46 research outputs found
Forms and Functioning of Local Accountability Mechanisms for Maternal, Newborn and Child Health: A Case Study of Gert Sibande District, South Africa
Philosophiae Doctor - PhDThe value of accountability as a key feature of strengthening health systems and reducing maternal, newborn and child mortality is increasingly emphasised globally, nationally and locally. Frontline health professionals and managers play a crucial role in promoting maternal, newborn and child health (MNCH) services in an equitable and accountable manner. They are at the interface between higher-level health system management and communities, facing demands from both sides and often expected to perform beyond their available means. Although accountability is a central topic in the governance of MNCH literature, it has mostly been approached at global and national
levels, with little understanding of how accountability is integrated into the routine functioning of local health systems. This PhD explores the forms and functioning of accountability at the district level focusing on MNCH as a programmatic area with long-established institutional
mechanisms (structures and processes) in South Africa (SA). The thesis is presented in the form of four empirical papers (published or submitted), exploring different dimensions of accountability, which are embedded in a series of narrative chapters. In this thesis, accountability is understood as a set of relations between an accountholder and ‘accountor’ (or duty bearer), in which the latter provides information or justification for actions or decisions taken, and faces the resulting consequences of his/her actions (reward or sanction). Accountability mechanisms are the means to regulate accountability relationships and include broad strategies, interventions or
instruments. These mechanisms can take various forms including performance, financial and public accountability, and operate both vertically (accountability inside bureaucratic hierarchies, or towards external stakeholders and/or the community), or horizontally (between peers, ‘neighbour’ units, departments or ministries in a national health system). Drawing conceptually on the field of governance and considering the complexity of the accountability phenomenon, I adopted a case study approach to the PhD research, using a combination of policy document review, interviews (with managers, providers, community representatives and members of labour unions) and field observations,
conducted iteratively over 16 months. The study was conducted in Gert Sibande District, one of the three South African health districts in Mpumalanga Province, with an in-depth focus on two of the seven sub-districts in the District. The research found that frontline health professionals have a clear understanding and conceptualisation of accountability in the SA health policy context, despite the reported inability to define accountability by health professionals described in the literature. Respondents referred to accountability as responsibility, answerability and virtue, and also argued for strengthening accountability mechanisms as critical to addressing maternal and child mortality. While deeming accountability as important, frontline professionals experienced the existing accountability mechanisms as ‘too much’ and indicated the desire for the streamlining of existing mechanisms. In this regard, the study documented numerous mechanisms at district level, almost all related to performance accountability in MNCH. These included a performance management system, quality assessment and accreditation processes, quarterly reviews, and death surveillance and response processes. The existence of multiple and overlapping accountability mechanisms engenders operational confusion and ‘accountability overload’ for frontline providers, encouraging empty bureaucratic compliance, while critical gaps – notably in community accountability – remain. In practice, at their best, some mechanisms operate following a reciprocal1 pathway of capacity building with resource provision (from management) and expectation for better performance (from providers). There were, however, contextual variations in the implementation and practice of the mechanisms between sub-district settings. The fieldwork observations and interviews were also able to document how formal institutionalised mechanisms are embedded within a complex system of informal accountability relationships and social norms (‘accountability ecosystem’) that enables
or constrains the ability of frontline professionals to fulfil their tasks. In addition, using a Social Network Analysis approach, the research identified key actors and their involved network, which form the relational backdrop to the functioning of accountability mechanisms for MNCH. By revealing complex relationships and collaboration patterns among frontline health professionals, the study was able to
show the multi-level action and multiple actors required to achieve MNCH goals
Forms and functioning of local accountability mechanisms for maternal, newborn and child health: A case study of Gert Sibande district, South Africa
Philosophiae Doctor - PhDThe value of accountability as a key feature of strengthening health systems and
reducing maternal, newborn and child mortality is increasingly emphasised globally,
nationally and locally. Frontline health professionals and managers play a crucial role
in promoting maternal, newborn and child health (MNCH) services in an equitable
and accountable manner. They are at the interface between higher-level health system
management and communities, facing demands from both sides and often expected to
perform beyond their available means. Although accountability is a central topic in the
governance of MNCH literature, it has mostly been approached at global and national
levels, with little understanding of how accountability is integrated into the routine
functioning of local health systems
Expressions of actor power in implementation: A qualitative case study of a health service intervention in South Africa
Implementation frameworks and theories acknowledge the role of power as a factor in the adoption (or
not) of interventions in health services. Despite this recognition, there is a paucity of evidence on how
interventions at the front line of health systems confront or shape existing power relations. This paper
reports on a study of actor power in the implementation of an intervention to improve maternal, neonatal
and child health care quality and outcomes in a rural district of South Africa.A retrospective qualitative case study based on interviews with 34 actors in three ‘implementation units’ –
a district hospital and surrounding primary health care services – of the district, selected as purposefully
representing full, moderate and low implementation of the intervention some three years after it was first
introduced. Data are analysed using Veneklasen and Miller’s typology of the forms of power – namely
‘power over’, ‘power to’, ‘power within’ and ‘power with’
Multilevel governance and control of the Covid-19 pandemic in the Democratic Republic of Congo: Learning from the four first waves
The COVID-19 pandemic continues to impose a heavy burden on people around the
world. The Democratic Republic of the Congo (DRC) has also been affected. The objective of this
study was to explore national policy responses to the COVID-19 pandemic in the DRC and drivers
of the response, and to generate lessons for strengthening health systems’ resilience and public
health capacity to respond to health security threats. This was a case study with data collected
through a literature review and in-depth interviews with key informants. Data analysis was carried
out manually using thematic content analysis translated into a logical and descriptive summary
of the results. The management of the response to the COVID-19 pandemic reflected multilevel
governance. It implied a centralized command and a decentralized implementation. The centralized
command at the national level mostly involved state actors organized into ad hoc structures. The
decentralized implementation involved state actors at the provincial and peripheral level including
two other ad hoc structures. Non-state actors were involved at both levels
Local dynamics of collaboration for maternal, newborn and child health: A social network analysis of healthcare providers and their managers in Gert Sibande district, South Africa
: Accountability for maternal, newborn and child health (MNCH) is a collaborative endeavour and
documenting collaboration dynamics may be key to understanding variations in the performance of MNCH services.
This study explored the dynamics of collaboration among frontline health professionals participating in two MNCH
coordination structures in a rural South African district. It examined the role and position of actors, the nature of their
relationships, and the overall structure of the collaborative network in two sub-districts.Cross-sectional survey using a social network analysis (SNA) methodology of 42 district and sub district
actors involved in MNCH coordination structures. Different domains of collaboration (eg, communication, professional
support, innovation) were surveyed at key interfaces (district-sub-district, across service delivery levels, and within
teams)
Practice of death surveillance and response for maternal, newborn and child health: A framework and application to a South African health district
To assess the functioning of maternal, perinatal,
neonatal and child death surveillance and response (DSR)
mechanisms at a health district level.A framework of elements covering analysis of
causes of death, and processes of review and response
was developed and applied to the smallest unit of
coordination (subdistrict) to evaluate DSR functioning. The
evaluation design was a descriptive qualitative case study,
based on observations of DSR practices and interviews
The crowded space of local accountability for maternal, newborn and child health: A case study of the South African health system
Global and national accountability for maternal, newborn and child health (MNCH) is increasingly invoked as central to addressing preventable mortality and morbidity. Strategies of accountability for MNCH include policy and budget tracking, maternal and perinatal death surveillance, performance targets and various forms of social accountability. However, little is known about how the growing number of accountability strategies for MNCH is received by frontline actors, and how they are integrated into the overall functioning of local health systems. We conducted a case study of mechanisms of local accountability for MNCH in South Africa, involving a document review of national policies, programme reports, and other literature directly or indirectly related to MNCH, and in-depth research in one district. The latter included observations of accountability practices (e.g. through routine meetings) and in-depth interviews with 37 purposely selected health managers and frontline health workers involved in MNCH. Data collection and analysis were guided by a framework that defined accountability as answerability and action (both individual and collective), addressing performance, financial and public accountability, and involving both formal and informal processes. Nineteen individual accountability mechanisms were identified, 10 directly and 9 indirectly related to MNCH, most of which addressed performance accountability
Multilevel Governance and Control of the COVID-19 Pandemic in the Democratic Republic of Congo: Learning from the Four First Waves
The COVID-19 pandemic continues to impose a heavy burden on people around the
world. The Democratic Republic of the Congo (DRC) has also been affected. The objective of this
study was to explore national policy responses to the COVID-19 pandemic in the DRC and drivers
of the response, and to generate lessons for strengthening health systems’ resilience and public
health capacity to respond to health security threats. This was a case study with data collected
through a literature review and in-depth interviews with key informants. Data analysis was carried
out manually using thematic content analysis translated into a logical and descriptive summary
of the results. The management of the response to the COVID-19 pandemic reflected multilevel
governance. It implied a centralized command and a decentralized implementation. The centralized
command at the national level mostly involved state actors organized into ad hoc structures. The
decentralized implementation involved state actors at the provincial and peripheral level including
two other ad hoc structures. Non-state actors were involved at both levels. These ad hoc structures
had problems coordinating the transmission of information to the public as they were operating
outside the normative framework of the health system. Conclusions: Lessons that can be learned
from this study include the strategic organisation of the response inspired by previous experiences
with epidemics; the need to decentralize decision-making power to anticipate or respond quickly and
adequately to a threat such as the COVID-19 pandemic; and measures decided, taken, or adapted
according to the epidemiological evolution (cases and deaths) of the epidemic and its effects on the
socio-economic situation of the population. Other countries can benefit from the DRC experience by
adapting it to their own context
Individual interactions in a multi-country implementation-focused quality of care network for maternal, newborn and child health: A social network analysis
The Network for Improving Quality of Care for Maternal, Newborn and Child Health (QCN) was established to build a cross-country platform for joint-learning around quality improvement implementation approaches to reduce mortality. This paper describes and explores the structure of the QCN in four countries and at global level. Using Social Network Analysis (SNA), this cross-sectional study maps the QCN networks at global level and in four countries (Bangladesh, Ethiopia, Malawi and Uganda) and assesses the interactions among actors involved. A pre-tested closed-ended structured questionnaire was completed by 303 key actors in early 2022 following purposeful and snowballing sampling. Data were entered into an online survey tool, and exported into Microsoft Excel for data management and analysis. This study received ethical approval as part of a broader evaluation. The SNA identified 566 actors across the four countries and at global level. Bangladesh, Malawi and Uganda had multiple-hub networks signifying multiple clusters of actors reflecting facility or district networks, whereas the network in Ethiopia and at global level had more centralized networks. There were some common features across the country networks, such as low overall density of the network, engagement of actors at all levels of the system, membership of related committees identified as the primary role of actors, and interactions spanning all types (learning, action and information sharing). The most connected actors were facility level actors in all countries except Ethiopia, which had mostly national level actors. The results reveal the uniqueness and complexity of each network assessed in the evaluation. They also affirm the broader qualitative evaluation assessing the nature of these networks, including composition and leadership. Gaps in communication between members of the network and limited interactions of actors between countries and with global level actors signal opportunities to strengthen QCN
A comparative evaluation of PDQ-Evidence
BACKGROUND: A strategy for minimising the time and obstacles to accessing systematic reviews of health system
evidence is to collect them in a freely available database and make them easy to find through a simple ‘Google-style’
search interface. PDQ-Evidence was developed in this way. The objective of this study was to compare PDQ-Evidence
to six other databases, namely Cochrane Library, EVIPNet VHL, Google Scholar, Health Systems Evidence, PubMed
and Trip.
METHODS: We recruited healthcare policy-makers, managers and health researchers in low-, middle- and highincome
countries. Participants selected one of six pre-determined questions. They searched for a systematic
review that addressed the chosen question and one question of their own in PDQ-Evidence and in two of the
other six databases which they would normally have searched. We randomly allocated participants to search
PDQ-Evidence first or to search the two other databases first. The primary outcomes were whether a systematic
review was found and the time taken to find it. Secondary outcomes were perceived ease of use and perceived
time spent searching. We asked open-ended questions about PDQ-Evidence, including likes, dislikes, challenges
and suggestions for improvements.
RESULTS: A total of 89 people from 21 countries completed the study; 83 were included in the primary analyses
and 6 were excluded because of data errors that could not be corrected. Most participants chose PubMed and
Cochrane Library as the other two databases. Participants were more likely to find a systematic review using
PDQ-Evidence than using Cochrane Library or PubMed for the pre-defined questions. For their own questions, this
difference was not found. Overall, it took slightly less time to find a systematic review using PDQ-Evidence. Participants
perceived that it took less time, and most participants perceived PDQ-Evidence to be slightly easier to use than the
two other databases. However, there were conflicting views about the design of PDQ-Evidence.
CONCLUSIONS: PDQ-Evidence is at least as efficient as other databases for finding health system evidence. However,
using PDQ-Evidence is not intuitive for some people