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

This is the third in a series of three blogs each addressing a specific question on ‘How can governance be strengthened in decentralised health systems’ from the session on District Performance hosted by PERFORM at the Third Global Symposium on Health Systems Research 2014 in Cape Town. The PERFORM  consortium, funded by the European Union, is supporting decentralised management to improve health workforce performance in Ghana, Uganda and Tanzania.

The importance of supporting sustained work at the district level came out loud and clear at the Health Systems Global panel “How can governance be strengthened in decentralised health systems? Lessons from Ghana, Tanzania and Uganda”. Districts 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 project . 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 newsheets. 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 not 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 better done 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.

Blog by Sally Theobald; www.performconsortium.com ; #performconsortium

Please read the two other blogs in this series: What decision space or room for manoeuvre is available to health service managers within decentralised contexts and what key factors influence this? and How can managers and their teams be supported through workshops and mentoring to use their management decision space?

This blog also appears on the PERFORM website.

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