Article Text
Abstract
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.
- health systems
- health policy
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Footnotes
Handling editor Seye Abimbola
Contributors The idea for the study and its design was conceived by all authors. Data coding and preliminary analysis was carried out by RM and RL, with review and discussion with all authors. RM prepared the initial draft of this paper. All authors reviewed the draft manuscript and provided input to preparation of and approval for the final version of the report.
Funding European Union Seventh Framework Programme ([FP7/2007-2013] [FP7/2007-2011]) under grant agreement number 306090 and was conducted in collaboration with the REACHOUT consortium. REACHOUT is an ambitious 5-year international research consor- tium aiming to generate knowledge to strengthen the performance of CHWs and other close-to-community providers in promotional, preventive and curative primary health services in low- and middle- income countries in rural and urban areas in Africa and Asia.
Competing interests None declared.
Patient consent Not required.
Ethics approval Ethical approval was received from Liverpool School of Tropical Medicine (Research Protocol 14.007 and Research Protocol 14.044) and in-country ethics from Kenya Medical Research Institute (Non-SSC Protocol 469) and Hasanuddin University, South Sulawesi, Indonesia (No. 02260/H4.8.4.5.31/PP36-KOMETIK/2014).
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement PhD thesis for the data collected in Kenya is available online.