Feasibility of Good Governance at Health Facilities: A Proposed Framework and its Application Using Empirical Insights From Kenya.

BACKGROUND: Governance is a social phenomenon which permeates throughout systemic, organisational and individual levels. Studies of health systems governance traditionally assessed performance of systems or organisations against principles of good governance. However, understanding key pre-conditions to embed good governance required for healthcare organisations is limited. We explore the feasibility of embedding good governance at healthcare facilities in Kenya. METHODS: Our conceptualisation of organisational readiness for embedding good governance stems from a theory of institutional analysis and frameworks for understanding organisational readiness for change. Four inter-related constructs underpin to embed good governance: (i) individual motivations, determined by (ii) mechanisms for encouraging adherence to good governance through (iii) organisation's institutional arrangements, all within (iv) a wider context. We propose a framework, validated through qualitative methods and collected through 39 semi-structured interviews with healthcare providers, county and national-level policy-makers in Kenya. Data was analysed using framework approach, guided by the four constructs of the theoretical framework. We explored each construct in relation to three key principles of good governance: accountability, participation and transparency of information. RESULTS: Embedding good governance in healthcare organisations in Kenya is influenced by political and socio-cultural contexts. Individual motivations were a critical element of self-enforcement to embed principles of good governance by healthcare providers within their facilities. Healthcare providers possess strong moral incentives to self-enforce accountability to local populations, but their participation in decision-making was limited. Health facilities lacked effective mechanisms for enforcing good governance such as combating corruption, which led to a proliferation of informal institutional arrangements. CONCLUSION: Organisational readiness for good governance is context-specific so future work should recognise different interpretations of acceptable degrees of transparency, accountability and participation. While good governance involves collective social action, organisational readiness relies on individual choices and decisions within the context of organisational rules and cultural and historical environments

Frameworks to assess health systems governance: a systematic review

Governance of the health system is a relatively new concept and there are gaps in understanding what health system governance is and how it could be assessed. We conducted a systematic review of the literature to describe the concept of governance and the theories underpinning as applied to health systems; and to identify which frameworks are available and have been applied to assess health systems governance. Frameworks were reviewed to understand how the principles of governance might be operationalized at different levels of a health system. Electronic databases and web portals of international institutions concerned with governance were searched for publications in English for the period January 1994 to February 2016. Sixteen frameworks developed to assess governance in the health system were identified and are described. Of these, six frameworks were developed based on theories from new institutional economics; three are primarily informed by political science and public management disciplines; three arise from the development literature and four use multidisciplinary approaches. Only five of the identified frameworks have been applied. These used the principal–agent theory, theory of common pool resources, North’s institutional analysis and the cybernetics theory. Governance is a practice, dependent on arrangements set at political or national level, but which needs to be operationalized by individuals at lower levels in the health system; multi-level frameworks acknowledge this. Three frameworks were used to assess governance at all levels of the health system. Health system governance is complex and difficult to assess; the concept of governance originates from different disciplines and is multidimensional. There is a need to validate and apply existing frameworks and share lessons learnt regarding which frameworks work well in which settings. A comprehensive assessment of governance could enable policy makers to prioritize solutions for problems identified as well as replicate and scale-up examples of good practice

Implementation of the free maternity services policy and its implications for health system governance in Kenya.

Introduction To move towards universal health coverage, the government of Kenya introduced free maternity services in all public health facilities in June 2013. User fees are, however, important sources of income for health facilities and their removal has implications for the way in which health facilities are governed. Objective To explore how implementation of Kenya's financing policy has affected the way in which the rules governing health facilities are made, changed, monitored and enforced. Methods Qualitative research was carried out using semistructured interviews with 39 key stakeholders from six counties in Kenya: 10 national level policy makers, 10 county level policy makers and 19 implementers at health facilities. Participants were purposively selected using maximum variation sampling. Data analysis was informed by the institutional analysis framework, in which governance is defined by the rules that distribute roles among key players and shape their actions, decisions and interactions. Results Lack of clarity about the new policy (eg, it was unclear which services were free, leading to instances of service user exploitation), weak enforcement mechanisms (eg, delayed reimbursement to health facilities, which led to continued levying of service charges) and misaligned incentives (eg, the policy led to increased uptake of services thereby increasing the workload for health workers and health facilities losing control of their ability to generate and manage their own resources) led to weak policy implementation, further complicated by the concurrent devolution of the health system. Conclusion The findings show the consequences of discrepancies between formal institutions and informal arrangements. In introducing new policies, policy makers should ensure that corresponding institutional (re)arrangements, enforcement mechanisms and incentives are aligned with the objectives of the implementers

Experiences from the field: maternal, reproductive and child health data collection in humanitarian and emergency situations

Background Humanitarian emergencies can disproportionately affect women of reproductive age, and children. Good data on reproductive maternal, newborn and child health (RMNCH) are vital to plan and deliver programmes to address RMNCH needs. There is currently a lack of information regarding the availability, use and applicability of data collection tools. Methods Key informant interviews (KII) were conducted with participants with experience of data collection in humanitarian settings, identified from relevant publications. Data were analysed using the thematic framework approach. Results All participants reported challenges, especially in the acute phase of an emergency and when there is insufficient security. Four common themes were identified: the importance of a mixed methods approach, language both with regard to development of data collection tools and data collection, the need to modify existing tools and build local capacity for data collection. Qualitative data collection was noted to be time consuming but considered to be important to understand the local context. Both those who have experienced trauma (including sexual violence) and data collectors require debriefing after documenting these experiences. Conclusions There were numerous challenges associated with data collection assessing the health status of, and services available, to women and children in humanitarian settings, and researchers should be well prepared

Strengthening close to community provision of maternal health services in fragile settings: an exploration of the changing roles of TBAs in Sierra Leone and Somaliland.

Efforts to take forward universal health coverage require innovative approaches in fragile settings, which experience particularly acute human resource shortages and poor health indicators. For maternal and newborn health, it is important to innovate with new partnerships and roles for Traditional Birth Attendants (TBAs) to promote maternal health. We explore perspectives on programmes in Somaliland and Sierra Leone which link TBAs to health centres as part of a pathway to maternal health care. Our study aims to understand the perceptions of communities, stakeholder and TBAs themselves who have been trained in new roles to generate insights on strategies to engage with TBAs and to promote skilled birth attendance in fragile affected settings. A qualitative study was carried out in two chiefdoms in Bombali district in Sierra Leone and the Maroodi Jeex region of Somaliland. Purposively sampled participants consisted of key players from the Ministries of Health, programme implementers, trained TBAs and women who benefitted from the services of trained TBAs. Data was collected through key informants and in-depth interviews and focus group discussions. Data was transcribed, translated and analyzed using the framework approach. For the purposes of this paper, a comparative analysis was undertaken reviewing similarities and differences across the two different contexts. Analysis of multiple viewpoints reveal that with appropriate training and support it is possible to change TBAs practices so they support pregnant women in new ways (support and referral rather than delivery). Participants perceived that trained TBAs can utilize their embedded and trusted community relationships to interact effectively with their communities, help overcome barriers to acceptability, utilization and contribute to effective demand for maternal and newborn services and ultimately enhance utilization of skilled birth attendants. Trained TBAs appreciated cordial relationship at the health centres and feeling as part of the health system. Key challenges that emerged included the distance women needed to travel to reach health centers, appropriate remuneration of trained TBAs and strategies to sustain their work. Our findings highlight the possible gains of the new roles and approaches for trained TBAs through further integrating them into the formal health system. Their potential is arguably critically important in promoting universal health coverage in fragile and conflict affected states (FCAS) where human resources are additionally constrained and maternal and newborn health care needs particularly acute

Data collection tools for maternal and child health in humanitarian emergencies: a systematic review

OBJECTIVE: To describe tools used for the assessment of maternal and child health issues in humanitarian emergency settings. METHODS: We systematically searched MEDLINE, Web of Knowledge and POPLINE databases for studies published between January 2000 and June 2014. We also searched the websites of organizations active in humanitarian emergencies. We included studies reporting the development or use of data collection tools concerning the health of women and children in humanitarian emergencies. We used narrative synthesis to summarize the studies. FINDINGS: We identified 100 studies: 80 reported on conflict situations and 20 followed natural disasters. Most studies (76/100) focused on the health status of the affected population while 24 focused on the availability and coverage of health services. Of 17 different data collection tools identified, 14 focused on sexual and reproductive health, nine concerned maternal, newborn and child health and four were used to collect information on sexual or gender-based violence. Sixty-nine studies were done for monitoring and evaluation purposes, 18 for advocacy, seven for operational research and six for needs assessment. CONCLUSION: Practical and effective means of data collection are needed to inform life-saving actions in humanitarian emergencies. There are a wide variety of tools available, not all of which have been used in the field. A simplified, standardized tool should be developed for assessment of health issues in the early stages of humanitarian emergencies. A cluster approach is recommended, in partnership with operational researchers and humanitarian agencies, coordinated by the World Health Organization

Introducing a sector-wide pooled fund in a fragile context: mixed-methods evaluation of the health transition fund in Zimbabwe.

IntroductionAid effectiveness and improving its impact is a central policy matter for donors and international organisations. Pooled funding is a mechanism, whereby donors provide financial contributions towards a common set of broad objectives by channelling finance through one instrument. The results of pooled funds as an aid mechanism are mixed, and there is limited data on both methodology for, and results of, assessment of effectiveness of pooled funding.MethodsThis study adapted a conceptual framework incorporating the Paris Principles of Aid Effectiveness and qualitative methods to assess the performance of the Health Transition Fund (HTF) Zimbabwe. 30 key informant interviews, and 20 focus group discussions were conducted with informants drawn from village to national level. Descriptive secondary data analysis of Demographic Health Surveys, Health Management Information Systems (HMIS) and policy reports complemented the study.ResultsThe HTF combined the most optimal option to channel external aid to the health sector in Zimbabwe during a period of socioeconomic and political crisis. It produced results quickly and at scale and enhanced coordination and ownership at the national and subnational level. Flexibility in using the funds was a strong feature of the HTF. However, the initiative compromised on the investment in local capacity and systems, since the primary focus was on restoring essential services within a nearly collapsed healthcare system, rather than building long-term capacity. Significant changes in maternal and newborn health outcomes were observed during the HTF implementation in Zimbabwe.ConclusionA framework which can be used to assess pooled funds was adapted and applied. Future assessments could use this or another framework to provide new evidence regarding effectiveness of pool donor funds although the frameworks should be properly tested and adapted in different contexts

2016 Zimbabwe: Independent Evaluation of the Health Transition Fund in Zimbabwe

With the aim to continuously improve transparency and use of evaluation, UNICEF Evaluation Office manages the "Global Evaluation Reports Oversight System (GEROS)". Within this system, an external independent company reviews and rates all evaluation reports. The quality rating scale for evaluation reports is as follows: “Highly Satisfactory”, “Satisfactory”, “Fair” or “Unsatisfactory”. You will find the link to the quality rating below, labelled as ‘Part 3’ of the report, and the executive feedback summary labelled as 'Part 4'

Factors governing the performance of Auxiliary Nurse Midwives in India: a study in Pune district

Background: The Auxiliary nurse midwife (ANM) cadre was created to focus on maternal and child health. ANMs are respected members of their communities and established providers of maternal and child health care within the community and at the facility level. Over time, additional roles and responsibilities have been added. Despite the importance of ANMs in the primary healthcare system in India, studies that consider factors governing the performance of ANMs in their workplaces are limited. We aimed to study factors governing performance of ANMs in Pune district, India. Methods: Semi-structured interviews were conducted with 13 purposely selected key informants at facility, district, state, and national levels. Focus group discussions were conducted with 41 ANMs and 25 members of the community. Non-participatory observations with eight ANMs provided information to expand on and scrutinise findings that emerged from the other lines of inquiry. A realist lens was applied to identify ANMs’ performance as a result of “mechanisms” (training, supervision, accountability mechanisms) within the given “context” (regulatory system, infrastructure and resources, ANMs’ expanded scope of work, gender roles and norms). Results: Weak enforcement of regulatory system led to poor standardisation of training quality among training institutions. Challenges in internal accountability mechanisms governing ANMs within the health system hierarchy made it difficult to ensure individual accountability. Training and supervision received were inadequate to address current responsibilities. The supervisory approach focused on comparing information in periodic reports against expected outputs. Clinical support in workplaces was insufficient, with very little problem identification and solving. Conclusion: Focusing on the tasks of ANMs with technical inputs alone is insufficient to achieve the full potential of ANMs in a changing context. Systematic efforts tackling factors governing ANMs in their workplaces can produce a useful cadre, that can play an important role in achieving universal health coverage in India