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

Abstract

BackgroundPriority setting and resource allocation in healthcare organizations often involves the balancing of competing interests and values in the context of hierarchical and politically complex settings with multiple interacting actor relationships. Despite this, few studies have examined the influence of actor and power dynamics on priority setting practices in healthcare organizations. This paper examines the influence of power relations among different actors on the implementation of priority setting and resource allocation processes in public hospitals in Kenya.MethodsWe used a qualitative case study approach to examine priority setting and resource allocation practices in two public hospitals in coastal Kenya. We collected data by a combination of in-depth interviews of national level policy makers, hospital managers, and frontline practitioners in the case study hospitals (n = 72), review of documents such as hospital plans and budgets, minutes of meetings and accounting records, and non-participant observations in case study hospitals over a period of 7 months. We applied a combination of two frameworks, Norman Long’s actor interface analysis and VeneKlasen and Miller’s expressions of power framework to examine and interpret our findingsResultsThe interactions of actors in the case study hospitals resulted in socially constructed interfaces between: 1) senior managers and middle level managers 2) non-clinical managers and clinicians, and 3) hospital managers and the community. Power imbalances resulted in the exclusion of middle level managers (in one of the hospitals) and clinicians and the community (in both hospitals) from decision making processes. This resulted in, amongst others, perceptions of unfairness, and reduced motivation in hospital staff. It also puts to question the legitimacy of priority setting processes in these hospitals.ConclusionsDesigning hospital decision making structures to strengthen participation and inclusion of relevant stakeholders could improve priority setting practices. This should however, be accompanied by measures to empower stakeholders to contribute to decision making. Strengthening soft leadership skills of hospital managers could also contribute to managing the power dynamics among actors in hospital priority setting processes.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1796-5) contains supplementary material, which is available to authorized users.

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Everyday resilience in district health systems: emerging insights from the front lines in Kenya and South Africa

“… 18 In district hospitals, meanwhile, hard budget choices had to be made to support continued service delivery given the funding challenges. Barasa et al 15 16 27 report experiences from two hospitals. In one ( box 1 ), a dedicated leader adopted inclusive and deliberative decision-making processes—generating wide-ranging staff commitment to the budget priorities set collectively and strengthening the collective sense of staff duty to the hospital and its patients.…”

“…These collaborations have provided the foundation for a range of interlinked analyses. 15–18 For each site, ethical approval was obtained from relevant national authorities and also from the London School of Hygiene and Tropical Medicine.…”

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“…In both instances, these committees were seen as passive, disempowered bodies that merely approved hospital decisions. Several factors contributed to this, including: the power relations between hospital staff; hospital managers' convictions that community members were ill-equipped (illiterate, uneducated, unable to understand budgets, and too narrowly focused on personal experiences) to play a useful role; and as a result, this affected managers' power to minimise community engagement; managers' failure to interrogate whom from the community participated; and the consequent potential for elite community representatives to benefit from the information shared in committee meetings (Barasa et al 2016).…”