Exploring how different modes of governance act across health system levels to influence primary healthcare facility managers' use of information in decisionmaking: experience from Cape Town, South Africa

摘要

BACKGROUND: Governance, which includes decision-making at all levels of the health system, and information havebeen identified as key, interacting levers of health system strengthening. However there is an extensive literaturedetailing the challenges of supporting health managers to use formal information from health information systems(HISs) in their decision-making. While health information needs differ across levels of the health system there hasbeen surprisingly little empirical work considering what information is actually used by primary healthcare facilitymanagers in managing, and making decisions about, service delivery. This paper, therefore, specifically examinesexperience from Cape Town, South Africa, asking the question: How is primary healthcare facility managers’ use ofinformation for decision-making influenced by governance across levels of the health system? The research is novelin that it both explores what information these facility managers actually use in decision-making, and considershow wider governance processes influence this information use.METHODS: An academic researcher and four facility managers worked as co-researchers in a multi-case study in whichthree areas of management were served as the cases. There were iterative cycles of data collection and collaborativeanalysis with individual and peer reflective learning over a period of three years.RESULTS: Central governance shaped what information and knowledge was valued – and, therefore, generatedand used at lower system levels. The central level valued formal health information generated in the district-based HISwhich therefore attracted management attention across the levels of the health system in terms of design, fundingand implementation. This information was useful in the top-down practices of planning and management of thepublic health system. However, in facilities at the frontline of service delivery, there was a strong requirement for local,disaggregated information and experiential knowledge to make locally-appropriate and responsive decisions, and toperform the people management tasks required. Despite central level influences, modes of governance operating atthe subdistrict level had influence over what information was valued, generated and used locally.CONCLUSIONS: Strengthening local level managers’ ability to create enabling environments is an important leveragepoint in supporting informed local decision-making, and, in turn, translating national policies and priorities, includingequity goals, into appropriate service delivery practices.