Decentralisation of the Health System Derailed by Organisational Inertia in Machinga, Malawi

Articles in Press

Document Type : Original Article

Authors

Graduate School of Business and Leadership Studies, University of KwaZulu-Natal, Durban, South Africa

Abstract

Background 
Managing the transition of a health system (HS) from a centralised to a decentralised model has been touted as a panacea to the complex challenges in developing countries like Malawi. However, recent studies have demonstrated that decentralisation of the HS has had mixed effects in service provision with more dominant negative outcomes than positive results. The aim of this study was to develop a substantive grounded theory (GT) that elaborates on how activities of central decision-makers and local healthcare mangers shape the process of shifting the HS to a decentralised model in Machinga, Malawi.

Methods 
The study was qualitative in nature and employed the Straussian version of GT. Some participants were interviewed twice, and a total of 36 semi-structured interviews were conducted with 25 purposively selected participants using an interview guide. The interviews were conducted at the headquarters of the Ministry of Health (MoH) and other ministries and agencies, and in Machinga District. Data were analysed using open, axial, and selective coding processes of the GT methodology; and the conditional matrix and paradigm model were used as data analysis tools.

Results 
The findings of this study revealed seven different activities, forming two opposing and interactional sub-processes of enabling and impeding patterns that derailed the decentralisation drive. The study generated a GT labelled “decentralisation of the HS derailed by organisational inertia,” which elaborates that decentralisation of the HS produced mixed results with more predominant negative outcomes than positive effects due to resistance at the upper organisational echelons and members of the District Health Management Team (DHMT).

Conclusion 
This article concludes that organisational inertia at the personal and strategic levels of leadership entrusted with decentralising the HS in Malawi, contributed immensely to the derailment of shifting the HS from the centralised to the decentralised model of health service provision.

Keywords

References

  1. Karmel E. Decentralising Government: What You Need to Know. Democracy Reporting International; 2017;87.
  2. Mudalige PW. The discussion of theory and practice on decentralization and service delivery. Eur Sci J. 2019;15(14):115-135. doi:19044/esj.2019.v15n14p115
  3. Dick-Sagoe C. Decentralization for improving the provision of public services in developing countries: a critical review. Cogent Econ Financ. 2020;8(1):1804036. doi:1080/23322039.2020.1804036
  4. Khan SA. Decentralisation and the Limits to Service Delivery: Evidence from Northern Pakistan. Sage Open. 2021;11(1). doi:10.1177/2158244021994505
  5. Panda B, Thakur HP. Decentralization and health system performance - a focused review of dimensions, difficulties, and derivatives in India. BMC Health Serv Res. 2016;16(Suppl 6):561. doi:1186/s12913-016-1784-9
  6. Bossert TJ. Decision space and capacities in the decentralization of health services in Fiji: Comment on "Decentralization of health services in Fiji: a decision space analysis". Int J Health Policy Manag. 2016;5(7):443-444. doi:15171/ijhpm.2016.51
  7. Liwanag HJ, Wyss K. Optimising decentralisation for the health sector by exploring the synergy of decision space, capacity and accountability: insights from the Philippines. Health Res Policy Syst. 2019;17(1):4. doi:1186/s12961-018-0402-1
  8. Sumah AM, Baatiema L. Decentralization and management of human resource for health in the health system of Ghana: a decision space analysis. Int J Health Policy Manag. 2019;8(1):28-39. doi:15171/ijhpm.2018.88
  9. Roman TE. Exploring Decision Space: A Case Study of Two South African Central Hospitals. University of Cape Town; 2017.
  10. 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:1093/heapol/czv034
  11. Mohammed J, North N, Ashton T. Decentralization of health services in Fiji: a decision space analysis. Int J Health Policy Manag. 2015;5(3):173-181. doi:15171/ijhpm.2015.199
  12. Liwanag HJ, Wyss K. What conditions enable decentralization to improve the health system? Qualitative analysis of perspectives on decision space after 25 years of devolution in the Philippines. PLoS One. 2018;13(11):e0206809. doi:1371/journal.pone.0206809
  13. Kigume R, Maluka S. Decentralization and health services delivery in 4 districts in Tanzania: how and why does the use of decision space vary across districts? Int J Health Policy Manag. 2019;8(2):90-100. doi:15171/ijhpm.2018.97
  14. Bulthuis SE, Kok MC, Amon S, et al. How district health decision-making is shaped within decentralised contexts: a qualitative research in Malawi, Uganda and Ghana. Glob Public Health. 2021;16(1):120-135. doi:1080/17441692.2020.1791213
  15. Brennan E, Abimbola S. Understanding and progressing health system decentralization in Myanmar. Glob Secur Health Sci Policy. 2020;5(1):17-27. doi:1080/23779497.2020.1782247
  16. Abimbola S, Baatiema L, Bigdeli M. The impacts of decentralization on health system equity, efficiency and resilience: a realist synthesis of the evidence. Health Policy Plan. 2019;34(8):605-617. doi:1093/heapol/czz055
  17. Reed JC. Health systems flattening - the failed promises of decentralization in Mozambique. Glob Public Health. 2018;13(12):1737-1752. doi:1080/17441692.2018.1436719
  18. Alonso-Garbayo A, Raven J, Theobald S, Ssengooba F, Nattimba M, Martineau T. Decision space for health workforce management in decentralized settings: a case study in Uganda. Health Policy Plan. 2017;32(Suppl 3):iii59-iii66. doi:1093/heapol/czx116
  19. Inkoom DKB, Gyapong AY. Decentralization in Africa: local government and health care in Ghana, Malawi and Tanzania. In: Silva CN, ed. Governing Urban Africa. London: Palgrave Macmillan; 2016:99-124. doi:1057/978-1-349-95109-3_4
  20. Roman TE, Cleary S, McIntyre D. Exploring the functioning of decision space: a review of the available health systems literature. Int J Health Policy Manag. 2017;6(7):365-376. doi:15171/ijhpm.2017.26
  21. Dwicaksono A, Fox AM. Does decentralization improve health system performance and outcomes in low- and middle-income countries? A systematic review of evidence from quantitative studies. Milbank Q. 2018;96(2):323-368. doi:1111/1468-0009.12327
  22. Zaidi SA, Bigdeli M, Langlois EV, et al. Health systems changes after decentralization: progress, challenges and dynamics in Pakistan. BMJ Glob Health. 2019;4(1):e001013. doi:1136/bmjgh-2018-001013
  23. Regmi K, Naidoo J, Greer A, Pilkington P. Understanding the effect of decentralization on health services: the Nepalese experience. J Health Organ Manag. 2010;24(4):361-382. doi:1108/14777261011064986
  24. Hudson B, Hunter D, Peckham S. Policy failure and the policy-implementation gap: can policy support programs help? Policy Des Pract. 2019;2(1):1-14. doi:1080/25741292.2018.1540378
  25. Khuluza F, Haefele-Abah C. The availability, prices and affordability of essential medicines in Malawi: a cross-sectional study. PLoS One. 2019;14(2):e0212125. doi:1371/journal.pone.0212125
  26. Mweninguwe R. Stealing Money from Sick People. Deutsch Development and Cooperation. https://www.dandc.eu/en/article/malawis-health-sector-crumbling-possibly-due-corruption. Published April 2018.
  27. Wiesche M, Jurisch M, Yetton P, Krcmar H. Grounded theory methodology in information systems research. MIS Q. 2017;41(3):685-701. doi:25300/misq/2017/41.3.02
  28. Zon H, Pavlova M, Drabo KM, Groot W. Municipal health services provision by local governments: a systematic review of experiences in decentralized sub-Saharan African countries. Health Policy Plan. 2017;32(9):1327-1336. doi:1093/heapol/czx082
  29. World Health Organization (WHO). Decentralization: Health Laws and Universal Health Coverage. https://www.who.int/health-laws/topics/governance-decentralisation/en/. Published 2019.
  30. Goel RK, Mazhar U, Nelson MA, Ram R. Different forms of decentralization and their impact on government performance: Micro-level evidence from 113 countries. Econ Model. 2017;62:171-183. doi:1016/j.econmod.2016.12.010
  31. Bossert T. Analyzing the decentralization of health systems in developing countries: decision space, innovation and performance. Soc Sci Med. 1998;47(10):1513-1527. doi:1016/s0277-9536(98)00234-2
  32. Chiweza AL. A Review of the Malawi Decentralization Process: Lessons from Selected Districts. Blantyre: Concern Universal; 2010.
  33. Malawi Government. Local Government Act. Malawi Government; 1998. p. 1-50.
  34. Mbeye J. Formulation of Decentralization Policies: The Case of Malawi. 2003.
  35. Strauss A, Corbin J. Basics of Qualitative Research: Grounded Theory Procedures and Techniques. Vol 13. SAGE Publications; 1990.
  36. Partington D. Building grounded theories of management action. Br J Manag. 2000;11(2):91-102. doi:1111/1467-8551.00153
  37. Ndoro TT. Differentiating Engagement of Opportunity Identification: A Grounded Theory Study of Chinese Immigrant Entrepreneurs [dissertation]. Grahamstown: Rhodes University; 2016.
  38. Creswell JW. Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. 4th ed. SAGE Publications; 2014.
  39. Chell E, Pittaway L. A study of entrepreneurship in the restaurant and café industry: exploratory work using the critical incident technique as a methodology: prize-winning Paper from the IAHMS Conference at Sheffield Hallam University, England, November 1997. Int J Hosp Manag. 1998;17(1):23-32. doi:1016/s0278-4319(98)00006-1
  40. Rizzo A, Fulford H. Understanding small business strategy: a grounded theory study on small firms in the EU State of Malta. Journal of Enterprising Culture. 2012;20(3):287-332. doi:1142/s0218495812500136
  41. Bossert T. Analyzing the decentralization of health systems in developing countries: decision space, innovation and performance. Soc Sci Med. 1998;47(10):1513-1527. doi:1016/s0277-9536(98)00234-2
  42. Khaw KW, Alnoor A, Al-Abrrow H, Tiberius V, Ganesan Y, Atshan NA. Reactions towards organizational change: a systematic literature review. Curr Psychol. 2023;42(22):19137-19160. doi:1007/s12144-022-03070-6
  43. Amarantou V, Kazakopoulou S, Chatzoglou P, Chatzoudes D. Factors affecting “resistance to change”: an explanatory study conducted in the healthcare sector. International Journal of Strategic Innovative Marketing. 2016;2016:23-40. doi:15556/ijsim.03.03.003
  44. Pearse N. Balancing Leadership Patterns to Promote Sense of Community During Cell-Church Transitioning: A Grounded Theory of Strategic Leadership and Change [dissertation]. Rhodes University; 2005.
  45. Pearse N. Effective strategic leadership: balancing roles during church transitions. HTS Teol Stud. 2011;67(2):1-7. doi:4102/hts.v67i2.980
  46. Super S, Klerkx LWA, Hermens N, Koelen MA. A multilevel transition perspective on embedding intersectoral action in local health policies. Health Promot Int. 2021;36(4):1050-1061. doi:1093/heapro/daaa131
  47. Bacud SA. Henri Fayol’s principles of management and its effect to organizational leadership and governance. J Crit Rev. 2020;7(11):162-167. doi:31838/jcr.07.11.25
  48. Liwanag HJ, Wyss K. Optimising decentralization for the health sector by exploring the synergy of decision space, capacity and accountability: insights from the Philippines. Health Res Policy Syst. 2019;17(1):4. doi:1186/s12961-018-0402-1
  49. Jagero N, Kwandayi HH, Longwe A. Challenges of decentralization in Malawi. International Journal of Management Sciences. 2014;2(7):315-322.
  50. Bracken J. The Important Difference between Change and Transition. Quality Texas Foundation; 2014. https://quality-texas.org/wp-content/uploads/2014/11/The-Important-Difference-between-Change-and-Transition.pdf.
  51. Amegashie-Viglo S. Decentralization as a strategy for development. Research on Humanities and Social Sciences. 2014;4(13):1-10. https://www.iiste.org/Journals/index.php/RHSS/article/viewFile/13629/14223.
  52. Organisation of African Unity. Abuja Declaration on HIV/AIDS, Tuberculosis and Other Related Infectious Diseases. Organisation of African Unity; 2001.
International Journal of Health Policy and Management

Articles in Press, Corrected Proof
Available Online from 08 July 2024

Files

History

  • Receive Date: 31 January 2023
  • Revise Date: 25 March 2024
  • Accept Date: 07 July 2024
  • First Publish Date: 08 July 2024

Share

How to cite

Statistics