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Health system governance following devolution: comparing experiences of decentralisation in Kenya and Indonesia
INTRODUCTION: Devolution reforms in Indonesia and Kenya have brought extensive changes to governance structures and mechanisms for financing and delivering healthcare. Community health approaches can contribute towards attaining many of devolution’s objectives, including community participation, res...
Autores principales: | , , , , |
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Formato: | Online Artículo Texto |
Lenguaje: | English |
Publicado: |
BMJ Publishing Group
2018
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Materias: | |
Acceso en línea: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6169670/ https://www.ncbi.nlm.nih.gov/pubmed/30294460 http://dx.doi.org/10.1136/bmjgh-2018-000939 |
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author | McCollum, Rosalind Limato, Ralalicia Otiso, Lilian Theobald, Sally Taegtmeyer, Miriam |
author_facet | McCollum, Rosalind Limato, Ralalicia Otiso, Lilian Theobald, Sally Taegtmeyer, Miriam |
author_sort | McCollum, Rosalind |
collection | PubMed |
description | INTRODUCTION: Devolution reforms in Indonesia and Kenya have brought extensive changes to governance structures and mechanisms for financing and delivering healthcare. Community health approaches can contribute towards attaining many of devolution’s objectives, including community participation, responsiveness, accountability and improved equity. We set out to examine governance in two countries at different stages in the devolution journey: Indonesia at 15 years postdevolution and Kenya at 3 years. METHODS: We collected qualitative data across multiple levels of the health system in one district in Indonesia and ten counties in Kenya, through 80 interviews and six focus group discussions (FGD) in Indonesia and 269 interviews and 14 FGDs in Kenya. Qualitative data were digitally recorded, transcribed and coded before thematic framework analysis. Common themes between contexts were identified inductively and deductively, and similarities and differences critically analysed during an inter-country analysis workshop. RESULTS: Following devolution both Indonesia and Kenya experienced similar challenges ensuring good governance for health. Devolution reforms transformed power relationships, increasing responsibilities at subnational levels and introducing opportunities for citizen participation. In both contexts, the impact of these mechanisms has been undermined by insufficiently clear guidance; failure to address pre-existing negative contextual norms and practices varied decision-maker values, limited priority-setting capacity and limited genuine community accountability. As a consequence, priorities in both contexts are too often placed on curative rather than preventive health services. CONCLUSION: We recommend consideration of increased intersectoral actions that address social determinants of health, challenge negative norms and practices and place emphasis on community-based primary health services. |
format | Online Article Text |
id | pubmed-6169670 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2018 |
publisher | BMJ Publishing Group |
record_format | MEDLINE/PubMed |
spelling | pubmed-61696702018-10-05 Health system governance following devolution: comparing experiences of decentralisation in Kenya and Indonesia McCollum, Rosalind Limato, Ralalicia Otiso, Lilian Theobald, Sally Taegtmeyer, Miriam BMJ Glob Health Research INTRODUCTION: Devolution reforms in Indonesia and Kenya have brought extensive changes to governance structures and mechanisms for financing and delivering healthcare. Community health approaches can contribute towards attaining many of devolution’s objectives, including community participation, responsiveness, accountability and improved equity. We set out to examine governance in two countries at different stages in the devolution journey: Indonesia at 15 years postdevolution and Kenya at 3 years. METHODS: We collected qualitative data across multiple levels of the health system in one district in Indonesia and ten counties in Kenya, through 80 interviews and six focus group discussions (FGD) in Indonesia and 269 interviews and 14 FGDs in Kenya. Qualitative data were digitally recorded, transcribed and coded before thematic framework analysis. Common themes between contexts were identified inductively and deductively, and similarities and differences critically analysed during an inter-country analysis workshop. RESULTS: Following devolution both Indonesia and Kenya experienced similar challenges ensuring good governance for health. Devolution reforms transformed power relationships, increasing responsibilities at subnational levels and introducing opportunities for citizen participation. In both contexts, the impact of these mechanisms has been undermined by insufficiently clear guidance; failure to address pre-existing negative contextual norms and practices varied decision-maker values, limited priority-setting capacity and limited genuine community accountability. As a consequence, priorities in both contexts are too often placed on curative rather than preventive health services. CONCLUSION: We recommend consideration of increased intersectoral actions that address social determinants of health, challenge negative norms and practices and place emphasis on community-based primary health services. BMJ Publishing Group 2018-09-28 /pmc/articles/PMC6169670/ /pubmed/30294460 http://dx.doi.org/10.1136/bmjgh-2018-000939 Text en © Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/. |
spellingShingle | Research McCollum, Rosalind Limato, Ralalicia Otiso, Lilian Theobald, Sally Taegtmeyer, Miriam Health system governance following devolution: comparing experiences of decentralisation in Kenya and Indonesia |
title | Health system governance following devolution: comparing experiences of decentralisation in Kenya and Indonesia |
title_full | Health system governance following devolution: comparing experiences of decentralisation in Kenya and Indonesia |
title_fullStr | Health system governance following devolution: comparing experiences of decentralisation in Kenya and Indonesia |
title_full_unstemmed | Health system governance following devolution: comparing experiences of decentralisation in Kenya and Indonesia |
title_short | Health system governance following devolution: comparing experiences of decentralisation in Kenya and Indonesia |
title_sort | health system governance following devolution: comparing experiences of decentralisation in kenya and indonesia |
topic | Research |
url | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6169670/ https://www.ncbi.nlm.nih.gov/pubmed/30294460 http://dx.doi.org/10.1136/bmjgh-2018-000939 |
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