How district health decision-making is shaped within decentralised contexts: A qualitative research in Malawi, Uganda and Ghana

Abstract

District Health Management Teams (DHMTs) are often entry points for the implementation of health interventions. Insight into decision-making and power relationships at district level could assist DHMTs to make better use of their decision space. This study explored how district-level health system decision-making is shaped by power dynamics in different decentralised contexts in Ghana, Malawi and Uganda. In-depth interviews took place with national-and district-level stakeholders. To unravel how power dynamics influence decision-making, the Arts and Van Tatenhove (2004) framework was applied. In Ghana and Malawi, the national-level Ministry of Health substantially influenced district-level decision-making, because of dispositional power based on financial resources and hierarchy. In Uganda and Malawi, devolution led to decision-making being strongly influenced by relational power, in the form of politics, particularly by district-level political bodies. Structural power based on societal structures was less visible, however, the origin, ethnicity or gender of decisionmakers could make them more or less credible, thereby influencing distribution of power. As a result of these different power dynamics, DHMTs experienced a narrow decision space and expressed feelings of disempowerment. DHMTs' decision-making power can be expanded through using their unique insights into the health realities of their districts and through joint collaborations with political bodies.

Analysis of public hospital governance reforms: a case from a developing country

“…Thus, although executive management roles were shifted from the Ministry of Health, the shift was to the district councils and not necessary to the district hospitals or their managers (Bulthuis et al , 2021). It was further interesting to note that in the current set-up, district hospitals have been “stripped” some organisational features that they used to have in the pre-decentralisation era.…”

“…The results show that the actors' view about the reforms is in terms of mere devolution mirroring the instruments underlying them. This is problematic because experience shows that devolution on its own is not complete as it does not automatically result in the devolved entities and their managers enjoying greater autonomy; often the opposite is achieved (Barasa et al , 2017; Bulthuis et al , 2021). True to the experience, the results show that instead of the hospitals being progressively reformed towards greater autonomy, they are being reduced in organisational status they possessed in the pre-decentralisation era.…”

“…Experience shows that where blank devolution is insisted, implementation of best practice models, in the light of the public sector reforms championed by New Public Management, produces unhealthy systemic friction among the actors within the public sector hierarchy (Athanasiadis et al , 2018; Sumah and Baatiema, 2019). Otherwise the devolved entities either remain the same, as they were within the central government structure or get deformed through loss of some pre-reforms autonomy, which negatively affects the morale of staff and overall productivity (Barasa et al , 2017; Bulthuis et al , 2021).…”

Transitioning health workers from PEPFAR contracts to the Uganda government payroll

“…Although there is an accumulating evidence base on the notion of decision space in district health systems, in general ( Bossert and Mitchell, 2011 ; Liwanag and Wyss, 2018 ; Henriksson et al. , 2019 ; Bulthuis et al. , 2021 ), and around Human Resources for Health in particular ( Alonso-Garbayo et al.…”

Unlocking fiscal space of expanding the health workforce in district health systems in Uganda in the context of PEPFAR transition  

“…As donors like PEPFAR reduce their nancial support to workforce costs, little is known about which factors hinder or facilitate the expansion of scal space for health worker recruitments within the Government. These data are critical to understanding the dynamics involved, and strategies needed for increasing domestic nancial Although there is an accumulating evidence base on the notion of decision space in district health systems, in general (Bossert and Mitchell 2011;Henrikson et al 2016;Liwanag et al 2018;Bulthuis et al 2020), and around Human Resources for Health in particular (Alonso-Garbayo et al 2017; Sumah and Baetia 2019), there is little empirical attention to the prospect of creating scal space for expanding the health workforce in decentralized settings in low-income countries. We aimed to understand the process of health worker transition from PEPFAR to Uganda Government payrolls and to explore the facilitators and barriers encountered in increasing domestic nancial responsibility for this transition.…”