How can governance be strengthened in decentralised health systems? Lessons from Ghana, Tanzania and Uganda

Poor governance is a major issue in our local health systems. Most of the time, our interventions focus rather on resource allocations. Improving governance is not an easy task. We need innovative strategies. Sally Theobald proposes some key strategies that were used in Ghana, Tanzania and Uganda.

Please, give your comments and share your experience. There is a space for comments at the end of the blog.

By Sally Theobald; www.performconsortium.com ; #performconsortium

Setting the scene

At the Health Systems Global Conference in Cape Town Tim Martineau introduced the EU funded PERFORM project which is taking place in 3 decentralised African settings– Tanzania, Uganda and Ghana – where  District Health Management Teams (DHMTs) have some autonomy and decision space in certain areas  for action. PERFORM is conducting a comparative analysis across districts and countries to identify strategic management strengthening interventions for integrating HR strategies and identifying unintended consequences.  This engaging panel session in Cape Town addressed 3 questions:

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

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

c. How can good practice be shared across decentralised structure to improve governance structures more widely?
I have summarised the discussion and learning against each questions.

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

 A view from Jinja, Uganda

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

Maximising decision space requires strategic team work

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

Context and power are key

Sreytouch Vong from the Cambodia Development Research Institute highlighted the importance of understanding the social, cultural and political context for decision making space and how this is realised or constrained in practice.  Vathanak Khim also from Cambodia highlighted that decentralisation  may be the official policy and written down but the reality is that this can be constrained. Aaron Black, from the Health policy project in Kenya also highlighted the importance of context in the Kenyan transition to a devolved system of governance and their learning here. He said that politics and resources are key, arguing that politicians want to invest in hardware and that you can have “a huge decisions space but if there is no money or resources the decision space is redundant.” Dyogo agreed saying that politics within organisation play the biggest role and how we manage those determines whether you will succeed. Stefan Peters from Makerere University, Uganda and the Karolinska Institute also referred to power “as the elephant in the room, or the whale as we are in Cape Town”. He argued that power and politics ultimately constrain or open decision making space, triggering Sue Patton from Management Science for Health to add another question – “in decentralised systems the bigger the decisions space becomes, are we not creating a bigger space for corruption?”

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

The PERFORM Ghana experience

Patricia Akweongo, University of Ghana presented on her experience of being part of the Country Research Team (CRT) that supported 3 DMHTs to undertake a reflective action research process to improve workforce performance. She explained how the CRTs supported DHMTs to identify problems and integrate them into district plans. They prioritised the problems they wanted to address and used an iterative process to review the cause and effect of each of the problems and in many cases these related to time and staff’s ability to proactively deliver on their key tasks. For example in Upper Manya Krobo the main problem is low coverage in ANC and maternal health. The problem was analysed locally and contextualised solutions were implemented, DHMTs also highlighted how much of their time was taken up receiving visitors or waiting to receive visitors. Patricia highlighted the importance for sustainability and ownership of identifying and solving problems at district level and with funding available at district level.

Models for mentoring

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

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

Districts are where health systems are realised

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

Sharing practice within country contexts

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

Strategic positioning in a crowded field

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