Innovation to improve health care provision and health systems in sub-Saharan Africa – Promoting agency in mid-level workers and district managers

Initiatives to address the human resource crisis in African health systems have included expanded training of mid-level workers (MLWs). Currently, MLWs are the backbone of many health systems in Africa but they are often de-motivated and they often operate in circumstances in which providing high quality care is challenging. Therefore, assuming that introducing additional people will materially change health system performance is unrealistic. We briefly critique such unifocal interventions and review the literature to understand the factors that affect the motivation and performance of MLWs. Three themes emerge: the low status and inadequate recognition of MLWs, quality of care issues and working in poorly managed systems. In response we propose three interrelated interventions: a regional association of MLWs to enhance their status and recognition, a job enrichment and mentoring system to address quality and a district managers’ association to improve health systems management. The professionalisation of MLWs and district managers to address confidence, self-esteem and value is considered. The paper describes the thinking behind these interventions, which are currently being tested in Kenya, Nigeria, South Africa and Uganda for their acceptability and appropriateness. We offer the policy community a complementary repertoire to existing human resource strategies in order to effect real change in African health systems.     

Concepts of health and well-being in managers: An organizational study

Global changes and new managerial challenges require new concepts of health and well-being in organizational contexts. In the South African context, health and well-being of managers have gained relevance in organizations and in management sciences. International organizations, in particular, attempt to address the increasing demand for health care and the delivery of health services to their managers. Careful and appropriate health management requires research to evaluate context-specific health concepts and strategies. The purpose and aim of this article is to assess managerial concepts on health and well-being that could be used by the organization to contribute to managerial well-being by implementing health promotion according to managerial needs. At the same time, this article contributes to salutogenetic health research that is very rare with regard to the South African organizational management research.This study is a multi-method research study conducted in a selected international organization in South Africa. However, in this article, selected qualitative findings will only be presented.This organizational study presents selected research findings on health concepts and strategies employed by managers. Findings demonstrate that the managerial concepts of health and strategies mainly refer to not only physical but also to mental and spiritual aspects, with a priority on physical health and well-being.The findings presented are based on qualitative research methods and their research criteria.This assessment serves as a foundation for new approaches to health management within the international work context in South Africa. It also contributes to a paradigm shift from pathogenetic to salutogenetic concepts of health and well-being within the South African organizational work context.The article produces new insights into the qualitative health concepts of South African managers and expatriates and contributes to promoting salutogenesis in organization within South Africa.     

Bridging the quality chasm: integrating professional and organizational approaches to quality.

Current Western health care practices face the challenge to improve their quality on multiple dimensions simultaneously. This requires new ways to think about how to deliver health care services. A careful and 'flexible' standardization of care into 'care programs', we argue, is central. Yet such standardization is powerless without the application of four additional design principles: a thorough restructuring and delegation of tasks, the application of integrated planning, the use of indicators about the functioning of the care programs, and implementing process-supporting information technology. Vice versa, these additional principles can only function properly when integrated with care programs. We will only be able to improve the safety, effectiveness, patient-centeredness, and timeliness of health care, while reducing costs and improving equity, by integrating professional and organizational approaches to quality. This paper describes a series of interrelated design principles that together depict how future health care delivery could be organized.     

Staff perception of the impact of health care transformation on quality of care.

OBJECTIVES: To study how medical professionals perceived recent organizational changes and financial cut-backs in terms of organizational and health care quality. DESIGN: A cross-sectional questionnaire survey. SETTING: County council of Stockholm. PARTICIPANTS: A random sample (n=936; 70% response rate) of physicians and nurses employed by the county council of Stockholm. MAIN OUTCOME MEASURES: Staff perception of how recent changes impacted on staff-perceived quality of care, staffs' skills development, management, and perceived organizational efficacy. RESULTS: Over 60% of the respondents rated that patients' access to health care had diminished as a result of ongoing changes. A similar percentage also perceived a decline in the quality of health care delivered in general. However, fewer staff rated a decline during the last year in the quality of care provided by their own department (44%). Staff rating that quality of care in their own department had worsened during the last year also scored substantially lower on all counts of organizational well-being. The most important determinants of staff-perceived quality of care were staff access to pertinent information concerning their daily work and organizational changes, participatory management, performance management, and job commitment. Job satisfaction was more strongly associated with organizational well-being than staff-perceived quality of care. CONCLUSION: Staff perception should be used as an additional indicator of quality of care. To improve quality of care further, management should encourage staff involvement in everyday management issues, including up-to-date information about organizational goals and mission.     

Collaboration or renunciation? The role of traditional medicine in mental health care in Rwanda and Eastern Cape Province,South Africa

Traditional medicine (TM) and biomedicine represent parallel health systems in many developing countries; the latter dominating in public policies, while the former still retain considerable influence among the general public. This study investigates how mental health care professionals responsible for mental health care implementation comprehend and relate to the intersection between TM and biomedicine in the cases of Rwanda and the Eastern Cape Province, South Africa. The material is based on semi-structured interviews with mental health care stakeholders in Eastern Cape, South Africa and Rwanda. The findings confirm an impact of TM in the treatment of mental health issues in Rwanda and South Africa due to TM being more accessible than biomedical medicine, widespread traditional perceptions of mental illness in society, and the lack of knowledge of biomedical treatments. Furthermore, the respondents identified three strategies to manage the impact of TM; improved accessibility of biomedical facilities, outreach education about mental illness, and, in the Eastern Cape case, collaboration between traditional healers and biomedicine. The study points to the necessity to take TM into consideration as an important component of health systems and policies in the Global south.     

Assessment of medical technology and the challenge for health reform in Africa

Introduces an African perspective to existing research and scholarship on the relationship between western medical technology and health care planning in Africa. Examining the broader issues of development and underdevelopment, contends that the present health care system, fashioned after western medical systems (focusing on hospital and curative care), has failed to make significant impact by reducing mortality rates in Africa. Describes the already precarious health conditions in Africa and argues that, while Africa can benefit from the application of western medical technology, the irrelevance of current strategies to people's needs and the widespread abuse of medical resources have rendered western technology ineffective in Africa. Concludes by calling for the creation of a council of technological assessment in Africa to review requirements and recommend to African governments appropriate and efficient medical technologies to meet the health needs of Africans.     

Community-oriented primary care: new relevance in a changing world

Since its inception in rural, pre-apartheid South Africa, community-oriented primary care (COPC) has intrigued and informed public health and primary care leaders worldwide. COPC has influenced such programs as the US community health center movement, the general practice movement in the United Kingdom, and recent reforms in the public health system of South Africa. We provide a global overview of COPC, tracing its conceptual roots, reviewing its many manifestations, and exploring its future prospects as an organizational paradigm for the democratic organization of community health services. We examine the pitfalls and paradoxes of COPC and suggest its future utility. COPC has important values and methods to offer disparate but powerful movements in public health worldwide.     

A shared mission? Changing relationships between government and church health services in Africa

This article reviews the relationships between government and church health providers within sub-Saharan Africa with a particular focus on East and Southern Africa. This is of particular interest at this time, given the changing configuration of the health sector in many countries as a result of health sector reform policies. The article provides a historical overview of the development and emerging role of the church health services within this changing environment. The factors affecting the relationship between the government and church sector are identified. These include differences in objectives, types of service provided, and the organizational culture and management styles. The paper then explores key issues seen to affect the future pattern of relationships including the changing scene, and identifies different models for relationships and implications for key actors including the Ministry of Health, church health agencies and coordinating bodies. The article concludes that church health services will continue to play a key role in health care in sub-Saharan Africa; however, there are challenges facing them and both parties need to develop a response to these.     

Building primary health care systems: a case study from Sweden.

Health policy planners have discussed for some years how to transform existing hospital-based health delivery systems into primary-care-driven systems. Although this policy goal has been adopted in a number of western European nations, the actual process of implementing such a major change has proven stubborn and complex. In particular, efforts to transfer existing resources out of the hospital sector for use in building primary care activities have proven difficult. This paper examines the effort to design and implement a primary health care strategy in Sweden. It is divided into two segments. The first section sketches the broad health system context within which the Swedish primary care effort is being conducted. The second section focuses directly on Sweden's primary care strategy, detailing both its conceptual foundation and the organizational obstacles that have impeded the policy's implementation. This discussion is punctuated with findings from a 1981 survey of county council administrators' attitudes toward this primary care strategy. The paper concludes with a short discussion of several alternative organizational approaches that might speed the development of a primary-care-driven health system.     

The application of geographical information systems to important public health problems in Africa

Africa is generally held to be in crisis, and the qualsity of life for the majority of the continent's inhabitants has been declining in both relative and absolute terms. In addition, the majority of the world's disease burden is realised in Africa. Geographical information systems (GIS) technology, therefore, is a tool of great inherent potential for health research and management in Africa. The spatial modelling capacity offered by GIS is directly applicable to understanding the spatial variation of disease, and its relationship to environmental factors and the health care system. Whilst there have been numerous critiques of the application of GIS technology to developed world health problems it has been less clear whether the technology is both applicable and sustainable in an African setting. If the potential for GIS to contribute to health research and planning in Africa is to be properly evaluated then the technology must be applicable to the most pressing health problems in the continent. We briefly outline the work undertaken in HIV, malaria and tuberculosis (diseases of significant public health impact and contrasting modes of transmission), outline GIS trends relevant to Africa and describe some of the obstacles to the sustainable implementation of GIS. We discuss types of viable GIS applications and conclude with a discussion of the types of African health problems of particular relevance to the application of GIS.     

IS/IT the prescription to enable medical group practices attain their goals

The US spends significantly more money as a percentage of GDP on health care than any other OECD country and more importantly, this amount is anticipated to increase exponentially. In this high cost environment, two important trends have occurred: (1) the movement to managed care, and (2) large investments in Information Systems/Information Technology (IS/IT). Managed care has emerged as an attempt to provide good quality yet cost effective health care treatment. Its implications are not well discussed in the literature while, its impact on different types of medical group practices is even less well understood. The repercussions of the large investments in IS/IT on the health care sector in general and on the medical group practice in particular, although clearly of importance, are also largely ignored by the literature. This study attempts to address this significant void in the literature. By analyzing three different types of group practices; an Independent Practice Association (IPA), a Faculty Practice and a Multi Specialty Group Practice in a managed care environment during their implementation of practice management/billing systems, we are able to draw some conclusions regarding the impacts of these two central trends on health care in general as well as on the medical group practice in particular.     

On being comfortable with being uncomfortable: centering an Africanist vision in our gateway to global health.

African identity must be central to research on African health and development. This article focuses on three primary themes for advancing a different vision for understanding health issues in Africa. The first is the need to deconstruct conventional assumptions and theories that have been used to frame public health problems and solutions in Africa. The second is to insist that identity be central to how we frame issues of health and behavior in general and in Africa in particular. The third is the importance of the notion of "social cultural infrastructure" in defining African ways of knowing to guide public health research and intervention in Africa. Finally, the metaphor of the "African gate" is used to illuminate these themes while drawing on examples from an HIV- and AIDS-related stigma research in South Africa and its implications for addressing the critical global public-health issues of today.     

Research gaps in routine health information system design barriers to data quality and use in low‐ and middle‐income countries: A literature review

Despite the potential impact of health information system (HIS) design barriers on health data quality and use and, ultimately, health outcomes in low‐ and middle‐income countries (LMICs), no comprehensive literature review has been conducted to study them in this context. We therefore conducted a formal literature review to understand system design barriers to data quality and use in LMICs and to identify any major research gaps related understanding how system design affects data use. We conducted an electronic search across 4 scientific databases—PubMed, Web of Science, Embase, and Global Health—and consulted a data use expert. Following a systematic inclusion and exclusion process, 316 publications (316 abstracts and 18 full papers) were included in the review. We found a paucity of scientific publications that explicitly describe system design factors that hamper data quality or data use for decision making. Although user involvement, work flow, human‐computer interactions, and user experience are critical aspects of system design, our findings suggest that these issues are not discussed or conceptualized in the literature. Findings also showed that individual training efforts focus primarily on imparting data analysis skills. The adverse impact of HIS design barriers on data integrity and health system performance may be even bigger in LMICs than elsewhere, leading to errors in population health management and clinical care. We argue for integrating systems thinking into HIS strengthening efforts to reduce the HIS design‐user reality gap.     

Developing a framework of, and quality indicators for, general practice management in Europe

OBJECTIVES: To develop a framework for general practice management made up of quality indicators shared by six European countries. METHODS: Two-round postal Delphi questionnaire in the setting of general practice in Belgium, France, Germany, The Netherlands, Switzerland and the United Kingdom. Six national expert panels, each consisting of 10 members, primarily primary care practitioners and experts in the field of quality in primary care participated in the study. The main outcome measures were: (a) a European framework with indicators for the organization of primary care; and (b) ratings of the face validity of the usefulness of the indicators by expert panels in six countries. RESULTS: Agreement was reached about a definition of practice management across five domains (infrastructure, staff, information, finance, and quality and safety), and a common set of indicators for the organization of general practice. The panellist response rate was 95%. Sixty-two indicators (37%) were rated face valid by all six panels. Examples include out of hours service, accessibility, the content of doctors' bags and staff involvement in quality improvement. No indicators were rated invalid by all six panels. CONCLUSIONS: It proved to be possible to develop a European set of indicators for assessing the quality of practice management, despite the differences in health care systems and cultures in the six different countries. These indicators will now be used in a quality assessment procedure of practice management in nine European countries. While organizational indicators are part of the new GMS contract in the UK, this research shows that many practice management issues within primary care are also of relevance in other European countries.     

Curing a meagre health care system by lean methods--translating 'chains of care' in the Swedish health care sector

The purpose of this article is to discuss what happens when work embedded in a 'meagre' organizational context is changed by lean production-related methods. The article is based on studies of seven lean production-inspired projects in the Swedish health care sector, a sector already poor due to organizational slack. The projects were directed to develop 'health care chains', an organizational concept regarded as a way to rationalize health care organizations as well as to develop them, i.e. increase productivity, quality from a customer perspective and quality of working conditions. The article analyses the projects from an interpretative perspective and discusses how modem management models with ambitions to concurrently rationalize and develop organizations--e.g. lean production and health care chains--are used in a 'meagre' organizational field. As an outcome, a model is presented that explores what is beyond simple imitations and unique translations of ideas when a new concept is implemented in local organizations.     

Overcoming adversity: a grounded theory of health management among middle-aged and older gay men

This article presents findings from a grounded theory study in which we explored how self-identifying gay men between 40 and 76 years of age manage their health in the context of homophobia, heteronormativity and discrimination. Data were collected with 25 men over a 6-month period in a large urban setting in Western Canada. A preliminary theory of health management is discussed, consisting of the central phenomenon of overcoming adversity. Three thematic processes are considered that illustrate how adversity and health management are situated within the interrelationships of historical and ongoing discrimination inclusive of and external to the healthcare encounter, the complexity of men’s illnesses, and the temporal aspects of HIV epidemics and treatments that occurred throughout their lives. These themes include: advocating for health needs, knowing about health issues and treatments, and engaging in health promoting practices. These findings help to address a gap in knowledge concerning health management among older gay men and support that initiatives aimed at health care with gay men must appreciate the systemic role of discrimination, while supporting men’s individual efforts in actively managing their health.     

Rejection of an innovation: health information management training materials in east Africa

A shift towards decentralization in many low-income countries has meant more skills are demanded of primary health care managers, including data and information handling at all levels of the health care system. Ministries of Health are changing their central reporting health information systems to health management information systems with emphasis on managers utilizing information at the point of collection. This paper reports on a research study to investigate the introduction of new information management strategies intended to promote an informational approach to management at the operational health service level in low-income countries. It aims to understand the process taking place when externally developed training materials (PHC MAP), which are intended to strengthen health management information systems, are introduced to potential users in an east African country. A case study has been undertaken and this research has demonstrated that the dynamic equilibrium approach to organizational change is applicable to the introduction of new information management strategies and management approaches in low-income countries. Although PHC MAP developers envisaged a technical innovation needing implementation, potential users saw the situation as one of organizational change. Contributions to theory have been made and many implications for introducing new information systems or the informational approach to management are identified. This theoretical framework could also facilitate the introduction of future information management innovations and would allow practitioners to perceive the introduction of information management innovations as one of organizational change that needs to be managed. Consequently, issues that may facilitate or inhibit adoption could be identified in advance.     

Progress on quality management in the German health system – a long and winding road

The interest in quality management in health care has increased in the last decades as the financial crises in most health systems generated the need for solutions to contain costs while maintaining quality of care. In Germany the development of quality management procedures has been closely linked with health care reforms. Starting in the early nineties quality management issues gained momentum in reform legislation only 10 years later.     

Understanding the linkages between informal and formal care for people living with HIV in sub-Saharan Africa

Abstract

In response to the human resource challenges facing African health systems, there is increasing involvement of informal care providers in HIV care. Through social and institutional interactions that occur in the delivery of HIV care, linkages between formal and informal systems of care often emerge. Based on a review of studies documenting the relationships between formal and informal HIV care in sub-Saharan Africa, we suggest that linkages can be conceptualised as either ‘actor-oriented’ or ‘systems-oriented’. Studies adopting an actor-oriented focus examine hierarchical working relationships and communication practices among health systems actors, while studies focusing on systems-oriented linkages document the presence, absence or impact of formal inter-institutional partnership agreements. For linkages to be effective, the institutional frameworks within which linkages are formalised, as well as the ground-level interactions of those engaged in care, ought to be considered. However, to date, both actor- and system-oriented linkages appear to be poorly utilised by policy makers to improve HIV care. We suggest that linkages between formal and informal systems of care be considered across health systems, including governance, human resources, health information and service delivery in order to improve access to HIV services, enable knowledge transfer and strengthen health systems.