Governance and participation in health

Malaria control in rural Malawi: implementing peer health education for behaviour change
Malenga T; Kabaghe A; Manda-Taylor L; et al: Globalization and Health 13(84), doi:, 2017

This descriptive study reports on the feasibility, acceptability and appropriateness of health animator-led community workshops for malaria control. Quantitative data were collected from self-reporting and researcher evaluation forms. Qualitative assessments were done with health animators, using three focus groups in 2015 and seven in-depth interviews (October 2016–February 2017). Seventy seven health animators were trained from 62 villages. A total of 2704 workshops were conducted, with consistent attendance from January 2015 to June 2017, representing 10–17% of the population. Attendance was affected by social responsibilities and activities, relationship of the village leaders and their community and involvement of community health workers. Active discussion and participation were reported as main strengths of the workshops. Health animators personally benefited from the mind-set change and were proactive peer influencers in the community. Although the information was comprehended and accepted, availability of adequate health services was a challenge for maintenance of behaviour change. the authors argue that community workshops on malaria are a potential tool for influencing a positive change in behaviour towards malaria, and applicable for other health problems in rural African communities. Social structures of influence and power dynamics affect community response. they suggest that there is need for systematic monitoring of community workshops to ensure implementation and sustain health behaviour change.

The role of NGOs in Africa: are they a force for good?
Sangonet Pulse, December 2017

Non-governmental organisations (NGOs) have become key actors in responding to poverty and related suffering. In Africa, NGOs play a leading role in providing health care and education. But NGOs also have their detractors who argue that they are receiving growing amounts of external aid, but aren’t the most suitable actors for really improving people’s lives. Some critics insist that the neoliberal policies advanced by international actors have limited the influence of the state and that NGOs have benefited as a result. NGOs are criticised for their focus on technical solutions to poverty instead of the underlying issues, and for being more dependent and accountable to their funders than those they serve. Instead of empowering local populations to organise themselves, the authors argue that there is a risk that NGOs empower people to attain licensed, rather than emancipatory, freedoms; these are freedoms achieved “within the system” which improve lives, but don’t dramatically change power dynamics.

Mobile instant messaging for rural community health workers: a case from Malawi
Pimmer C; Mhango S; Mzumara A; et al: Global Health Action 10(1), doi:, 2017

Mobile instant messaging (MIM) tools, such as WhatsApp, have transformed global communication practice. In the field of global health, MIM is an increasingly used, but little understood, phenomenon. It remains unclear how MIM can be used by rural community health workers (CHWs) and their facilitators, and what are the associated benefits and constraints. To address this gap, WhatsApp groups were implemented and researched in a rural setting in Malawi. The multi-site case study research triangulated interviews and focus groups of CHWs and facilitators with the thematic qualitative analysis of the actual conversations on WhatsApp. The use of MIM was differentiated according to instrumental (e.g. mobilising health resources) and participatory purposes (e.g. the enactment of emphatic ties). The identified benefits were centred on the enhanced ease and quality of communication of a geographically distributed health workforce, and the heightened connectedness of a professionally isolated health workforce. Alongside minor technical and connectivity issues, the main challenge for the CHWs was to negotiate divergent expectations regarding the social versus the instrumental use of the space. Despite some challenges and constraints, the implementation of WhatsApp was received positively by the CHWs and it was found to be a useful tool to support distributed rural health work.

Tanzania: Campaigners March Peacefully in Dar for Universal Health Coverage
Buguzi S: All Africa, 12 December 2017

Campaigners for Universal Health Coverage (UHC) camped at Mwananyamala Regional Hospital in Dar es Salaam in December 2017, raising voices for people who fail to access healthcare services due to financial constraints. Campaigns went out of the hospital as Kinondoni District residents and some health activists carried out peaceful demonstrations as a sign of solidarity for the UHC movement. The Universal Health Coverage Day, marked December 12 every year, is a time when health advocates around the globe join forces to demand action and results in healthcare access in every country.

Exploring how different modes of governance act across health system levels to influence primary healthcare facility managers’ use of information in decision-making: experience from Cape Town, South Africa
Scott V and Gilson L: International Journal for Equity in Health 16(159)1-15, 2017

This paper reports on work to explore how primary healthcare facility managers’ use of information for decision-making is influenced by governance across levels of the health system in Cape Town, South Africa. Central governance shaped what information and knowledge was valued – and, therefore, generated and used at lower system levels. The central level valued formal health information generated in the district-based health information system which therefore attracted management attention across the levels of the health system in terms of design, funding and implementation. This information was useful in the top-down practices of planning and management of the public health system. However, in facilities at the frontline of service delivery, there was a strong requirement for local, disaggregated information and experiential knowledge to make locally-appropriate and responsive decisions, and to perform the people management tasks required. Despite central level influences, modes of governance operating at the sub-district level had influence over what information was valued, generated and used locally. Strengthening local level managers’ ability to create enabling environments is an important leverage point in supporting informed local decision-making, and, in turn, translating national policies and priorities, including equity goals, into appropriate service delivery practices.

How does decentralisation affect health sector planning and financial management? a case study of early effects of devolution in Kilifi County, Kenya.
Tsofa B; Goodman C; Gilson L; et al.: International Journal for Equity Health 16(1)151-163, 2017

In 2010, Kenya passed a new constitution that introduced 47 semi-autonomous devolved county governments, with a substantial transfer of responsibility for healthcare from the central government to these counties. This study analysed the effects of this decentralization on health sector planning, budgeting and financial management at county level in Kilifi County. The authors found that the implementation of devolution created an opportunity for local level prioritisation and community involvement in health sector planning and budgeting, increasing opportunities for equity in local level resource allocation. However, this opportunity was not harnessed due to accelerated transfer of functions to counties before county level capacity had been established to undertake the decentralised functions. The authors also observed some indication of re-centralisation of financial management from health facility to county level. They conclude that to enhance the benefits of decentralised health systems, resource allocation, priority setting and financial management functions between central and decentralised units need to be guided by considerations around decision space, organisational structure and capacity and accountability.

Organisational culture and trust as influences over the implementation of equity-oriented policy in two South African case study hospitals
Erasmus E; Gilson L; Govender V; et al: International Journal of Equity in Health 16(1)164-177, 2017

This paper uses the concepts of organizational culture and organizational trust to explore the implementation of equity-oriented policies - the Uniform Patient Fee Schedule and Patients' Rights Charter - in two South African district hospitals. The hospitals' implementation approaches were similar in that both primarily understood it to be about revenue generation, that granting fee exemptions was not a major focus, and considerable activity, facility management support, and provincial support was mobilised behind the Uniform Patient Fee Schedule. The hospitals' Patients' Rights Charter paths diverged quite significantly, as Hospital A was more explicit in communicating and implementing the Patients' Rights Charter, while the policy also enjoyed stronger managerial support in Hospital A than Hospital B. Beneath these experiences lie differences in how people's values, decisions and relationships influence health system functioning and in how the nature of policies, culture, trust and power dynamics can combine to create enabling or disabling micro-level implementation environments. Achieving equity in practice requires managers to take account of "unseen" but important factors such as organisational culture and trust, as key aspects of the organisational context that can profoundly influence policies. In addition to putting in place necessary staff and resources, tasks such as relationship management, the negotiation of values and paying careful attention to how policies are practically framed and translated into practice are seen to be necessary to ensure equity aspects are not neglected.

Unpicking Power and Politics for Transformative Change: Towards Accountability for Health Equity
Accountability for Health Equity Programme: Institute of Development Studies, Sussex, 2017

While “accountability” has become an increasingly popular buzzword in health systems debates and health service delivery, it has multiple – and contested – meanings. In July 2017, IDS brought together 80 activists, researchers, public health practitioners and policy makers to examine the forces that shape accountability in health systems, from local to global levels. This workshop report records the presentations and discussions on accountability for health equity that are emerging in different country contexts, exploring how accountability relationships develop and change over time.

“We are toothless and hanging, but optimistic”: sub county managers’ experiences of rapid devolution in coastal Kenya
Nyikuri M; Tsofa B, Okoth P; et al.: International Journal for Equity in Health 16(113)1-11, 2017

This study presents qualitative research to examine the early experiences of devolution in the health sector in Kenya in March 2013. The authors observed a diverse range of management meetings, support supervision visits and outreach activities involving sub-county managers between May 2013 and June 2015, and conducted interviews with purposively selected sub-county managers from three sub-counties. The authors found that sub county managers as with many other health system actors were anxious about and ill-prepared for the unexpectedly rapid devolution of health functions to the newly created county government. They experienced loss of autonomy and resources and confused lines of accountability within the health system. The study illustrates the importance in accelerated devolution contexts for: mid-level managers to adopt new ways of working and engagement with higher and lower levels in the system; clear lines of communication during reforms to these actors and anticipating and managing the effect of change on intangible software issues such as trust and motivation. More broadly, the authors show the value of examining organisational change from the perspective of key actors within the system, and highlight the importance in times of rapid change of drawing upon and working with those already in the system. These actors have valuable tacit knowledge, but tapping into and building on this knowledge to enable positive response in times of health system shocks requires greater attention to sustained capacity building within the health system.

Community-based initiatives improving critical health literacy: a systematic review and meta-synthesis of qualitative evidence
de Wit L; Benenga C; Giammarchi C; di Furia L; Hutter I; de Winter A; Meijering L: BMC Public Health 18(40), 2017,

This study explored how community-based initiatives address the critical health literacy of older adults and their communities. A systematic literature search was conducted. Two reviewers independently screened titles and abstracts, as well as the quality of the methodological and community-based elements of the studies. In addition, a meta-synthesis was carried out, consisting of a qualitative text analysis of the results sections of the 23 included studies. The authors identified two main themes, which are practices that contribute to the critical health literacy of older adults as well as their communities: collaborative learning, and social support. In these practices they identified reciprocity as a key characteristic of both co-learning and social support. This study provides the first overview of community-based initiatives that implicitly address the critical health literacy of adults and their community. The results demonstrate that in the context of one’s own life collaborative learning and social support could contribute to people’s understanding and ability to judge, sift and use health information. The authors therefore suggest to add these two practices to the definition of critical health literacy.