Understanding the micro-practices of accountability and governance in health systems

Overview

Front-line health managers play a critical role in health systems governance, policy implementation and in accountability processes. However, their decision-making practices are dynamic and complex, and it is difficult to observe and to disentangle the effects of governance issues from other health system dimensions.

As a consequence, conducting research on governance faces significant challenges. One way of overcoming these challenges is for researchers to work directly with health managers to define research questions, identify appropriate methodologies and generate shared knowledge.

This is known as action learning research, and is the approach being used by RESYST at learning sites in Kenya and South Africa to better understand district-level governance issues.

Kenya

In Kenya, learning sites have been established among District Health Management Teams in rural Malindi and Kaloleni districts in Kilifi County. Researchers have been conducting interviews and observations at national, county, sub-county and facility level to understand the implications for health delivery and management of ongoing devolution to 47 semi- autonomous counties. The Kilifi learning site was established in 2013.

Kenya summary

South Africa

Since 2014 there are two additional RESYST learning sites in South Africa (Sedibeng District in Gauteng Province and Mitchells Plain sub-district in Western Cape). Work in the Mitchells Plain learning site builds on the collaborative research activities of the DIAHLS project which have focussed on strengthening leadership and governance to support improvements in primary health care.

Nigeria

In addition to the learning sites, a related study in Nigeria will develop guidelines for accountability in the implementation of the Nigerian Primary Health Care (PHC) Fund. An initial review of relevant documentation was undertaken in 2013 and empirical work began in 2014.

Nigeria summary

Publications

• Journal publication: Resources, attitudes and culture: an understanding of the factors that influence the functioning of accountability mechanisms in primary health care settings

• Poster: Maximising impact through collaborative research practice

• Policy brief: Recentralisation within decentralisation? Improving the functioning of Kenyan hospitals through increased hospital autonomy

• Policy brief: Crisis and resilience at the frontline: Coping strategies of Kenyan primary health care managers in a context of devolution and uncertainty

• Policy brief: Health system learning sites: understanding health systems through research collaboration and engagement

• Journal publication: Significance of informal (on-the-job) learning and leadership development in health systems: lessons from a district finance team in South Africa

• Journal publication: Hospitals as complex adaptive systems: A case study of factors influencing priority setting practices at the hospital level in Kenya

• Journal publication: The influence of power and actor relations on priority setting and resource allocation practices at the hospital level in Kenya: a case study

• Journal publication: Setting healthcare priorities: a description and evaluation of the budgeting and planning process in county hospitals in Kenya

• Podcast and infographic: What is a health system learning site?

• Key findings sheet: What is everyday health system resilience and how might it be nurtured?

• Blog: What is a learning site?