Deciphering Governance: Analysing constructs of governance, and how they facilitate attainment of health goals in a low- or middle-income country. A Case Study from Kenya

Challenges with ensuring effective governance persist in low- and middle-income countries in part due to lack of a common approach to interpreting and applying it by those responsible for providing direction and oversight of the health agenda. My study explores how to overcome this challenge. I document several theoretical, institutional or conceptual approaches to define the concept of governance. I postulate that through identifying a clear way to interpret and apply governance, health stewards and managers in low- or middle-income countries would be better able to plan, implement and monitor governance actions needed to facilitate attainment of their health results. To explore this through case studies involving forty-nine Key Informants in Kenya representing health stewards and managers at macro, meso and micro levels of oversight, plus public, faith based and private sector providers plus civil society organizations. Amongst these, I explored the various ways governance is understood, and factors needed from the health sector and other sectors. To ensure a depth of exploration, I deconstructed governance into its constituent constructs. I found that, these persons expected to implement governance actions understood these from the perspective of six primary characteristics. I also find that health sectors need to ensure a range of policy/legal, and structural (tangible) / process (intangible) based instruments and tools to facilitate the action of governance. Finally, other sectors need to focus on ensuring there are community transformation initiatives, processes to build social capital, participatory decision-making culture, systems to ensure equity and the right to health, governance improving processes and opportunities to expand devolved level decision space. My results have some elements that have been identified before in literature, and some which are new or not part of the mainstream thinking. I therefore build a reconstruction of governance through structuring and outlining the actions health stewards and managers need to focus on for effective influence on their health results. It would be worthwhile to explore how to make this construction of governance operational for health stewards and managers in low- or middle-income countries

Health sector reforms and human resources for health in Uganda and Bangladesh: mechanisms of effect

BACKGROUND: Despite the expanding literature on how reforms may affect health workers and which reactions they may provoke, little research has been conducted on the mechanisms of effect through which health sector reforms either promote or discourage health worker performance. This paper seeks to trace these mechanisms and examines the contextual framework of reform objectives in Uganda and Bangladesh, and health workers' responses to the changes in their working environments by taking a 'realistic evaluation' approach. METHODS: The study findings were generated by triangulating both qualitative and quantitative methods of data collection and analysis among policy technocrats, health managers and groups of health providers. Quantitative surveys were conducted with over 700 individual health workers in both Bangladesh and Uganda and supplemented with qualitative data obtained from focus group discussions and key interviews with professional cadres, health managers and key institutions involved in the design, implementation and evaluation of the reforms of interest. RESULTS: The reforms in both countries affected the workforce through various mechanisms. In Bangladesh, the effects of the unification efforts resulted in a power struggle and general mistrust between the two former workforce tracts, family planning and health. However positive effects of the reforms were felt regarding the changes in payment schemes. Ugandan findings show how the workforce responded to a strong and rapidly implemented system of decentralisation where the power of new local authorities was influenced by resource constraints and nepotism in recruitment. On the other hand, closer ties to local authorities provided the opportunity to gain insight into the operational constraints originating from higher levels that health staff were dealing with. CONCLUSION: Findings from the study suggest that a) reform planners should use the proposed dynamic responses model to help design reform objectives that encourage positive responses among health workers b) the role of context has been underestimated and it is necessary to address broader systemic problems before initiating reform processes, c) reform programs need to incorporate active implementation research systems to learn the contextual dynamics and responses as well as have inbuilt program capacity for corrective measures d) health workers are key stakeholders in any reform process and should participate at all stages and e) some effects of reforms on the health workforce operate indirectly through levels of satisfaction voiced by communities utilising the services

On the resilience of health systems: A methodological exploration across countries in the WHO African Region

The need for resilient health systems is recognized as important for the attainment of health outcomes, given the current shocks to health services. Resilience has been defined as the capacity to “prepare and effectively respond to crises; maintain core functions; and, informed by lessons learnt, reorganize if conditions require it”. There is however a recognized dichotomy between its conceptualization in literature, and its application in practice. We propose two mutually reinforcing categories of resilience, representing resilience targeted at potentially known shocks, and the inherent health system resilience, needed to respond to unpredictable shock events. We determined capacities for each of these categories, and explored this methodological proposition by computing country-specific scores against each capacity, for the 47 Member States of the WHO African Region. We assessed face validity of the computed index, to ensure derived values were representative of the different elements of resilience, and were predictive of health outcomes, and computed bias-corrected non-parametric confidence intervals of the emergency preparedness and response (EPR) and inherent system resilience (ISR) sub-indices, as well as the overall resilience index, using 1000 bootstrap replicates. We also explored the internal consistency and scale reliability of the index, by calculating Cronbach alphas for the various proposed capacities and their corresponding attributes. We computed overall resilience to be 48.4 out of a possible 100 in the 47 assessed countries, with generally lower levels of ISR. For ISR, the capacities were weakest for transformation capacity, followed by mobilization of resources, awareness of own capacities, self-regulation and finally diversity of services respectively. This paper aims to contribute to the growing body of empirical evidence on health systems and service resilience, which is of great importance to the functionality and performance of health systems, particularly in the context of COVID-19. It provides a methodological reflection for monitoring health system resilience, revealing areas of improvement in the provision of essential health services during shock events, and builds a case for the need for mechanisms, at country level, that address both specific and non-specific shocks to the health system, ultimately for the attainment of improved health outcomes