Understanding the dynamic interactions driving Zambian health centre performance: a case-based health systems analysis

Topp, Stephanie M., Chipukuma, Julien M., and Hanefeld, Johanna (2015) Understanding the dynamic interactions driving Zambian health centre performance: a case-based health systems analysis. Health Policy and Planning, 30 (4). pp. 485-499.

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Background: Despite being central to achieving improved population health outcomes, primary health centres in low- and middle-income settings continue to underperform. Little research exists to adequately explain how and why this is the case. This study aimed to test the relevance and usefulness of an adapted conceptual framework for improving our understanding of the mechanisms and causal pathways influencing primary health centre performance.

Methods: A theory-driven, case-study approach was adopted. Four Zambian health centres were purposefully selected with case data including health-care worker interviews (n¼60); patient interviews (n¼180); direct observation of facility operations (2 weeks/centre) and key informant interviews (n¼14). Data were analysed to understand how the performance of each site was influenced by the dynamic interactions between system 'hardware' and 'software acting on mechanisms of accountability.

Findings: Structural constraints including limited resources created challenging service environments in which work overload and stockouts were common. Health workers' frustration with such conditions interacted with dissatisfaction with salary levels eroding service values and acting as a catalyst for different forms of absenteeism. Such behaviours exacerbated patient–provider ratios and increased the frequency of clinical and administrative shortcuts. Weak health information systems and lack of performance data undermined providers' answerability to their employer and clients, and a lack of effective sanctions undermined supervisors’ ability to hold providers accountable for these transgressions. Weak answerability and enforceability contributed to a culture of impunity that masked and condoned weak service performance in all four sites.

Conclusions Health centre performance is influenced by mechanisms of accountability, which are in turn shaped by dynamic interactions between system hardware and system software. Our findings confirm the usefulness of combining Sheikh et al.'s (2011) hardware–software model with Brinkerhoff's (2004) typology of accountability to better understand how and why health centre micro-systems perform (or under-perform) under certain conditions.

Item ID: 39587
Item Type: Article (Research - C1)
ISSN: 1460-2237
Keywords: health systems, health system strengthening, primary health centres, service-delivery, accountability, complexity
Additional Information:

© The Author 2014.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

Funders: Australian Postgraduate Award
Date Deposited: 29 Jul 2015 01:31
FoR Codes: 16 STUDIES IN HUMAN SOCIETY > 1608 Sociology > 160801 Applied Sociology, Program Evaluation and Social Impact Assessment @ 30%
11 MEDICAL AND HEALTH SCIENCES > 1117 Public Health and Health Services > 111799 Public Health and Health Services not elsewhere classified @ 40%
15 COMMERCE, MANAGEMENT, TOURISM AND SERVICES > 1503 Business and Management > 150310 Organisation and Management Theory @ 30%
SEO Codes: 92 HEALTH > 9204 Public Health (excl. Specific Population Health) > 920499 Public Health (excl. Specific Population Health) not elsewhere classified @ 40%
92 HEALTH > 9202 Health and Support Services > 920299 Health and Support Services not elsewhere classified @ 60%
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