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

This is the first 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.

This question was interrogated during a participatory panel at health systems global hosted by the PERFORM project. PERFORM deploys participatory action research approaches to make better use of the current health workforce through supporting integrated human resource and management strategies. PERFORM 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.

A view from Jinja: Dyogo Nantamu, the District Health Officer from Jinja, Uganda kicked off by outlining the structures and roles of the DHMT within his district. The core functions of the DHMT include planning, M&E, HRH deployment, mentorship, training, supervision and rewards and sanctions of staff. They have the autonomy to decide on staff appraisal, posting, rewards and sanctions but not recruitment, dismissal, promotion/demotion or determination of pay for staff. Within PERFORM Dyogo and 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? How do we make it meaningful? 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 said that decentralisation  may be the official policy and written down but the reality is that this is constrained by the dictates that come from above.  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” arguing that power and politics ultimately constrains or opens decision making space.

PERFORM will continue to document and share lessons on ways in which DHMTs can be best supported to seize decision space to support health systems strengthening at district level.

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

Please read the two other blogs in this series: How can managers and their teams be supported through workshops and mentoring to use their management decision space? and How can good practice be shared across decentralised structure to improve governance structures more widely?

This blog also appears on the PERFORM website.

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