Governance and participation in health

This paper reports on work to explore how primary healthcare facility managers’ use of information for decision-making is influenced by governance across levels of the health system in Cape Town, South Africa. Central governance shaped what information and knowledge was valued – and, therefore, generated and used at lower system levels. The central level valued formal health information generated in the district-based health information system which therefore attracted management attention across the levels of the health system in terms of design, funding and implementation. This information was useful in the top-down practices of planning and management of the public health system. However, in facilities at the frontline of service delivery, there was a strong requirement for local, disaggregated information and experiential knowledge to make locally-appropriate and responsive decisions, and to perform the people management tasks required. Despite central level influences, modes of governance operating at the sub-district level had influence over what information was valued, generated and used locally. Strengthening local level managers’ ability to create enabling environments is an important leverage point in supporting informed local decision-making, and, in turn, translating national policies and priorities, including equity goals, into appropriate service delivery practices.

This paper uses the concepts of organizational culture and organizational trust to explore the implementation of equity-oriented policies - the Uniform Patient Fee Schedule and Patients' Rights Charter - in two South African district hospitals. The hospitals' implementation approaches were similar in that both primarily understood it to be about revenue generation, that granting fee exemptions was not a major focus, and considerable activity, facility management support, and provincial support was mobilised behind the Uniform Patient Fee Schedule. The hospitals' Patients' Rights Charter paths diverged quite significantly, as Hospital A was more explicit in communicating and implementing the Patients' Rights Charter, while the policy also enjoyed stronger managerial support in Hospital A than Hospital B. Beneath these experiences lie differences in how people's values, decisions and relationships influence health system functioning and in how the nature of policies, culture, trust and power dynamics can combine to create enabling or disabling micro-level implementation environments. Achieving equity in practice requires managers to take account of "unseen" but important factors such as organisational culture and trust, as key aspects of the organisational context that can profoundly influence policies. In addition to putting in place necessary staff and resources, tasks such as relationship management, the negotiation of values and paying careful attention to how policies are practically framed and translated into practice are seen to be necessary to ensure equity aspects are not neglected.

This study presents qualitative research to examine the early experiences of devolution in the health sector in Kenya in March 2013. The authors observed a diverse range of management meetings, support supervision visits and outreach activities involving sub-county managers between May 2013 and June 2015, and conducted interviews with purposively selected sub-county managers from three sub-counties. The authors found that sub county managers as with many other health system actors were anxious about and ill-prepared for the unexpectedly rapid devolution of health functions to the newly created county government. They experienced loss of autonomy and resources and confused lines of accountability within the health system. The study illustrates the importance in accelerated devolution contexts for: mid-level managers to adopt new ways of working and engagement with higher and lower levels in the system; clear lines of communication during reforms to these actors and anticipating and managing the effect of change on intangible software issues such as trust and motivation. More broadly, the authors show the value of examining organisational change from the perspective of key actors within the system, and highlight the importance in times of rapid change of drawing upon and working with those already in the system. These actors have valuable tacit knowledge, but tapping into and building on this knowledge to enable positive response in times of health system shocks requires greater attention to sustained capacity building within the health system.

The Forum on Internet Freedom in Africa convened stakeholders in end September 2017 from the internet governance and online rights arenas in Africa and beyond to deliberate on gaps, concerns and opportunities for advancing the right to privacy, access to information, free expression, non-discrimination, and the free flow of information online. The Forum gathered human rights defenders, journalists, government officials, private sector players, global information intermediaries, bloggers, developers, the arts community, law enforcers and regulators – all of whom have a role to play in advancing internet freedom in Africa. Highlights at FIFAfrica include the launch of the annual State of Internet Freedom in Africa research report, as well the commemoration of the International Day for Universal Access to Information (IDUAI), which falls on September 28. Further information, thoughts and ideas can be found at the #InternetFreedomAfrica hashtag.