Devolution and human resources in primary healthcare in rural Mali

Devolution, as other types of decentralization (e.g. deconcentration, delegation, privatization), 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. The key question of this article is: what does devolution mean for human resources for health in Mali

What is health systems responsiveness? Review of existing knowledge and proposed conceptual framework

Responsiveness is a key objective of national health systems. Responsive health systems anticipate and adapt to existing and future health needs, thus contributing to better health outcomes. Of all the health systems objectives, responsiveness is the least studied, which perhaps reflects lack of comprehensive frameworks that go beyond the normative characteristics of responsive services. This paper contributes to a growing, yet limited, knowledge on this topic. Herewith, we review the current frameworks for understanding health systems responsiveness and drawing on these, as well as key frameworks from the wider public services literature, propose a comprehensive conceptual framework for health systems responsiveness. This paper should be of interest to different stakeholders who are engaged in analysing and improving health systems responsiveness. Our review shows that existing knowledge on health systems responsiveness can be extended along the three areas. First, responsiveness entails an actual experience of people’s interaction with their health system, which confirms or disconfirms their initial expectations of the system. Second, the experience of interaction is shaped by both the people and the health systems sides of this interaction. Third, different influences shape people’s interaction with their health system, ultimately affecting their resultant experiences. Therefore, recognition of both people and health systems sides of interaction and their key determinants would enhance the conceptualisations of responsiveness. Our proposed framework builds on, and advances, the core frameworks in the health systems literature. It positions the experience of interaction between people and health system as the centrepiece and recognises the determinants of responsiveness experience both from the health systems (eg, actors, processes) and the people (eg, initial expectations) sides. While we hope to trigger further thinking on the conceptualisation of health system responsiveness, the proposed framework can guide assessments of, and interventions to strengthen, health systems responsiveness

Protocol for a mixed methods realist evaluation of a health service user feedback system in Bangladesh

Introduction: Responsiveness to service users’ views is a widely-recognised objective of health systems. A key component of responsive health systems is effective interaction between users and service providers. Despite a growing literature on patient feedback from high-income settings, less is known about effectiveness of such systems in low and middle income countries. Methodology and analysis: This paper disseminates the protocol for an 18-month ‘RESPOND’ project that aims to evaluate the system of collecting and responding to user feedback in Bangladesh. This mixed-method study uses a Realist Evaluation approach to examine user feedback systems at two Upazila Health Complexes in Comilla district of Bangladesh, and comprises three steps: i) initial theory development; ii) theory validation; and iii) theory refinement and development of lessons learned. The project also utilises: i) Process evaluation to understand causal mechanisms and contexts of implementation; ii) Statistical analysis of patient feedback to clarify the nature of issues reported; iii) Social science methods to illuminate feedback processes and user and provider experiences; and iv) Health policy and systems research to clarify issues related to integration of feedback systems with quality assurance and human resource management. During data analysis, qualitative and quantitative findings will be integrated throughout to help achieve study objectives. Analysis of qualitative and quantitative data will be done using a convergent mixed methods model, involving continuous triangulation of multiple datasets to facilitate greater understanding of the context of user feedback systems including the links with relevant policies, practices and programmes. Ethics and dissemination: Ethics approvals were obtained from the University of Leeds and the Bangladesh Medical Research Council. All data collected for this study will be anonymised and identifying characteristics of respondents will not appear in a final manuscript or reports. The study findings will be presented at scientific conferences and published in peer-reviewed journals

When information is not power:Community-elected health facility committees and health facility performance indicators

Health Facility Committees (HFCs) made of elected community members are often presented as key for improving the delivery of services in primary health-care facilities. They are expected to help Health Facility (HF) staff make decisions that best serve the interests of the population. More recently, Performance-Based Financing (PBF) advocates have also put the HFC at the core of health reform, expecting it to hold HF staff into account for the HF performances and development. In Burundi, a country where PBF is implemented nationwide, a randomised control trial was implemented in 251 health facilities where the HFC had been largely inactive in recent years. A random sample of 168 HFCs was trained on their roles and rights, with a subset also given information about the performance of their HF (using PBF indicators) and the PBF approach in general. The interventions, taking place in 2011-2013, made the HFCs better organised but largely failed to generate any effect on HF management and service delivery. Nested qualitative analysis reveals important tensions between nurses and HFC members that often prevent further change at the HF. In the HFs that received both the training and information interventions, this tension appeared exacerbated: the turnover of chief nurses was significantly higher as the HFCs exerted pressure to remove them. This situation was more likely to happen if the HFC had already received training before the interventions, thereby suggesting that repeated training empowers committees. Overall, the results provide rare rigorous evidence on HFCs, suggesting that more attention needs to be paid to the socio-economic and cultural contexts in which they operate. They also invite to caution when discussing the role of HFCs as a possible watchdog in PBF schemes

Governance and human resources for health

Despite an increase in efforts to address shortage and performance of Human Resources for Health (HRH), HRH problems continue to hamper quality service delivery. We believe that the influence of governance is undervalued in addressing the HRH crisis, both globally and at country level. This thematic series has aimed to expand the evidence base on the role of governance in addressing the HRH crisis. The six articles comprising the series present a range of experiences. The articles report on governance in relation to developing a joint vision, building adherence and strengthening accountability, and on governance with respect to planning, implementation, and monitoring. Other governance issues warrant attention as well, such as corruption and transparency in decision-making in HRH policies and strategies. Acknowledging and dealing with governance should be part and parcel of HRH planning and implementation. To date, few experiences have been shared on improving governance for HRH policy making and implementation, and many questions remain unanswered. There is an urgent need to document experiences and for mutual learning

Legal Empowerment and Social Accountability: Complementary Strategies Toward Rights-based Development in Health?

Citizen-based accountability strategies to improve the lives of the poor and marginalized groups are increasingly being used in efforts to improve basic public services. The latest thinking suggests that broader, multi-pronged, multi-level, strategic approaches that may overcome the limitations of narrow, localized successes, hold more promise. This paper examines the challenges and opportunities, in theory and practice, posed by the integration of two such citizen-based accountability strategies—social accountability and legal empowerment. It traces the foundations of each of these approaches to highlight the potential benefits of integration. Consequently it examines whether these benefits have been realized in practice, by drawing upon five cases of organizations pursuing integration of social accountability and legal empowerment for health accountability in Macedonia, Guatemala, Uganda, and India. The cases highlight that while integration offers some promise in advancing the cause of social change, it also poses challenges for organizations in terms of strategies they pursue

Social accountability in primary health care in West and Central Africa: exploring the role of health facility committees

Background: Social accountability has been emphasised as an important strategy to increase the quality, equity, and responsiveness of health services. In many countries, health facility committees (HFCs) provide the accountability interface between health providers and citizens or users of health services. This article explores the social accountability practices facilitated by HFCs in Benin, Guinea and the Democratic Republic of Congo. Methods: The paper is based on a cross-case comparison of 11 HFCs across the three countries. The HFCs were purposefully selected based on the (past) presence of community participation support programs. The cases were derived from qualitative research involving document analysis as well as interviews and focus group discussions with health workers, citizens, committee members, and local authorities. Results: Most HFCs facilitate social accountability by engaging with health providers in person or through meetings to discuss service failures, leading to changes in the quality of services, such as improved health worker presence, the availability of night shifts, the display of drug prices and replacement of poorly functioning health workers. Social accountability practices are however often individualised and not systematic, and their success depends on HFC leadership and synergy with other community structures. The absence of remuneration for HFC members does not seem to affect HFC engagement in social accountability. Conclusions: Most HFCs in this study offer a social accountability forum, but the informal and non-systematic character and limited community consultation leave opportunities for the exclusion of voices of marginalised groups. More inclusive, coherent and authoritative social accountability practices can be developed by making explicit the mandate of HFC in the planning, monitoring, and supervision of health services; providing instruments for organising local accountability processes; strengthening opportunities for community input and feedback; and strengthening links to formal administrative accountability mechanisms in the health system

The Challenges of Institutionalizing Community-Level Social Accountability Mechanisms for Health and Nutrition: a Qualitative Study in Odisha, India

Background: India has been at the forefront of innovations around social accountability mechanisms in improving the delivery of public services, including health and nutrition. Yet little is known about how such initiatives are faring now that they are incorporated formally into government programmes and implemented at scale. This brings greater impetus to understand their effectiveness. This formative qualitative study focuses on how such mechanisms have sought to strengthen community-level nutrition and health services (the Integrated Child Development Services and the National Rural Health Mission) in the state of Odisha. It fills a gap in the literature on considering how such initiatives are running when institutionalised at scale. The primary research questions were ‘what kinds of community level mechanisms are functioning in randomly selected villages in 3 districts of state of Odisha' and 'how are they perceived to function by their members and frontline workers’