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21. Opening decision spaces: A case study on the opportunities and constraints in the public health sector of Mpumalanga Province, South Africa.

Author

Witter, Sophie, van der Merwe, Maria, Twine, Rhian, Mabetha, Denny, Hove, Jennifer, Tollman, Stephen M., and D'Ambruoso, Lucia

Subjects
*COMMUNITY health workers, *PUBLIC sector, *OPEN spaces, *COMMUNITY-based participatory research, *CAPACITY (Law)
Abstract

Background: Decentralised and evidence-informed health systems rely on managers and practitioners at all levels having sufficient 'decision space' to make timely locally informed and relevant decisions. Our objectives were to understand decision spaces in terms of constraints and enablers and outline opportunities through which to expand them in an understudied rural context in South Africa. Methods: This study examined decision spaces within Mpumalanga Province, using data and insights generated through a participatory action research process with local communities and health system stakeholders since 2015, which was combined with published documents and research team participant observation to produce findings on three core domains at three levels of the health system. Results: Although capacity for decision making exists in the system, accessing it is frequently made difficult due to a number of intervening factors. While lines of authority are generally well-defined, personal networks take on an important dimension in how stakeholders can act. This is expressed through a range of informal coping strategies built on local relationships. There are constraints in terms of limited formal external accountability to communities, and internal accountability which is weak in places for individuals and focused more on meeting performance targets set at higher levels and less on enabling effective local leadership. More generally, political and personal factors are clearly identified at higher levels of the system, whereas at sub-district and facility levels, the dominant theme was constrained capacity. Conclusions: By examining the balance of authority, accountability and capacity across multiple levels of the provincial health system, we are able to identify emergent decision space and areas for enlargement. Creating spaces to support more constructive relationships and dialogue across system levels emerges as important, as well as reinforcing horizontal networks to problem solve, and developing the capacity of link-agents such as community health workers to increase community accountability. [ABSTRACT FROM AUTHOR]

Published
2024
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33. Making delivery care free : evidence from Ghana and Senegal on implementation, costs and effectiveness of national delivery exemption policies

Author

Witter, Sophie

Subjects
337, Maternal health services, Medical economics, Obstetrics, Women’s health services
Abstract

Continuing high maternal mortality ratios, especially in Africa, and high discrepancies between richer and poorer households in relation to access to maternal health care and maternal health status have focussed attention on the importance of reducing financial barriers to skilled care. This PhD compares the findings of two evaluations of national policies exempting women from user fees for deliveries, conducted in Ghana in 2005-6 and in Senegal in 2006-7. The detailed findings from each evaluation are presented as well as the broad lessons learnt from what are similar (but not identical) policies with similar goals, both of which were implemented in poorer regions initially but then scaled up, using national resources.  Both demonstrate the potential of fee exemption policies to increase utilisation.  The cost per additional associated delivery was $62 (average) in Ghana and $21 (normal delivery) and $457 (caesarean section) in Senegal. However, despite reducing direct costs for women (from $195 to $153 for caesareans and from $42 to $34 for normal deliveries in Ghana), in neither country were delivery fees costs reduced to zero.  This was linked to a number of important factors, including inadequate budgets (in Ghana) and failure to adequately reimburse lower level providers (in Senegal).  The study also highlights the need to address quality of care and geographical access issues alongside fee exemption. While there has been a lot of debate over the relative merits of different targeting approaches and design of policies to reduce financial barriers to health care (maternal and general), the Ghana and Senegal evaluations suggest the details of implementation and their interaction with contextual factors can be more significant than design of the policy per se.

Published
2009

39. Provision of Mental Health and Psychosocial Support Services to Health Workers and Community Members in Conflict-affected Northwest Syria: A Mixed-Methods study

Author

Bou-Orm, Ibrahim R., primary, Moussallem, Marianne, additional, Karam, Joelle, additional, deLara, Manuel, additional, Varma, Vinod, additional, Diaconu, Karin, additional, Apaydin, Murat Can Birand, additional, Bergh, Rafael Van den, additional, Ager, Alastair, additional, and Witter, Sophie, additional

Published
2023
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