Exploring the Functioning of Decision Space: A Review of the Available Health Systems Literature

Document Type : Review Article

Authors

Health Economics Unit, University of Cape Town, Cape Town, South Africa

Abstract

Background
The concept of decision space holds appeal as an approach to disaggregating the elements that may influence decision-making in decentralized systems. This narrative review aims to explore the functioning of decision space and the factors that influence decision space.
 
Methods
A narrative review of the literature was conducted with searches of online databases and academic journals including PubMed Central, Emerald, Wiley, Science Direct, JSTOR, and Sage. The articles were included in the review based on the criteria that they provided insight into the functioning of decision space either through the explicit application of or reference to decision space, or implicitly through discussion of decision-making related to organizational capacity or accountability mechanisms.
 
Results
The articles included in the review encompass literature related to decentralisation, management and decision space. The majority of the studies utilise qualitative methodologies to assess accountability mechanisms, organisational capacities such as finance, human resources and management, and the extent of decision space. Of the 138 articles retrieved, 76 articles were included in the final review.
 
Conclusion
The literature supports Bossert’s conceptualization of decision space as being related to organizational capacities and accountability mechanisms. These functions influence the decision space available within decentralized systems. The exact relationship between decision space and financial and human resource capacities needs to be explored in greater detail to determine the potential influence on system functioning.

Keywords

Main Subjects


  1. Bossert T, Beauvais JC. Decentralization of health systems in Ghana, Zambia, Uganda and the Phillipines: a comparative analysis of decision space. Health Policy Plan. 2002;17(1):14-31.
  2. Tang S, Bloom G. Decentralising rural health services: A case study in China. Int J Health Plann Manage. 2000;15:189-200.
  3. Khaleghian P. Decentralization and public services: the case of immunization. Soc Sci Med. 2004;59(1):163-183. doi:10.1016/j.socscimed.2003.10.013
  4. Vargas Bustamante A. The tradeoff between centralized and decentralized health services: evidence from rural areas in Mexico. Soc Sci Med. 2010;71(5):925-934. doi:10.1016/j.socscimed.2010.05.022
  5. Faguet JP. Low decision space means no decentralisation in Fiji: Comment on "Decentralisation of health services in Fiji A decision space analysis." Int J Health Policy Manag. 2016;5(11):663-665. doi:10.15171/ijhpm.2016.82
  6. Bossert T, Mitchell AD, Janjua MA. Improving health system performance in a decentralized health system: capacity building in Pakistan. Health Systems and Reforms. 2015;1(4):276-284. doi:10.1080/23288604.2015.1056330
  7. Bossert T. Analyzing the decentralisation of health systems in developing countries: Decision space, innovation and performance. Soc Sci Med. 1998;47(10):1513-1527.
  8. Mitchell AD, Bossert T. Decentralisation, governance and health-system performance: "Where you stand depends on where you sit". Dev Policy Rev. 2010;28(6):669-691.
  9. Bossert TJ, Mitchell AD. Health sector decentralization and local decision-making: Decision space, institutional capacities and accountability in Pakistan. Soc Sci Med. 2011;72(1):39-48. doi:10.1016/j.socscimed.2010.10.019
  10. Marchal B, Denerville E, Dedzo M, De Brouwere V, Kegels G. Decentralisation, decision spaces and human resource management at hospital level: High commitment human resource management approaches used by the management team of Ghana’s Cape Coast Central Regional Hospital. Antwerp: Institute of Tropical Medicine;2005.
  11. Mohammed J, North N, Ashton T. Decentralisation of health services in Fiji: a decision space analysis. Int J Health Policy Manag. 2015;5(3):173-181. doi:10.15171/ijhpm.2015.199
  12. Kwamie A, van Dijk H, Ansah EK, Agyepong IA. The path dependence of district manager decision-space in Ghana. Health Policy Plan. 2016;31:356-366. doi:10.1093/heapol/czv069
  13. Atkinson S, Medeiros R, Henrique P, Oliveira L, de Almeida R. Going down to the local: Incorporating social organisation and political culture into assessments of decentralised health care. Soc Sci Med. 2000;51:619-636.
  14. Marchal B, Kegels G. Focusing on the software of managing health workers: what can we learn from high commitment management practices? Int J Health Plann Manage. 2008;23(4):299-311. doi:10.1002/hpm.882
  15. Bossert TJ. Decision space and capacities in the decentralization of health services in Fiji: Comment on "Decentralisation of health services in Fiji: a decision space analysis." Int J Health Policy Manag. 2016;5(7):443-444. doi:10.15171/ijhpm.2016.51
  16. Mills A, Antonius R, Danial J, Gray H, Haqq E, Rutten F. The distribution of health planning and management responsibilities between centre and periphery: Historical patterns and reform trends in four Caribbean territories. Health Policy. 2002;62:65-84.
  17. Newell JN, Collins CD, Baral SC, Omar MA, Pande SB. Decentralisation and TB control in Nepal: understanding the views of TB control staff. Health Policy. 2005;73(2):212-227. doi:10.1016/j.healthpol.2004.11.014
  18. Pettersen IJ, Nyland K. Reforms and clinical managers' responses: a study in Norwegian hospitals. J Health Organ Manag. 2012;26(1):15-31. doi:10.1108/14777261211211070
  19. Waweru E, Opwora A, Toda M, et al. Are Health Facility Management Committees in Kenya ready to implement financial management tasks: findings from a nationally representative survey. BMC Health Serv Res. 2013;13:404. doi:10.1186/1472-6963-13-404
  20. Ensor T, Ronoh J. Impact of organizational change on the delivery of reproductive services: a review of the literature. Int J Health Plann Manage. 2005;20(3):209-225. doi:10.1002/hpm.810
  21. Heywood P, Choi Y. Health system performance at the district level in Indonesia after decentralization. BMC Int Health Hum Rights. 2010;10:3. doi:10.1186/1472-698X-10-3
  22. Lieberman ES. The perils of polycentric governance of infectious disease in South Africa. Soc Sci Med. 2011;73(5):676-684. doi:10.1016/j.socscimed.2011.06.012
  23. Mubyazi G, Kamugisha M, Mushi A, Blas E. Implications of decentralisation for the control of tropical diseases in Tanzania: a case study of four districts. Int J Health Plann Manage. 2004;19:S167-185. doi:10.1002/hpm.776
  24. Raut MK, Sekher TV. Decentralization of Health Care Systems: Findings from Odisha and Gujarat, India. Journal of Health Management. 2013;15(2):235-251. doi:10.1177/0972063413489007
  25. Scott V, Schaay N, Olckers P, Nqana N, Lehmann U, Gilson L. Exploring the nature of governance at the level of implementation for health system strengthening: the DIALHS experience. Health Policy Plan. 2014;29 Suppl 2:ii59-70. doi:10.1093/heapol/czu073
  26. Seshadri SR, Parab S, Kotte S, Latha N, Subbiah K. Decentralization and decision space in the health sector: a case study from Karnataka, India. Health Policy Plan. 2016;31(2):171-181. doi:10.1093/heapop/czv034
  27. Kwamie A, Agyepong IA, van Dijk H. What governs district manager decision making? A case study of complex leadership in Dangme West District, Ghana. Health Systems and Reforms. 2015;1(2):167-177. doi:10.1080/23288604.2015.1032475
  28. Kawonga M, Fonn S, Blaauw D. Administrative integration of vertical HIV monitoring and evaluation into health systems: a case study from South Africa. Glob Health Action. 2013;6:19252. doi:10.3402/gha.v6i0.19252
  29. London JD. The promises and perils of hospital autonomy: reform by decree in Viet Nam. Soc Sci Med. 2013;96:232-240. doi:10.1016/j.socscimed.2013.07.009
  30. Frumence G, Nyamhanga T, Mwangu M, Hurtig AK. Challenges to the implementation of health sector decentralization in Tanzania: experiences from Kongwa district council. Glob Health Action. 2012;6:20983. doi:10.3402/gha.v6i0.20983
  31. Marchal B, Dedzo M, Kegels G. A realist evaluation of the management of a well-performing regional hospital in Ghana. BMC Health Serv Res. 2010;10:24. doi:10.1186/1472-6963-10-24
  32. Men B, Grundy J, Cane J, et al. Key issues relating to decentralization at the provincial level of health management in Cambodia. Int J Health Plann Manage. 2005;20(1):3-19. doi:10.1002/hpm.793
  33. Regmi K, Naidoo J, Greer A, Pilkington P. Understanding the effect of decentralisation on health services: the Nepalese experience. J Health Organ Manag. 2010;24(4):361-382. doi:10.1108/14777261011064986
  34. Munga MA, Songstad NG, Blystad A, Maestad O. The decentralisation-centralisation dilemma: recruitment and distribution of health workers in remote districts of Tanzania. BMC Int Health Hum Rights. 2009;9:9. doi:10.1186/1472-698X-9-9
  35. Meng Q, Li R, Cheng G, Blas E. Provision and financial burden of TB services in a financially decentralized system: a case study from Shandong, China. Int J Health Plann Manage. 2004;19 Suppl 1:S45-62. doi:10.1002/hpm.774
  36. Kivumbi GW, Nangendo F, Ndyabahika BR. Financial management systems under decentralization and their effect on malaria control in Uganda. Int J Health Plann Manage. 2004;19 Suppl 1:S117-131. doi:10.1002/hpm.773
  37. Oliveira-Cruz V, Hanson K, Mills A. Approaches to overcoming constraints to effective health service delivery: a review of the evidence. J Int Dev. 2003;15(1):41-65. doi:10.1002/jid.965
  38. Asante AD, Zwi AB, Ho MT. Getting by on credit: how district health managers in Ghana cope with the untimely release of funds. BMC Health Serv Res. 2006;6:105. doi:10.1186/1472-6963-6-105
  39. Delkhosh RA, Ardam A, Salamzadeh J. Decentralisation and hospital pharmacy services: The case of Iranian univeristy affiliated hospitals. Iran J Pharm Res. 2013;12(Suppl):183-188.
  40. Rocha GM, Martinez AM, Rios EV, Elizondo ME. Resource allocation equity in northeastern Mexico. Health Policy. 2004;70(3):271-279. doi:10.1016/j.healthpol.2004.04.007
  41. Blas E. The proof of the reform is in the implementation. Int J Health Plann Manage. 2004;19 Suppl 1:S3-23. doi:10.1002/hpm.781
  42. Hanson K, Atuyambe L, Kamwanga J, McPake B, Mungule O, Ssengooba F. Towards improving hospital performance in Uganda and Zambia: reflections and opportunities for autonomy. Health Policy. 2002;61:73-94.
  43. Abimbola S, Negin J, Jan S, Martiniuk A. Towards people-centred health systems: a multi-level framework for analysing primary health care governance in low- and middle-income countries. Health Policy Plan. 2014;29(suppl 2):ii29-ii39. doi:10.1093/heapol/czu069
  44. Kwamie A, van Dijk H, Agyepong IA. Advancing the application of systems thinking in health: realist evaluation of the Leadership Development Programme for district manager decision-making in Ghana. Health Res Policy Syst. 2014;12:29. doi:10.1186/1478-4505-12-29
  45. Waweru E, Goodman C, Kedenge S, Tsofa B, Molyneux S. Tracking implementation and (un)intended consequences: A process evaluation of an innovative peripheral health facility financing mechanism in Kenya. Health Policy Plan. 2016;31:137-147. doi:10.1093/heapol/czv030
  46. Maharani A, Femina D, Tampubolon G. Decentralization in Indonesia: lessons from cost recovery rate of district hospitals. Health Policy Plan. 2015;30(6):718-727. doi:10.1093/heapol/czu049
  47. Hodge A, Firth S, Jimenez-Soto E, Trisnantoro L. Linkages between decentralisation and inequalities in neonatal health: Evidence from Indonesia. J Dev Stud. 2015;51(12):1634-1652. doi:10.1080/00220388.2015.1081172
  48. Fritzen SA. Strategic management of the health workforce in developing countries: what have we learned? Hum Resour Health. 2007;5:4. doi:10.1186/1478-4491-5-4
  49. Heywood PF, Harahap NP. Human resources for health at the district level in Indonesia: the smoke and mirrors of decentralization. Hum Resour Health. 2009;7:6. doi:10.1186/1478-4491-7-6
  50. Hailemichael Y, Jira C, Girma B, Tushune K. Health workforce deployment, attrition and density in East Wollega Zone, Western Ethiopia. Ethiopian Journal of Health Sciences. 2010;20(1):15-23.
  51. Bonenberger M, Aikins M, Akweongo P, Wyss K. Factors infleuncing the work efficiency of district health managers in low resource settings: a qualitative study in Ghana. BMC Health Serv Res. 2016;16(12). doi:10.1186/s12913-016-1271-3
  52. Bonenberger M, Aikins M, Akweongo P, Wyss K. The effects of health worker motivation and job satisfaction on turnover intention in Ghana: a cross-sectional study. Human Resources for Health. 2014;12(1):43. doi:10.1186/1478-4491-12-43
  53. Maharani A, Tampubolon G. Has decentralisation affected child immunisation status in Indonesia? Glob Health Action. 2014;7:24913. doi:10.3402/gha.v7.24913
  54. Sherr K, Cuembelo F, Michel C, et al. Strengthening integrated primary health care in Sofala, Mozambique. BMC Health Serv Res. 2013;13 Suppl 2:S4. doi:10.1186/1472-6963-13-S2-S4
  55. Asangansi I. Understanding HMIS implementation in a developing country ministry of health context: An institutional logics perspective. Online J Public Health Inform. 2012;4(3). doi:10.5210/ojphi.v4i3.4302.
  56. Ghuman BS, Singh R. Decentralization and delivery of public services in Asia. Policy and Society. 2013;32(1):7-21. doi:10.1016/j.polsoc.2013.02.001
  57. Hartwig K, Pashman J, Cherlin E, et al. Hospital management in the context of health sector reform: a planning model in Ethiopia. Int J Health Plann Manage. 2008;23(3):203-218. doi:10.1002/hpm.915
  58. Madon S, Krishna S, Michael E. Health information systems, decentralisation and democratic accountability. Public Adm Dev. 2010;30(4):247-260. doi:10.1002/pad.571
  59. Fritzen SA. Legacies of primary health care in an age of health sector reform: Vietnam's commune clinics in transition. Soc Sci Med. 2007;64(8):1611-1623. doi:10.1016/j.socscimed.2006.12.008
  60. Martin GP, Learmonth M. A critical account of the rise and spread of 'leadership': the case of U.K. healthcare. Soc Sci Med. 2012;74(3):281-288. doi:10.1016/j.socscimed.2010.12.002
  61. Olukoga A, Bachmann M, Harris G, Olukoga T, Oluwadiya K. Analysis of the perception of institutional function for health sector reform in Nigeria. Int Health. 2010;2(2):150-155. doi:10.1016/j.inhe.2009.12.006
  62. Rausch E, Rausch E. A practical focus on leadership in management − for research, education and management development. Management Decision. 2005;43(7/8):988-1000. doi:10.1108/00251740510609983
  63. Khaleghian P, Gupta MD. Public management and the essential public health functions. World Development. 2005;33(7):1083-1099. doi:10.1016/j.worlddev.2005.04.001
  64. Prashanth NS, Marchal B, Kegels G, Criel B. Evaluation of capacity-building program of district health managers in India: a contextualized theoretical framework. Front Public Health. 2014;2:89. doi:10.3389/fpubh.2014.00089
  65. Brinkerhoff DW. Accountability and health systems: toward conceptual clarity and policy relevance. Health Policy Plan. 2004;19(6):371-379. doi:10.1093/heapol/czh052
  66. Cleary SM, Molyneux S, Gilson L. Resources, attitudes and culture: an understanding of the factors that influence the functioning of accountability mechanisms in primary health care settings. BMC Health Serv Res. 2013;13:320. doi:10.1186/1472-6963-13-320
  67. O'Meara WP, Tsofa B, Molyneux S, Goodman C, McKenzie FE. Community and facility-level engagement in planning and budgeting for the government health sector--a district perspective from Kenya. Health Policy. 2011;99(3):234-243. doi:10.1016/j.healthpol.2010.08.027
  68. Molyneux S, Atela M, Angwenyi V, Goodman C. Community accountability at peripheral health facilities: a review of the empirical literature and development of a conceptual framework. Health Policy Plan. 2012;27(7):541-554. doi:10.1093/heapol/czr083
  69. Pettersen IJ, Nyland K, Kaarboe K. Governance and the functions of boards: an empirical study of hospital boards in Norway. Health Policy. 2012;107(2-3):269-275. doi:10.1016/j.healthpol.2012.07.006
  70. McNatt Z, Thompson JW, Mengistu A, et al. Implementation of hospital governing boards: views from the field. BMC Health Serv Res. 2014;14:178. doi:10.1186/1472-6963-14-178
  71. Minvielle E. New public management à la Française: The case of regional hospital agencies. Public Adm Rev. 2006;66(5):753-763.
  72. Yakam JCYT, Gruenais M-E. Involving new actors to achieve ART scaling-up: Difficulties in an HIV/AIDS counselling and testing centre in Cameroon. International Council of Nurses;2009.
  73. Exworthy M, Frosini F, Jones L, et al. Decentralisation and performance: Autonomy and incentives in local health economies. National Institute for Health Research Service Delivery and Organisation Programme;2010.
  74. Ssengooba F, McPake B, Palmer N. Why performance-based contracting failed in Uganda--an "open-box" evaluation of a complex health system intervention. Soc Sci Med. 2012;75(2):377-383. doi:10.1016/j.socscimed.2012.02.050
  75. Nielsen AJ, Knudsen M, Finke K. Expansive or limitative strategy? A case study of organisational responses to new public health. J Health Organ Manag. 2008;22(4):384-399. doi:10.1108/14777260810893971
  76. Smith SL. Political contexts and maternal health policy: insights from a comparison of south Indian states. Soc Sci Med. 2014;100:46-53. doi:10.1016/j.socscimed.2013.10.029
  77. Klotzbucher S, Lassig P, Jiangmei Q, Weigelin-Schwiedrzik S. What is new in the "New Rural Co-operative Medical System"? An assessment in one Kazak county of the Xinjiang Uyghur autonomous region. China Q. 2010;201:38-57. doi:10.1017/S0305741009991068
  78. Peckham S. Decentralisation - A portmanteau concept that promises much but fails to deliver? Comment on "Decentralisation of Health service in Fiji a decision space analysis." Int J Health Policy Manag. 2016;5(12):729-732. doi:10.15171/ijhpm.2016.88
  79. Hipgrave DB, Alderman KB, Anderson I, Soto EJ. Health sector priority setting at meso-level in lower and middle income countries: lessons learned, available options and suggested steps. Soc Sci Med. 2014;102:190-200. doi:10.1016/j.socscimed.2013.11.056
  • Receive Date: 23 March 2016
  • Revise Date: 17 February 2017
  • Accept Date: 18 February 2017
  • First Publish Date: 01 July 2017