We estimated mortality rates for stomach cancer in Peru by sex and geographical region between 2008 and 2015. MethodsWe obtained death data for stomach cancer from the Peruvian Ministry of Health database. We estimated the age-standardized mortality rate (ASMR) per 100,000 persons using the direct method and the world standard population. ResultsA total of 25,020 deaths from stomach cancer were identified in the study period. At national level, stomach cancer mortality rates (per 100,000 population) for men ranged from 9.8 in 2008 to 8.8 in 2015 with a percent change of −16%, and for women from 8.8 in 2008 to 7.7 in 2015 with a percent change of −16.8%. The highlands had the highest mortality rates overall, mainly in Huancavelica and Huánuco. The rainforest had the lowest rates and the highest decline in stomach cancer ASMRs. The coast displayed intermediate rates overall. ConclusionsWithin the study period, mortality rates from stomach cancer in Peru declined by 16%. The highlands had the highest mortality rates as compared to those from the coast or rainforest region. These geographical differences in mortality could reflect a different distribution in stomach cancer risk factors as the prevalence of H. pylori, poor dietary habits, low socioeconomic background of the Andean population and the lack of a decentralized health system.

Elections and externalities of health expenditures

PurposeThe purpose of this paper is to examine the determinants of local public health expenditure in a decentralized health system, taking into account the electoral calendar and the effect of central and local elections, besides spatial interaction among municipalities and political alignment. The authors state that the expenditure in public health at the local level is positively influenced by vicinity and by elections calendar.Design/methodology/approachThe authors performed a Spatial Durbin Model with a balanced panel using the data from 399 Brazilian municipalities from 2005 to 2012. The authors use a distance-based spatial matrix, whose choose was based on simplicity and relevance of Moran’s I and Geary’s C coefficients for spatial autocorrelation. The authors also cluster the data in the estimations, according to the distribution of regional facilities in the entire period and considering the occurrence of regionalization in public health services.FindingsThe empirical contribution lies in four issues: first, the authors demonstrate a positive spatial effect in the public health expenditure. Second, the estimations show that election-year shifts public spent, as a response for vote-seeking incumbents’ behavior. Third, reelected mayors increase local public health allocations, as well as single candidates and incumbents from the same party of central governments. Finally, populational concentration directly decreases health expenditure (even if those municipalities represent a lower unit cost of acquiring votes, the optimization of public health infrastructure and mobility in achieving public health services negatively affect health spent).Originality/valueThis study supports the statement that public health spent at local level is positively influenced by vicinity and by occurrence of elections.

Health system decentralization and recentralization in Italy: Ideas, discourse, and institutions

AbstractThis paper explores the dynamics of health system decentralization and recentralization in Italy, investigating why and how the territorial organization of the health system has changed over time. Drawing from discursive and historical institutionalism, the explanatory framework revolves around the role of ideational and institutional factors. The methods include process tracing and interpretive‐discourse analysis. Empirical material is drawn from documents and in‐depth interviews to experts and decision‐makers. Through the analysis of the reform trajectories in light of decentralization and recentralization processes, the paper shows that the territorial organization of the Italian health system has changed through a mechanism of gradual transformative change that I here call ideational and institutional bricolage, which involves the interplay between ideas, discourse, and institutions.

The new profile of local managers in the decentralized health system in Brazil

ABSTRACT This article analyzes the impact of decentralization on the recruiting standards for the position of municipal health secretary, aiming to understand the extent to which local power has been democratized, as a consequence of the Unified Health System (SUS) implementation. Municipal health secretaries all over the country answered a questionnaire at two different times in the decentralization process - 1996 and 2006 - achieving representative results. The goal was to collect data about their socioeconomic, professional profile, political trajectory and public life. Results show that there are more women, brown (‘pardos’) and low-income people holding the position, and that the qualification of municipal health secretary improved in the period between the two surveys. However, this does not apply to the larger cities and more developed regions, where competition for this position has led to a recruiting standard that combines high levels of professionalism with restricted access for disadvantaged groups. We also found that municipal health secretary are now more politically engaged in manager’s associations than in their previous insertion in civil society networks.

Data for decision making: using a dashboard to strengthen routine immunisation in Nigeria

Availability of reliable data has for a long time been a challenge for health programmes in Nigeria. Routine immunisation (RI) data have always been characterised by conflicting coverage figures for...

Analysis of Health System Decentralization Outcomes on Governance and Justice in Health: Updating Regular Review Studies

Analysis of Health System Decentralization Outcomes on Governance and Justice in Health: Updating Regular Review Studies

Implementation process and quality of a primary health care system improvement initiative in a decentralized context: A retrospective appraisal using the quality implementation framework.

Effective implementation processes are essential in achieving desired outcomes of health initiatives. Whereas many approaches to implementation may seem straightforward, careful advanced planning, multiple stakeholder involvements, and addressing other contextual constraints needed for quality implementation are complex. Consequently, there have been recent calls for more theory-informed implementation science in health systems strengthening. This study applies the quality implementation framework (QIF) developed by Meyers, Durlak, and Wandersman to identify and explain observed implementation gaps in a primary health care system improvement intervention in Nigeria. We conducted a retrospective process appraisal by analyzing contents of 39 policy document and 15 key informant interviews. Using the QIF, we assessed challenges in the implementation processes and quality of an improvement model across the tiers of Nigeria's decentralized health system. Significant process gaps were identified that may have affected subnational implementation quality. Key challenges observed include inadequate stakeholder engagements and poor fidelity to planned implementation processes. Although needs and fit assessments, organizational capacity building, and development of implementation plans at national level were relatively well carried out, these were not effective in ensuring quality and sustainability at the subnational level. Implementing initiatives between levels of governance is more complex than within a tier. Adequate preintervention planning, understanding, and engaging the various interests across the governance spectrum are key to improving quality.

Health sector decentralisation in Tanzania: How do institutional capacities influence use of decision space?

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.

Self-testing, communication and information technology to promote HIV diagnosis among young gay and other men who have sex with men (MSM) in Brazil.

Self-testing, communication and information technology to promote HIV diagnosis among young gay and other men who have sex with men (MSM) in Brazil.

Retention of medical doctors at the district level: a qualitative study of experiences from Tanzania

BackgroundRetention of Human Resources for Health (HRH), particularly doctors at district level is a big challenge facing the decentralized health systems in poorly resourced countries. Tanzania, with 75% of its population in rural areas, has only 26% of doctors serving in rural areas. We aimed to analyze the experiences regarding the retention of doctors at district level in Tanzania from doctors’ and district health managers’ perspectives.MethodsA qualitative study was carried out in three districts from June to September 2013. We reviewed selected HRH documents and then conducted 15 key informant interviews with members of the District Health Management teams and medical doctors working at the district hospitals. In addition, we conducted three focus group discussions with Council Health Management Team members in the three districts. Incentive package plans, HRH establishment, and health sector development plans from the three districts were reviewed. Data analysis was performed using qualitative content analysis.ResultsNone of the districts in this study has the number of doctors recommended. Retention of doctors in the districts faced the following challenges: unfavourable working conditions including poor working environment, lack of assurance of career progression, and a non-uniform financial incentive system across districts; unsupportive environment in the community, characterized by: difficulty in securing houses for rent, lack of opportunities to earn extra income, lack of appreciation from the community and poor social services.Health managers across districts endeavour to retain their doctors through different retention strategies, including: career development plans, minimum financial incentive packages and avenues for private practices in the district hospitals. However, managers face constrained financial resources, with many competing priorities at district level.ConclusionsRetention of doctors at district level faces numerous challenges. Assurance of career growth, provision of uniform minimum financial incentives and ensuring availability of good social services and economic opportunities within the community are among important retention strategies.

Decentralisation and health services delivery in Tanzania: Analysis of decision space in planning, allocation, and use of financial resources.

While decentralisation of health systems has been on the policy agenda in low-income and middle-income countries since the 1970s, many studies have focused on understanding who has more decision-making powers but less attention is paid to understand what those powers encompass. Using the decision space approach, this study aimed to understand the amount of decision-making space transferred from the central government to institutions at the periphery in the decentralised health system in Tanzania. The findings of this study indicated that the decentralisation process in Tanzania has provided authorities with a range of decision-making space. In the areas of priority setting and planning, district health authorities had moderate decision space. However, in the financial resource allocation and expenditure of funds from the central government, the districts had narrow decision-making space. The districts, nevertheless, had wider decision-making space in mobilising and using locally generated financial resources. However, the ability of the districts to allocate and use locally generated resources was constrained by bureaucratic procedures of the central government. The study concludes that decentralisation by devolution which is being promoted in the policy documents in Tanzania is yet to be realised at the district and local levels. The study recommends that the central government should provide more space to the decentralised district health systems to incorporate locally defined priorities in the district health plans.

Strengthening Public Health Management Capacity in Vietnam: Preparing Local Public Health Workers for New Roles in a Decentralized Health System.

Health sector decentralization has created an urgent need to strengthen public health management capacity in many countries throughout the developing world. This article describes the establishment of a national management training network in Vietnam that used Project-Based Learning to strengthen management competencies of HIV program workers and linked training to measurable improvement in HIV/AIDS public health program outcomes. Skills were taught using a combination of classroom learning and mentored fieldwork. From 2005 to 2015, 827 HIV/AIDS program managers were trained with this method throughout Vietnam by trainers in 3 regional training centers. A total of 218 applied learning projects were carried out by trainees during this period; 132 resulted in measurable improvements in HIV/AIDS program outputs, and 86 produced well-organized plans for implementing, monitoring, and evaluating HIV/AIDS intervention strategies. Vietnam's management training network represents an important advancement in public health workforce development that helps prepare workers for new roles and responsibilities in a decentralized health system.