'Four' types of decentralization are distinguished in health care: deconcentration when the shift in authority is to regional or district offices; devolution when the shift is to state, provincial or municipal governments; delegation when semi-autonomous agencies are granted new powers; and privatization when ownership is granted to private entities. This article systematically reviews the experiences of local governments of Sub-Saharan African countries with the provision of health services during and after decentralization reforms. The article highlights the achievements, challenges and issues associated with decentralization. The review shows that most countries have mainly focused on the process by enacting numerous policies, regulations and standards with mixed outcomes for health services delivery. Decentralization in general, and resource transfer from the central to local governments in particular, are a highly political issue that influences the health reform strategy on decentralization. The literature shows the complexity of implementing decentralization schemes which strongly impact the health service organization and delivery. The theory of decision space applied in a comparative analysis found that some functions, particularly financing, remain under the control of the central state. Despite the numerous challenges, this review identifies some good practices in resources transfer, key determinants being the type of decentralization and the government's will to make legislative and administrative changes required for the effectiveness of decentralization. The literature search, even though systematic, resulted in a limited number of relevant publications with evidence on the link between decentralization and health services delivery. This is a largely unexplored research area, especially the use of financial resources by local governments, the factors that drive local decision-making processes and the effects of decentralization on health care sector performance.
BACKGROUND: The concept of decision space holds appeal as an approach to disaggregating the elements that may influence decision-making in decentralized systems. This narrative review aims to explore the functioning of decision space and the factors that influence decision space. METHODS: A narrative review of the literature was conducted with searches of online databases and academic journals including PubMed Central, Emerald, Wiley, Science Direct, JSTOR, and Sage. The articles were included in the review based on the criteria that they provided insight into the functioning of decision space either through the explicit application of or reference to decision space, or implicitly through discussion of decision-making related to organizational capacity or accountability mechanisms. RESULTS: The articles included in the review encompass literature related to decentralisation, management and decision space. The majority of the studies utilise qualitative methodologies to assess accountability mechanisms, organisational capacities such as finance, human resources and management, and the extent of decision space. Of the 138 articles retrieved, 76 articles were included in the final review. CONCLUSION: The literature supports Bossert's conceptualization of decision space as being related to organizational capacities and accountability mechanisms. These functions influence the decision space available within decentralized systems. The exact relationship between decision space and financial and human resource capacities needs to be explored in greater detail to determine the potential influence on system functioning.
Introduction According to Canavan et al. [1], results-based financing (RBF) is a method of financing focused on the assumption that linking motivations to the performance would help to improve accessibility, quality and equity in the provision of health services. Blanchett quoted by Canavan et al., [1] argues that its impact would vary
The promulgation of the new constitution in Kenya in August 2010 effectively ushered in devolution as the latest and highest form of decentralization in Kenya. The health sector was the largest service sector to be devolved under this new governance arrangement. The rationale for devolving the sector was to allow the county governments to design innovative models and interventions that suited the unique health needs in their contexts, encourage effective citizen participation and make autonomous and quick decisions on resource mobilization and management possible issues. However, the sector in nearly all counties is currently bedevilled with monumental challenges ranging from capacity gaps, human resource deficiency, lack of critical legal and institutional infrastructure, rampant corruption and a conflictual relationship with the national government. The net effect of these challenges is the stagnation of healthcare and even a reversal of some gains according to health indicators. No doubt what is needed to guarantee an all-inclusive rights-based approach to health service delivery is its proper institutionalization to ensure good governance and effective community participation. This must however be accompanied by wider governance reforms as envisaged in the new constitution for the sustainability of Healthcare Reforms. Key Words : Devolution, Healthcare Delivery, Healthcare Financing, Health Workforce, health governance.
BACKGROUND: Universal Health Coverage (UHC) has emerged as a major goal for health care delivery in the post-2015 development agenda. It is viewed as a solution to health care needs in low and middle countries with growing enthusiasm at both national and global levels. Throughout the world, however, the paths of countries to UHC have differed. South Africa is currently reforming its health system with UHC through developing a national health insurance (NHI) program. This will be practically achieved through a decentralized approach, the district health system, the main vehicle for delivering services since democracy. METHODS: We utilize a review of relevant documents, conducted between September 2014 and December 2015 of district health systems (DHS) and UHC and their ideological underpinnings, to explore the opportunities and challenges, of the district health system in achieving UHC in South Africa. RESULTS: Review of data from the NHI pilot districts suggests that as South Africa embarks on reforms toward UHC, there is a need for a minimal universal coverage and emphasis on district particularity and positive discrimination so as to bridge health inequities. The disparities across districts in relation to health profiles/demographics, health delivery performance, management of health institutions or district management capacity, income levels/socio-economic status and social determinants of health, compliance with quality standards and above all the burden of disease can only be minimised through positive discrimination by paying more attention to underserved and disadavantaged communities. CONCLUSIONS: We conclude that in South Africa the DHS is pivotal to health reform and UHC may be best achieved through minimal universal coverage with positive discrimination to ensure disparities across districts in relation to disease burden, human resources, financing and investment, administration and management capacity, service readiness and availability and the health access inequalities are consciously implicated. Yet ideological and practical issues make its achievement problematic.
-Within the last two decades, the Nigerian government has committed to strengthening its primary health care system, through reforms addressing institutional restructuring, deepening decentralized governance, and the incorporation of an alternative health care financing strategy. One of these reforms prescribed the establishment of state primary health care agencies/boards (SPHCDBs) as an integral part of the national health system, with the principal responsibility "for the coordination of planning, budgeting, provision and monitoring of all primary health care services that affect residents of the state." Central to this reform is the integration of primary health care (PHC) governance and management, popularly called primary health care under one roof. Another reform, piloting results-based financing, has been implemented since 2011 in three states under the Nigeria State Health Investment Project. This study assesses the implementation of the Primary Health Care Under One Roof (PHCUOR) policy as part of the broader PHC reforms, with a specific focus on how this policy has been strengthened through the Nigeria State Health Investment Project (NSHIP) in Adamawa, Nasarawa, and Ondo states, documenting the evolution of SPHCDB and PHC service delivery, with a focus on management, accountability, and incentives. The study shows that, in the above-mentioned states, significant milestones were achieved in the establishment of the SPHCDB, the strengthening of PHC systems, the improvement of accountability linkages, and an increase in service utilization. The authors therefore argue that integrated PHC systems through SPHCDBs, as enshrined in the PHCUOR guidelines, are a panacea for effective provision of primary health care and a potential game changer for health outcomes, especially when reinforced with a results-based financing approach.
Cara Smith Gueye, Gretchen Newby, Jim Tulloch, Laurence Slutsker · 6 authors
BACKGROUND: A malaria eradication goal has been proposed, at the same time as a new global strategy and implementation framework. Countries are considering the strategies and tools that will enable progress towards malaria goals. The eliminating malaria case-study series reports were reviewed to identify successful programme management components using a cross-case study analytic approach. METHODS: Nine out of ten case-study reports were included in the analysis (Bhutan, Cape Verde, Malaysia, Mauritius, Namibia, Philippines, Sri Lanka, Turkey, Turkmenistan). A conceptual framework for malaria elimination programme management was developed and data were extracted and synthesized. Findings were reviewed at a consultative workshop, which led to a revision of the framework and further data extraction and synthesis. Success factors of implementation, programme choices and changes, and enabling factors were distilled. RESULTS: Decentralized programmes enhanced engagement in malaria elimination by sub-national units and communities. Integration of the malaria programme into other health services was also common. Decentralization and integration were often challenging due to the skill and experience levels of newly tasked staff. Accountability for programme impact was not clarified for most programmes. Motivation of work force was a key factor in maintaining programme quality but there were few clear, detailed strategies provided. Different incentive schemes targeted various stakeholders. Training and supervision, although not well described, were prioritized by most programmes. Multi-sectoral collaboration helped some programmes share information, build strategies and interventions and achieve a higher quality of implementation. In most cases programme action was spurred by malaria outbreaks or a new elimination goal with strong leadership. Some programmes showed high capacity for flexibility through introduction of new strategies and tools. Several case-studies described methods for monitoring implementation quality and coverage; however analysis and feedback to those implementing malaria elimination in the periphery was not well described. Political commitment and sustained financing contributed to malaria programme success. Consistency of malaria programmes depends on political commitment, human and financial resources, and leadership. Operational capacity of the programme and the overall health system structure and strength are also important aspects. CONCLUSIONS: Malaria eradication will require adaptive, well-managed malaria programmes that are able to tailor implementation of evidence-based strategies, founded upon strong sub-national surveillance and response, with adequate funding and human resources.
For more than three decades healthcare decentralization has been promoted in developing countries as a way of improving the financing and delivery of public healthcare. Decision autonomy under healthcare decentralization would determine the role and scope of responsibility of local authorities. Jalal Mohammed, Nicola North, and Toni Ashton analyze decision autonomy within decentralized services in Fiji. They conclude that the narrow decision space allowed to local entities might have limited the benefits of decentralization on users and providers. To discuss the costs and benefits of healthcare decentralization this paper uses the U-form and M-form typology to further illustrate the role of decision autonomy under healthcare decentralization. This paper argues that when evaluating healthcare decentralization, it is important to determine whether the benefits from decentralization are greater than its costs. The U-form and M-form framework is proposed as a useful typology to evaluate different types of institutional arrangements under healthcare decentralization. Under this model, the more decentralized organizational form (M-form) is superior if the benefits from flexibility exceed the costs of duplication and the more centralized organizational form (U-form) is superior if the savings from economies of scale outweigh the costly decision-making process from the center to the regions. Budgetary and financial autonomy and effective mechanisms to maintain local governments accountable for their spending behavior are key decision autonomy variables that could sway the cost-benefit analysis of healthcare decentralization.
Ernest Mensah, Moses Aikins, Margaret Gyapong, Francis Anto · 6 authors
BACKGROUND: The global health system has a large arsenal of interventions, medical products and technologies to address current global health challenges. However, identifying the most effective and efficient strategies to deliver these resources to where they are most needed has been a challenge. Targeted and integrated interventions have been the main delivery strategies. However, the health system discourse increasingly favours integrated strategies in the context of functionally merging targeted interventions with multifunctional health care delivery systems with a focus on strengthening country health systems to deliver needed interventions. Neglected Tropical Diseases (NTD) have been identified to promote and perpetuate poverty hence there has been global effort to combat these diseases. The Neglected Tropical Diseases Programme (NTDP) in Ghana has a national programme team and office, however, it depends on the multifunctional health delivery system at the regional and district level to implement interventions. The NTDP seeks further health system integration to accelerate achievement of coverage targets. The study estimated the extent of integration of the NTDP at the national, regional and district levels to provide evidence to guide further integration. METHODOLOGY/PRINCIPAL FINDINGS: The research design was a descriptive case study that interviewed key persons involved in the programme at the three levels of the health system as well as extensive document review. Integration was assessed on two planes-across health system functions-stewardship and governance, financing, planning, service delivery, monitoring and evaluation and demand generation; and across three administrative levels of the health system-national, regional and district. A composite measure of integration designated Cumulative Integration Index (CII) with a range of 0.00-1.00 was used to estimate extent of integration at the three levels of the health system. Service delivery was most integrated while financing and planning were least integrated. Extent of integration was partial at all levels of the health system with a CII of 0.48-0.68; however it was higher at the district compared to the national and regional levels. CONCLUSIONS/SIGNIFICANCE: To ensure further integration of the NTDP, planning and finance management activities must be decentralized to involve regional and district levels of the health system. The study provides an empirical measure of extent of integration and indicators to guide further integration.
Obinna Ositadimma Oleribe, Olabisi Oladipo, Iheaka Paul Ezieme, Mary Margaret Elizabeth · 5 authors
Access to quality care is essential for improved health outcomes. Decentralization improves access to healthcare services at lower levels of care, but it does not dismantle structural, funding and programming restrictions to access, resulting in inequity and inequality in population health. Unlike decentralization, Commonization Model of care reduces health inequalities and inequity, dismantles structural, funding and other program related obstacles to population health. Excellence and Friends Management Care Center (EFMC) using Commonization Model (CM), fully integrated HIV services into core health services in 121 supported facilities. This initiative improved access to care, treatment, support services, reduced stigmatization/discrimination, and improved uptake of HTC. We call on governments to adequately finance CM for health systems restructuring towards better health outcomes.
Aku Kwamie, Han van Dijk, Evelyn Ansah, IrĂšne Akua Agyepong
The district health system in Ghana today is characterized by high resource-uncertainty and narrow decision-space. This article builds a theory-driven historical case study to describe the influence of path-dependent administrative, fiscal and political decentralization processes on development of the district health system and district manager decision-space. Methods included a non-exhaustive literature review of democratic governance in Ghana, and key informant interviews with high-level health system officials integral to the development of the district health system. Through our analysis we identified four periods of district health system progression: (1) development of the district health system (1970-85); (2) Strengthening District Health Systems Initiative (1986-93); (3) health sector reform planning and creation of the Ghana Health Service (1994-96) and (4) health sector reform implementation (1997-2007). It was observed that district manager decision-space steadily widened during periods (1) and (2), due to increases in managerial profile, and concerted efforts at managerial capacity strengthening. Periods (3) and (4) saw initial augmentation of district health system financing, further widening managerial decision-space. However, the latter half of period 4 witnessed district manager decision-space contraction. Formalization of Ghana Health Service structures influenced by self-reinforcing tendencies towards centralized decision-making, national and donor shifts in health sector financing, and changes in key policy actors all worked to the detriment of the district health system, reversing early gains from bottom-up development of the district health system. Policy feedback mechanisms have been influenced by historical and contemporary sequencing of local government and health sector decentralization. An initial act of administrative decentralization, followed by incomplete political and fiscal decentralization has ensured that the balance of power has remained at national level, with strong vertical accountabilities and dependence of the district on national level. This study demonstrates that the rhetoric of decentralization does not always mirror actual implementation, nor always result in empowered local actors.
Xiaoyun Liu, Lixia Dou, Huan Zhang, Yang Sun · 5 authors
BACKGROUND: Current literature systematically reports that interventions to attract and retain health workers in underserved areas need to be context specific but rarely defines what that means. In this systematic review, we try to summarize and analyse context factors influencing the implementation of interventions to attract and retain rural health workers. METHODS: We searched online databases, relevant websites and reference lists of selected literature to identify studies on compulsory rural service programmes and financial incentives. Forty studies were selected. Information regarding context factors at macro, meso and micro levels was extracted and synthesized. RESULTS: Macro-level context factors include political, economic and social factors. Meso-level factors include health system factors such as maldistribution of health workers, growing private sector, decentralization and health financing. Micro-level factors refer to the policy implementation process including funding sources, administrative agency, legislation process, monitoring and evaluation. CONCLUSIONS: Macro-, meso- and micro-level context factors can play different roles in agenda setting, policy formulation and implementation of health interventions to attract and retain rural health workers. These factors should be systematically considered in the different stages of policy process and evaluation.
Devolution, as other types of decentralization, profoundly changes governance relations in the health system. Devolution is meant to affect performance of the health system by transferring responsibilities and authority to locally elected governments. This study aimed to establish the effect of devolved governance on the performance of the health sector in Kenya. The guiding objectives included: To establish the influence of devolved procurement on the performance of the health sector; to determine the effect of devolved leadership on the performance of the health sector; to evaluate the effect of devolved resources on the performance of the health sector; and to establish the effect of devolved policy and regulatory framework on the performance of the health sector in Kenya. The study adopted the descriptive survey research design. The target population was 572 patients and health care providers from Nairobi and Mombasa County. Stratified sampling method was adopted at the rate of 10% to come up with a sample size of 57 respondents. Primary data was collected using questionnaires from all the respondents. Secondary data was sourced from health sector reports in Kenya from the year 2010 to 2014. The collected data was then analyzed through frequencies and percentages to enable the research come up with conclusions and recommendations for the study. The researcher employed the assistance of some computer tools, including the Statistical Programmes for Social Sciences (SPSS) and excel version 16 to analyze the data quantitatively. The analyzed data was presented in the form of graphs tables and charts. The Study established that devolution process has not been fully implemented and its effect has not been fully experienced in the health sector. The sector performance was averagely rated in the study and its contribution to GDP reduced by 0.5 percent by the end of the year 2013. The devolved procurement process, organizational leadership, resources allocation and availability as well as policy and regulatory framework had a significant influence on the performance of the level four hospitals and the overall health sector. It was recommended that the health sector players should improve in financing of critical health investment areas, particularly those relating to improving quality of care.
Evelyn Waweru, Catherine Goodman, Sarah Kedenge, Benjamin Tsofa · 5 authors
In many African countries, user fees have failed to achieve intended access and quality of care improvements. Subsequent user fee reduction or elimination policies have often been poorly planned, without alternative sources of income for facilities. We describe early implementation of an innovative national health financing intervention in Kenya; the health sector services fund (HSSF). In HSSF, central funds are credited directly into a facility's bank account quarterly, and facility funds are managed by health facility management committees (HFMCs) including community representatives. HSSF is therefore a finance mechanism with potential to increase access to funds for peripheral facilities, support user fee reduction and improve equity in access. We conducted a process evaluation of HSSF implementation based on a theory of change underpinning the intervention. Methods included interviews at national, district and facility levels, facility record reviews, a structured exit survey and a document review. We found impressive achievements: HSSF funds were reaching facilities; funds were being overseen and used in a way that strengthened transparency and community involvement; and health workers' motivation and patient satisfaction improved. Challenges or unintended outcomes included: complex and centralized accounting requirements undermining efficiency; interactions between HSSF and user fees leading to difficulties in accessing crucial user fee funds; and some relationship problems between key players. Although user fees charged had not increased, national reduction policies were still not being adhered to. Finance mechanisms can have a strong positive impact on peripheral facilities, and HFMCs can play a valuable role in managing facilities. Although fiduciary oversight is essential, mechanisms should allow for local decision-making and ensure that unmanageable paperwork is avoided. There are also limits to what can be achieved with relatively small funds in contexts of enormous need. Process evaluations tracking (un)intended consequences of interventions can contribute to regional financing and decentralization debates.
Renate Hartwig, Robert Sparrow, Sri Budiyati, Athia Yumna · 7 authors
We exploit variation in the design of subnational health-care financing initiatives in Indonesian districts to assess the effects of these local schemes on maternal care from 2004 to 2010. The analysis is based on a district pseudopanel, combining data from a unique survey among District Health Offices with the Indonesian Demographic and Health Surveys, the national socioeconomic household surveys, and the village census. Our results show that these district schemes contribute to an increase in antenatal care visits and the probability of receiving basic recommended antenatal care services for households that are not targeted by the national health insurance programs. We observe a decrease in home births. However, there is no effect on professional assistance at birth. We also observe variation in scheme design across districts as well as constraints to the effectiveness of local schemes. Including antenatal and delivery services explicitly in benefits packages and contracting local rather than national health-care providers increases the effects on maternal care. Increasing population coverage reduces effectiveness, delineating limitations to local funding and risk pooling. Furthermore, we do not find any effects for districts outside Java and Bali, where access to basic health care remains a key policy concern.
The Government of Lao PDR has formulated a National Growth and Poverty Eradication Strategy (NGPES) that links sustainable economic growth, human development, reduced vulnerability and poverty alleviation; and addresses the key issues of public sector governance and public sector management. Implementation of the overall strategy focuses on rural Districts and relies on decentralized authority and beneficiary participation. Health services are a vital component of the NGPES, which reiterates the Governmentâs commitment to achieving the Millennium Development Goals (MDGs) and identifies improved access, equity, quality and strengthening the health workforce as key goals. Ministry of Health (MOH) supported by the World Bank (WB) is implementing the Health Services Improvement Project-Additional Financing (HSIP-AF) with the objective to increase utilization and quality of health services, particularly for the poor women and children in rural areas. The consultations with ethnic groups during project implementation is necessary in order to assess whether the design of the HSIP-AF is succeeding in responding to the needs for MNCH services of ethnic groups in project provinces, understand the extent to which free delivery, and outreach activities impact health seeking behaviour of pregnant women and new-born children from ethnic groups and ascertain based on the result of such consultations, broad community support to project activities. The principle of SWOT Analysis was adapted in the consultation methodology. The Consultations however, indicated that ethnic communities were not fully informed of and understood project benefits available to them and requirements for participation. Communication is often particular problematic in areas with language barriers. A higher degree of inclusion in terms of community participation in the identification of problems and ways of solving them would demand bottomup implementation mechanisms and more flexibility to adapt project activities and supplied resources to local needs. The health service providers should preferably be female and members of local communities in order to overcome cultural and language barriers.
Decentralization is assumed to be an important tool for a quality health care service delivery. The objective of the study was to assess the impacts of decentralization on the health care service delivery Gozamin District, Amhara State, Ethiopia. Primary data for this study were collected through questionnaire, interview, and focus group discussions. Whereas secondary data were collected from annual official health sector reports and documents. The analysis part was supported by legal and official documents. The findings of the study revealed that the health care service accessibility and coverage of the District in terms of expansion of health care institutions has shown an improvement, and it reaches 100 percent. However, shortage of health personnel (midwifery, lab technician and pharmacy technician), shortage of finance for duty service and perdiem payment, and drugs shortage are the challenges of the District health care delivery system that affects the quality of the services. The costs of health care treatment is high as compared to the ability of most beneficiaries incomes, the free service scheme-which is very impressive were abused by kebele officials are the challenges of Gozamin District health care service delivery system. Keywords: Decentralization, Health Care Service Delivery, health center, and health posts
Nader Markazi Moghaddam, Aidin Aryankhesal, Mohammad Arab
BACKGROUND: Liberalization and decentralization of public sector has been triggered in some developing countries and in Iran by the Ministry of Health and Medical Education (MOHME) that granted autonomy to 54 public hospitals. However, establishment of such a complex organizational reform was rather unsuccessful. We aimed to explore the obstacles and barriers caused such a failure and their mechanisms. METHODS: Using a qualitative approach in 2013, we consulted key informants at the autonomous hospitals and their affiliating universities. Data collection was done within two phases: (i) 276 unstructured questionnaires asking respondents of barriers, and (ii) 23 semi-structured interviews from the first phase's key respondents. The first phase data were analyzed using thematic analysis and the second's by framework approach based on the frame shaped at the first phase. RESULTS: Nine obstacles were recognized including "autonomous hospitals' board composition", "delay in announcing autonomous hospitals' charges by the MOHME", "lack of financing by the committed organizations", "poor follow up for implementation of the reform", "irregular board meetings", "lack of an external overseer", "shortage of full-time physicians", "lack of management stability", and "health insurance organizations' delayed payments". CONCLUSION: The MOHME and insurance organizations did not pay the reform expenses. There were some competing motives as well to slow the reform or to shut it down. The stages of policy formulation and implementation were done separately in Iran, so this big organizational reform encountered serious obstacles.
Background: In 2004, the health system in Iran initiated an organizational reform aiming to increase the autonomy \nof teaching hospitals and make them more decentralized. The policy led to the formation of a board of trustees in \neach hospital and significant modifications in hospitalsâ financing. Since the reform aimed to improve its predecessor \npolicy (implementation of hospital autonomy began in 1995), it expected to increase user satisfaction, as well as \nenhance effectiveness and efficiency of healthcare services in targeted hospitals. However, such expectations were \nnever realized. In this research, we explored the perceptions and views of expert stakeholders as to why the board of \ntrusteesâ policy did not achieve its perceived objectives. \nMethods:We conducted 47 semi-structured face-to-face interviews and two focus group discussions (involving 8 \nand 10 participants, respectively) with experts at high, middle, and low levels of Iranâs health system, using purposive \nand snowball sampling. We also collected a comprehensive set of relevant documents. Interviews were transcribed \nverbatim and analyzed thematically, following a mixed inductive-deductive approach. \nResults: Three main themes emerged from the analysis. The implementation approach (including the processes, views \nabout the policy and the links between the policy components), using research evidence about the policy (local and \nglobal), and policy context (health system structure, health insurers capacity, hospitalsâ organization and capacity \nand actorsâ interrelationships) affected the policy outcomes. Overall, the implementation of hospital decentralization \npolicies in Iran did not seem to achieve their intended targets as a result of assumed failure to take full consideration \nof the above factors in policy implementation into account. \nConclusion:The implementation of the board of trusteesâ policy did not achieve its desired goals in teaching hospitals \nin Iran. Similar decentralization policies in the past and their outcomes were overlooked, while the context was not \nprepared appropriately and key stakeholders, particularly the government, did not support the decentralization of \nIranâs health system.
James Kiarie, Carey Farquhar, Robert Redfield, Kefa O Bosire · 8 authors
Background: Lack and inequitable distribution of human resources for health (HRH) is a major health systems challenge in Sub-Saharan Africa.1,2 The Partnership for Innovative Medical Education for Kenya (PRIME-Kenya) is an innovative approach that seeks to strengthen health systems by increasing linkages and collaborations in health care, health education, and health research. This approach was informed by concerns of inadequate clinical exposure with increasing undergraduate student enrollment at a tertiary hospital; increasing demand for locally relevant health research; and the desire to retain health workers at nontertiary facilities during and after training. Intervention: We focused on three interventions as part of the PRIME-Kenya initiative: decentralized training of undergraduate students, building research capacity at 14 nontertiary health facilities, and a nurse training program based on an eLearning platform. Decentralized Training. We sought to improve medical education capacity at selected nontertiary health facilities by training facility staff that already had postgraduate clinical training by using e-resources (textbooks, guidelines, and online lectures). Staff that completed the training were appointed as adjunct faculty at the University of Nairobi (UoN). Building Research Capacity. We conducted two phases of implementation science research training. First, between December 2012 and August 2013, 354 staff (30â60 per facility) received three days of instruction at their facilities on how to develop research questions, write research proposals, and collect data. Second, in October and November 2013, 35 adjunct faculty (3â5 per facility) received two additional days of training during which they developed research proposals based on research questions developed during the first phase. These adjunct faculty will be mentored by UoN faculty to help them submit their proposals for ethics review, collect and analyze data, and disseminate results. eLearning. In 2012, the School of Nursing Sciences introduced an eLearning Bachelor of Nursing (eBScN) upgrading course for diploma-level nurses. Training is conducted in accredited county hospitals where students are supervised by UoN adjunct faculty. Outcomes: At 14 nontertiary health facilities, 182 adjunct faculty have been trained and 306 students have rotated. Adjunct faculty at 9 health facilities have developed draft research proposals covering various areas including the impact of national health financing policies, staff retention, and quality of services. At 28 county hospitals, 148 students are enrolled in the eBScN program, and initial exam results indicate that trainees are gaining expected knowledge and skills. Comment: According to the interviews, the students felt they had more opportunities to practice clinical skills, closer mentoring, and closer interactions with patients at the nontertiary facilities than at the tertiary hospital. Health workers at the nontertiary hospitals also reported improved quality of patient care, increased job satisfaction, and greater interest in research. Those working in the nontertiary health facilities prioritized research that was highly relevant to local practice and policy. In the eBScN training program, county hospitals have retained employees, and the nurses are upgrading their skills without losing income. This innovative approach is successfully addressing some of the HRH challenges in medical education, health care, and research. Acknowledgments: PRIME-Kenya Secretariat staff members included Collins Owek, Francis Njiri, Raphael Kinuthia, Samuel Runo, James Macharia, Wycliffe Ndege, Juliet Mwangi, Minnie Kibore, Linda Nyaga, Wycliffe Khaemba, Susan Wanja, and Luke D. Davies.
This paper examines how organization and financing of maternal health services influence health-seeking behavior in Bosomtwe district, Ghana. It contributes in furthering the discussions on maternal health-seeking behavior and health outcomes from a health system perspective in sub-Saharan Africa. From a health system standpoint, the paper first presents the resources, organization and financing of maternal health service in Ghana, and later uses case study examples to explain how Ghana's health system has shaped maternal health-seeking behavior of women in the district. The paper employs a qualitative case study technique to build a complex and holistic picture, and report detailed views of the women in their natural setting. A purposeful sampling technique is applied to select 16 women in the district for this study. Through face-to-face interviews and group discussions with the selected women, comprehensive and in-depth information on health- seeking behavior and health outcomes are elicited for the analysis. The study highlights that characteristics embedded in decentralization and provision of free maternal health care influence health-seeking behavior. Particularly, the use of antenatal care has increased after the delivery exemption policy in Ghana. Interestingly, the study also reveals certain social structures, which influence women's attitude towards their decisions and choices of health facilities.
Evidence-informed decision making (EIDM) can optimize health services and systems. EIDM involves defining problems, identifying measures to tackle them, assessing the quality of global and local evidence and translating it for the main stakeholders in line with social values and laws. Brazil encourages the use of EIDM in health policy in Piripiri, a municipality of 61,840 inhabitants in the country's poorest region, and launched Brazil's first Evidence Use in Health Care (NEv) center in 2010. The development and preliminary results of the NEv center are reported and its vision, composition, mandate, and activities are presented. The NEv center experience has the support of the Evidence-Informed Policy Network, the Latin American and Caribbean Center of Information on Health Sciences and federal and municipal governments. The decentralization of financing and the provision of healthcare services, the expansion of EIDM in management, and the local political context illustrate the progress of the experiment. Its activities include the production and dissemination of deliberative briefs and dialogues with opinion shapers, workers and health service users. Monitoring and evaluation are underway and the results will help to broaden the scale of activities in Brazil and abroad.