Decentralized Health System Research Articles

Capacity Building in Ghana's Decentralised Health System: A Qualitative Study

Capacity Building in Ghana's Decentralised Health System: A Qualitative Study

Retention of Human Resources for Health in the Decentralised Health System in Tanzania: Does Training matter?

Retention of Human Resources for Health in the Decentralised Health System in Tanzania: Does Training matter?

De facto health governance policies and practices in a decentralized setting of Ghana: Implication for policy making and implementation

BackgroundCurrent Universal Health Coverage (UHC) considerations confirm the need for strong governance in improving health sector performance. However, empirical evidence on the effects of decentralized health system governance remains limited in Low-and-middle-income countries (LMICs). This paper assesses the de facto health governance policies and practices of the decentralized health system of Ghana and its implications, for better policy formulation and implementation. Material and methodsThe study employed a cross-sectional design, comprising of systematic literature review (SLR) and in-depth interviews on health governance components. The literature review (n=103) was performed to document the factors that affect health governance management and policy uptake. A total of 32 purposively sampled key health system actors were individually interviewed face-to-face between January and February, 2018. Thematic content analyses of literature and interviews were done. ResultsTension regarding power relationships exists between the policies governing the health sector of Ghana, which has rendered the decentralization reform effort in health governance policies and practices uncoordinated, incoherent and sometimes contradictory. Implication of the de facto decentralized health governance policies and practice include: limited involvement of sub-national level in policy development; weak interaction between policy formulators and implementers; and political interference in policy implementations compromising evidence-based policy formulation. Originality/valueDrawing on diverse literatures and opinions of key health actors, this paper contributes to knowledge on health governance practices in a decentralized and resource constrained health system, and offers practical accounts of the implications of the de facto health governance system of Ghana for health policy formulation and implementation.

Decentralization of the health system - experiences from Pakistan, Portugal and Brazil.

Decentralization of a health system is a complex and multidimensional phenomenon that demands thorough investigation of its process logistics, predisposing factors and implementation mechanisms, within the broader socio-political environment of each nation. Despite its wide adoption across both high-income countries (HICs) and low-and-middle-income countries (LMICs), empirical evidence of whether decentralization actually translates into improved health system performance remains inconclusive and controversial. This paper aims to provide a comprehensive description of the decentralization processes in three countries at different stages of their decentralization strategies - Pakistan, Brazil and Portugal. This study employed a systematic analysis of peer-reviewed academic journals, official government reports, policy documents and publications from international organizations related to health system decentralization. A comprehensive search was conducted using reputable databases such as PubMed, Google Scholar, the WHO repository and other relevant databases, covering the period up to the knowledge cutoff date in June 2023. Information was systematically extracted and organized into the determinants, process mechanics and challenges encountered during the planning, implementation and post-decentralization phases. Although decentralization reforms have achieved some success, challenges persist in their implementation. Comparing all three countries, it was evident that all three have prioritized health in their decentralization reforms and aimed to enhance local decision-making power. Brazil has made significant progress in implementing decentralization reforms, while Portugal and Pakistan are still in the process. Pakistan has faced significant implementation challenges, including capacity-building, resource allocation, resistance to change and inequity in access to care. Brazil and Portugal have also faced challenges, but to a lesser extent. The extent, progress and challenges in the decentralization processes vary among the three countries, each requiring ongoing evaluation and improvement to achieve the desired outcomes. Notable differences exist in the extent of decentralization, the challenges faced during implementation and inequality in access to care between the three countries. It is important for Portugal, Brazil and Pakistan to address these through reinforcing implementation strategies, tackling inequalities in access to care and enhancing monitoring and evaluation mechanism. Additionally, fostering knowledge sharing among these different countries will be instrumental in facilitating mutual learning.

Identifying Physician Public Health Competencies to Address Healthcare Needs in Underserved, Border, and Outer Island Areas of Indonesia: A Rapid Assessment

Phenomenon: Most medical schools in Indonesia have developed innovations to integrate public health content into the curricula. However, ensuring that all schools meet appropriate standards regarding the quality of subjects, content relevancy, and course delivery takes time and effort. Approach: This study employed a rapid assessment procedure to identify the current knowledge and competencies required to practice medicine effectively in underserved, border, and outer island areas of Indonesia. Ninety-three participants from six remote districts were involved in 12 focus group discussions. Qualitative data were analyzed using content analysis using the social determinants of health as a guiding framework. Findings: Under decentralized health system governance, the local socio-geographical context is critical to understanding the current public health landscape. Medical education with respect to public health must emphasize physicians’ ability to advocate and encourage the coordination of healthcare services in responding to disasters, as well as community-based surveillance and other relevant data for synergistic disease control. As part of a healthcare facility management team, prospective doctors should be able to apply systems thinking and provide critical input to improve service delivery at local health facilities. Also, recognizing underlying factors is essential to realizing effective interprofessional collaboration practices and aligning them with leadership skills. Insights: This study outlines recommendations for medical schools and relevant colleges in formulating compulsory block or integrated public health curricula. It also provides a public health learning topic that may aid medical schools in training their students to be competent for practice in underserved, border, and outer island areas. Medical schools should offer initiatives for students to acquire the necessary public health competencies merited by the population’s health needs.

Effective multi-sectoral approach for rapid reduction in maternal and neonatal mortality: the exceptional case of Bangladesh

BackgroundBangladesh experienced impressive reductions in maternal and neonatal mortality over the past several decades with annual rates of decline surpassing 4% since 2000. We comprehensively assessed health system and non-health...

Communities organizing to promote equity: engaging local communities in public health responses to health inequities exacerbated by COVID-19-protocol paper.

The COVID-19 pandemic has disproportionately impacted rural and under-resourced urban communities in Kansas. The state's response to COVID-19 has relied on a highly decentralized and underfunded public health system, with 100 local health departments in the state, few of which had prior experience engaging local community coalitions in a coordinated response to a public health crisis. To improve the capacity for local community-driven responses to COVID-19 and other public health needs, the University of Kansas Medical Center, in partnership with the Kansas Department of Health and Environment, will launch Communities Organizing to Promote Equity (COPE) in 20 counties across Kansas. COPE will establish Local Health Equity Action Teams (LHEATs), coalitions comprised of community members and service providers, who work with COPE-hired community health workers (CHWs) recruited to represent the diversity of the communities they serve. CHWs in each county are tasked with addressing unmet social needs of residents and supporting their county's LHEAT. LHEATs are charged with implementing strategies to improve social determinants of health in their county. Monthly, LHEATs and CHWs from all 20 counties will come together as part of a learning collaborative to share strategies, foster innovation, and engage in peer problem-solving. These efforts will be supported by a multilevel communications strategy that will increase awareness of COPE activities and resources at the local level and successes across the state. Our mixed methods evaluation design will assess the processes and impact of COPE activities as well as barriers and facilitators to implementation using aspects of both the Consolidated Framework for Implementation Research (CFIR) and Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) models. This protocol is designed to expand community capacity to strategically partner with local public health and social service partners to prioritize and implement health equity efforts. COPE intentionally engages historically resilient communities and those living in underserved rural areas to inform pragmatic strategies to improve health equity.

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.

How Public Health Organizational Structure Affected the Response to the COVID-19 Pandemic: A Case Study in British Columbia, Canada.

Objectives: This study sought to examine how public health organizational structures affected decision-making and provides recommendations to strengthen future public health crisis preparedness. Methods: The Institutions-Politics-Organizations-Governance (IPOG) framework and an organizational lens was applied to the analysis of COVID-19 governance within British Columbia (BC). Organizational charts detailing the structure of public health systems were compiled using available data and supplemented with data collected through key informant interviews. Results: In response to the COVID-19 pandemic, BC initiated several changes in its public health organization. BC's COVID-19 response attempted to utilize a centralized command structure within a decentralized health system. Four key themes were identified pertaining to the 1) locus of decision-making and action; 2) role of emergency structures; 3) challenges in organizational structure; and 4) balance between authority and participation in decision-making. Conclusion: The organizational adaptations enabled a substantively effective response. However, our findings also illustrate deficiencies in organizational structure in the current public health system. Two recommendations for consideration are: 1) a more formal vertical organizational structure; and 2) developing new mechanisms to link health and general emergency response structures.

Using e-modules for acquisition of complex diabetes skills in diabetes care providers in Rwanda.

Type 1 Diabetes (T1D) is life-threatening without appropriate treatment. Though pediatric endocrinology care is limited in Rwanda, a decentralized health system allows access to local non-communicable disease (NCD) nurses through a network of 42 district hospitals. Recent rapid expansion of internet access in the country makes virtual diabetes education initiatives possible. We investigated whether Rwandan NCD nurses receiving diabetes education via online e-modules could make similar educational gains in insulin adjustment skills (IAS) compared to NCD nurses educated in a conference-style setting, and whether they would maintain equivalent competency at 1 year after education. We randomized 21 district hospitals and their NCD nurses to participate in a 1.5-day educational conference centered around care of type 1 diabetes (Group 1), while nurses from the remaining 21 hospitals (Group 2) received accommodation and access to equivalent educational materials in e-module form. Both groups were requested to review initial course materials at 4, 8, and 12 months. Ten-point IAS assessments were administered before and after education or review at each time point. Groups 1 and 2 had equal improvement after education (+2.0 vs. +2.0, p = 0.47) and equal final score at baseline (6.0 vs. 6.0, p = 0.74). However, both groups showed a diminishing improvement over time, so that any gains were lost by 4 months in Group 1 and 8 months in Group 2. Group 1 showed greater attrition in participation over time (19% vs 58% continued participation at one year, p = 0.002). Groups did not differ in subjective confidence in IAS after education. Both groups identified existing or potential access barriers to their respective educational method. While further modifications should be trialed to ensure equitable access and to maintain long-term engagement, online education is a feasible method to teach complex subspecialty skills to providers working in low-resource settings.

Pregnancy- and parenting-related barriers to receiving medication for opioid use disorder: A multi-paneled qualitative study of women in treatment, women who terminated treatment, and the professionals who serve them.

Women face unique barriers when seeking treatment for substance use disorders, often related to pregnancy and parenting. This study adds to the extant literature by elucidating the pregnancy- and parenting-related barriers women face when initiating or continuing medication for opioid use disorder, specifically. This study is based on qualitative semi-structured interviews. Three subgroups participated in semi-structured interviews regarding their experiences (N = 42): women with current or past opioid use disorders who have used or were presently using medication for opioid use disorder, professionals working in substance use disorder treatment programs, and criminal justice professionals. Three parenting-related subthemes were identified: (1) insufficient access to childcare to navigate appointments and meetings, (2) fear of losing custody of, or access to, one's children, and (3) prioritizing one's children's needs before one's own. Three subthemes were identified with regard to pregnancy as a barrier: (1) hesitancy among physicians to prescribe medication for opioid use disorder for pregnant patients, (2) limited access to resources in rural areas, and (3) difficulty navigating a complex, decentralized health system. Systemic changes are needed to reduce pregnant and parenting women's barriers to seeking medication for opioid use disorder. These include improved childcare support at both in-patient and outpatient treatment programs, which would assuage women's barriers related to childcare, as well as their fears of losing access to their children if they spend time away from their children for treatment. An additional systemic improvement that may reduce barriers for these women is access to comprehensive, integrated care for their prenatal care, postpartum care, pediatric appointments, and appropriate substance use disorder treatment.

“The trip actually opened our eyes to things that we were supposed to do and we were not doing”: developing primary health care system leadership in a low-income country with peer exchanges

BackgroundHealth care systems in low and middle-income countries are decentralizing and devolving power to the periphery. Transferring power without systematic processes to develop and nurture leaders at the district compromises the effectiveness and sustainability of the decentralized health system. To address this problem, we developed an approach to leadership learning by observation and experience that improved the organization and performance of the health care system in a district in Ghana.MethodologyUsing two rounds of a longitudinal qualitative study, the study explores the determinants of implementing the Community-Based Health Planning and Services (CHPS) initiative in a district in Ghana. Insights were gained concerning the leadership regimes of two leaders who administered health services in a common geographic area at different points in time with remarkably contrasting outcomes. Insights of health workers who participated in both periods were elicited to clarify interview contexts. Ten focus group discussions (FGDs) and five expert interviews were conducted for each round of the study. The study was informed by a systems appraisal approach that utilized a thematic analytical framework.ResultsProviding district leaders with a practical observational experience had a significant influence on health care delivery in all aspects of health care provision at the district level. Exposing participants to models of best practices facilitated the replication of processes that improved the conduct of service delivery and CHPS implementation. Upon reflection, district leaders attributed performance constraints to their lack of understanding of practical ways of responding to complex district health system development needs. Observation from community members, volunteers, and health workers who witnessed the system development period corroborated narratives that leaders had expressed.ConclusionEffective leadership is optimally developed with participatory learning that provides leaders with direct access to fully functioning systems. Learning by observation can be structured and used to quicken the spread of managerial excellence.

The 2022 primary care reform in Italy: Improving continuity and reducing regional disparities?

Several member countries of the Organisation for Economic Co-operation and Development are reforming their primary care systems to improve continuity and co-ordination of care. In May 2022, the Italian health minister issued a new Decree on ‘defining models and standards for the development of primary care in the national health service’, which addresses some of the major challenges outlined by the National Recovery and Resilience Plan. The reform will target many aspects of the Italian national health system by transforming primary care into community care, while aiming to overcome geographical disparities and achieve greater effectiveness of services. The reform seeks to establish a new organisational model of the primary care network. There exists the potential to guarantee the same quality of care nationwide, thereby reducing geographical differences in the provision of services and improving healthcare services overall. Nevertheless, in a decentralised health system such as Italy's, reform implementation could actually proliferate rather than reduce regional disparities. This study explains the main points of the Decree, shows how the primary care models of the Italian regions may evolve in relation to the specified criteria, and examines the Decree's capacity to bridge regional discrepancies.

Challenges in Assessment of Health Systems Decentralization: The Role of Path Dependence and Choice of Indicators Comment on "The Effects of Health Sector Fiscal Decentralisation on Availability, Accessibility, and Utilisation of Healthcare Services: A Panel Data Analysis".

Optimal resource allocation within national health systems represents the ultimate challenge in diverse countries worldwide. Major part of the literature points that health systems decentralization potentially address the challenge. The present commentary focuses on the debate referring to effects of health systems decentralization, based on the evidence of the study of Arianna Rotulo and colleagues. Studies on the subject emphasize the role of path dependence and the influence of choice of indicators for measurement of effects in the assessment of health systems decentralization. Acknowledging the complexity of the phenomena, the results of the study of Rotulo et al on health system decentralization in Italy are highlighted through the analysis of recent evidence from the literature. The present commentary shows that there are diverse indicators adopted in the literature on the subject, pointing to mixed results, depending on country characteristics and selection of indicators in the analysis. The synthesis of indicators gathered in recent studies also indicate that health system indicators are sensitive to path dependence, thus, requiring additional attention to assumptions of studies on health systems decentralization. Thus, studies should consider the influence of path dependence on organizational practices and institutional structures involved in decentralization processes, in addition to acknowledging that assessments on decentralization vary substantially according to indicators adopted in the analysis, and their links with previous decisions within health systems.

Perceptions of institutional performance and compliance to non-pharmaceutical interventions: How performance perceptions and policy compliance affect public health in a decentralized health system.

Trust in institutions is a key driver to shape population attitudes and behavior, such as compliance of non-pharmaceutical interventions (NPI). During the COVID-19 pandemic, this was fundamental and its compliance was supported by governmental and non-governmental institutions. Nevertheless, the situation of political polarization in some countries with decentralized health systems increased the difficulty of such interventions. This study analyzes the association between non-pharmaceutical interventions' compliance and individual perception regarding institutions' performance during the COVID-19 pandemic in Brazil. A web survey was conducted in Brazil between November 2020 and February 2021. Bivariate analysis and ordered logit regressions were performed to assess the association between NPIs compliance and perceived institutions' performance. Results suggest a negative association between NPIs' compliance and Federal Government and Ministry of health perceived performance, which may reflect the political positioning of the respondents. Moreover, we find a positive association between NPI compliance and the perceived performance of the remaining institutions (state government, federal supreme court, national congress, WHO, media and SUS). Our contribution goes beyond the study of a relationship between non-pharmaceutical interventions' compliance and institutions' performance, by pointing out the importance of subnational and local governmental spheres in a decentralized health system, as well as highlighting the importance of social communication based on health organizations' information and scientific institutions.

The contribution of community health systems to resilience: Case study of the response to the 2015 earthquake in Nepal.

Key informant interviews and focus group discussions were utilised. Participants included FCHVs, primary healthcare workers, community leaders and mothers, district health managers, representatives from the Ministry of Health and Population, multilateral health organisations, bilateral development partners, local non-governmental organisations, community-based organisations, and international non-governmental organisations. We used thematic content analysis to identify emerging themes. Seventy-seven people participated in the study in September 2016 from communities (n = 53, 69%), districts (n = 8, 10%), and national levels (n = 16, 21%). Strong coordination, international and national support, and community engagement and participation were reported as successes of the earthquake response. Challenges included a lack of preparedness and supplies, a lack of earthquake-resistant infrastructure, and the centralisation of the response. FCHVs continued to work, despite being victims of the earthquake themselves. Facilitators of the continuation of the FCHVs' duties included their strong ties with the communities and facilities, international support, and the ability to mobilise existing community resources. Barriers included fear, communities' attitudes, high workloads, large geographic distances, and difficult geography. Participants identified the importance of having strong, connected, and supported communities, adaptable funding and policies, and decentralised decision-making within strong health systems. Building resilience in community-based health systems must start with strong communities that are prepared, trained, equipped, and empowered. Health systems must be decentralised and adaptable, with strong coordination and leadership. Capable community health workers such as FCHVs were an important part of building resilience during the earthquake. These lessons can assist countries in strengthening decentralised health systems to better respond to a multitude of shocks, while still providing essential health services for communities.

Comparing pharmaceutical company payments in the four UK countries: a cross-sectional and social network analysis

ObjectivesTo examine the characteristics of pharmaceutical payments to healthcare and patient organisations in the four UK countries. Compare companies spending the most; types of organisations receiving payments and types of...

Comparison of COVID-19 Vaccination Rollout Approaches across Canada: Case Studies of Four Diverse Provinces

Across Canada, there were notable differences in the rollout of provincial/territorial COVID-19 vaccination programs, reflecting diverse sociodemographic profiles, geopolitical landscapes, health system designs, and pandemic experiences. We collected information regarding underlying principles and goals, governance and authority, transparency and diversity of communications, activities to strengthen infrastructure and workforce capacity, and entitlement and access in four diverse provinces (British Columbia, Saskatchewan, Ontario, Nova Scotia). Through cross-case analysis, we observed significant differences in provincial rollouts of the primary two-dose vaccination series in adults between December 2020 and December 2021. Nova Scotia was the only province to state explicit coverage goals and adhere to plans tying coverage to the relaxation of public health measures. Both Nova Scotia and British Columbia implemented fully centralized vaccination booking systems. In contrast, Saskatchewan's initial highly centralized approach enabled the rapid delivery of first doses; however, rollout of second doses was slower and more decentralized, occurring primarily through community pharmacies. In alignment with its decentralized health system, Ontario pursued a regionalized approach, primarily led by its existing public health unit network. Our research suggests explicit goals, centralized booking, and flexible delivery strategies improved uptake; however, ongoing learning will be crucial for informing the success of future vaccination efforts.

PS-P12-2: NEEDS ASSESSMENT OF LEADERSHIP AND GOVERNANCE IN CARDIOVASCULAR HEALTH IN NEPAL

Objective: Good governance and leadership to address non-communicable diseases and minimization of their risk factors is crucial to improve healthy life expectancy particularly in low- and middle-income countries. The objective of this study was to understand and document cardiovascular disease (CVD) programs and policy formulation process and epitomize the challenges and opportunities for leadership and good governance for the health system to address non-communicable diseases particularly cardiovascular diseases in Nepal. Design and method: A national level task force was formed to coordinate and steer the overall needs assessment process. A qualitative study design was adopted using The Health System Assessment Approach Manual. Eighteen indicators under six topical areas of leadership and governance in cardiovascular health were assessed. Health laws, policies, regulatory standards, planning and strategy documents and reports on civil society engagement were reviewed. Seven key stakeholders from ministry, professional councils and non-governmental organizations working on CVD were identified and in depth interviews were conducted. Field notes and tape records of interview were compiled and transcribed. Strength, weakness, opportunities and threats in each topical area of leadership and governance were analyzed. Results: Voice and accountability exist in planning for health from the local level. The government has shown strong willingness and has a strategy to work together with the private and non-government sectors in health however, the coordination with non-state actors during policy formulation has not been effective. There are strong rules in place for regulatory quality, control of corruption and maintaining financial transparency. The government frequently relies on evidence generated from large-scale surveys for health policy formulation and planning but research in cardiovascular health has been below par. There is a scarcity of CVD-specific treatment protocols at all levels of government coupled with weak reporting from the private sector. Expensive health care with ineffective cost control over drugs and services, medical malpractice with commission system and lack of interest among donors to invest in CVD were important challenges for strong leadership and governance. Conclusions: Despite plenty of opportunities, much homework is needed to improve leadership and governance in cardiovascular health in Nepal. The government needs to designate a workforce for specific programs to help monitor the enforcement of health sector regulations, allocate enough funding to encourage CVD research and work towards developing CVD-specific guidelines, protocols, and capacity building. The government needs to leverage the opportunities associated with the current decentralized health system.

“Local cooperation has been the cornerstone”: facilitators and barriers to resilience in a decentralized health system during COVID-19 in Finland

PurposeThe purpose of this study was to elucidate facilitators and barriers to health system resilience and resilient responses at local and regional levels during the first year of the COVID-19 pandemic in Finland.Design/methodology/approachThe authors utilized a qualitative research approach and conducted semi-structured interviews (n = 32) with study participants representing five different regions in Finland. Study participants were recruited using purposive and snowball sampling. All study participants had been in management and civil servant positions during the first year of the pandemic, representing municipalities, municipalities' social and healthcare services, hospital districts and regional state administrative agencies. All interviews were completed remotely from April to December 2021 and the recordings transcribed verbatim. The authors coded the transcripts in ATLAS.ti 9.1 using directed content analysis.FindingsThe findings highlighted a wide range of localized responses to the pandemic in Finland. Facilitators to health system resilience included active networks of cooperation, crisis anticipation, transitioning into crisis leadership mode, learning how to incorporate new modes of operation, as well as relying on the competencies and motivation of health workforce. The authors found several barriers to health system resilience, including fragmented organization and management particularly in settings where integrated health care systems were not in place, insufficient preparedness to a prolonged crisis, lack of reliable information regarding COVID-19, not having plans in place for crisis communication, pandemic fatigue, and outflux of health workforce to other positions with better compensation and working conditions.Originality/valueFactors affecting health system resilience are often studied at the aggregate level of a nation. This study offers insights into what resilient responses look like from the perspective of local and regional actors in a decentralized health system. The results highlight that local capacities and context matter greatly for resilience. The authors call for more nuanced analyses on health systems and health system resilience at the sub-national level.