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      District decision-making for health in low-income settings: a systematic literature review

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          Abstract

          Health management information systems (HMIS) produce large amounts of data about health service provision and population health, and provide opportunities for data-based decision-making in decentralized health systems. Yet the data are little-used locally. A well-defined approach to district-level decision-making using health data would help better meet the needs of the local population. In this second of four papers on district decision-making for health in low-income settings, our aim was to explore ways in which district administrators and health managers in low- and lower-middle-income countries use health data to make decisions, to describe the decision-making tools they used and identify challenges encountered when using these tools. A systematic literature review, following PRISMA guidelines, was undertaken. Experts were consulted about key sources of information. A search strategy was developed for 14 online databases of peer reviewed and grey literature. The resources were screened independently by two reviewers using pre-defined inclusion criteria. The 14 papers included were assessed for the quality of reported evidence and a descriptive evidence synthesis of the review findings was undertaken. We found 12 examples of tools to assist district-level decision-making, all of which included two key stages—identification of priorities, and development of an action plan to address them. Of those tools with more steps, four included steps to review or monitor the action plan agreed, suggesting the use of HMIS data. In eight papers HMIS data were used for prioritization. Challenges to decision-making processes fell into three main categories: the availability and quality of health and health facility data; human dynamics and financial constraints. Our findings suggest that evidence is available about a limited range of processes that include the use of data for decision-making at district level. Standardization and pre-testing in diverse settings would increase the potential that these tools could be used more widely.

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          Decentralization of health systems in Ghana, Zambia, Uganda and the Philippines: a comparative analysis of decision space.

          This study reviews the experience of decentralization in four developing countries: Ghana, Uganda, Zambia and the Philippines. It uses two analytical frameworks to describe and compare the types and degrees of decentralization in each country. The first framework specifies three types of decentralization: deconcentration, delegation and devolution. The second framework uses a principal agent approach and innovative maps of 'decision space' to define the range of choice for different functions that is transferred from the centre to the periphery of the system. The analysis finds a variety of different types and degrees of decentralization, with the Philippines demonstrating the widest range of choice over many functions that were devolved to local government units. The least choice was transferred through delegation to an autonomous health service in Ghana. Uganda and Zambia display variations between these extremes. There was insufficient evidence of the impact of decentralization to assess how these differences in 'decision space' influenced the performance of each health system. The authors suggest that this is a major area for future research.
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            Evidence-based Management: From Theory to Practice in Health Care

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              Design and implementation of a health management information system in Malawi: issues, innovations and results.

              As in many developing countries, lack of reliable data and grossly inadequate appreciation and use of available information in planning and management of health services were two main weaknesses of the health information systems in Malawi. Malawi began strengthening its health management information system with an analysis of the strengths and weaknesses of existing information systems, sharing findings with all stakeholders. All were agreed on the need for reformation of various, vertical programme-specific information systems into a comprehensive, integrated, decentralized and action-oriented simple system. As a first step towards conceptualization and design of the system, a minimum set of indicators was identified and a strategy was formulated for establishing a system in the country. The design focused only on the use of information in planning, management and the improvement of quality and coverage of services. All health and support personnel were trained, employing a training of trainers cascade approach. Information management and use was incorporated into the pre-service training curriculum and the job description of all health workers and support personnel. Quarterly feedback, supportive supervision visits and annual reviews were institutionalized. Civil society organizations were involved in monitoring coverage of health services at local levels. A mid-term review of the achievements of the health information system judged it to be one of the best in Africa. For the first time in Malawi, the health sector has information by facility by month. Yet very little improvement has been noted in use of information in rationalizing decisions. The conclusion is that, no matter how good the design of an information system, it will not be effective unless there is internal desire, dedication and commitment of leadership to have an effective and efficient health service management system.
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                Author and article information

                Journal
                Health Policy Plan
                Health Policy Plan
                heapol
                heapol
                Health Policy and Planning
                Oxford University Press
                0268-1080
                1460-2237
                September 2016
                01 September 2016
                01 September 2016
                : 31
                : Suppl 2
                : ii12-ii24
                Affiliations
                1IDEAS Project, London School of Hygiene & Tropical Medicine, UK
                Author notes
                *Corresponding author. London School of Hygiene & Tropical Medicine (LSHTM), London WC1E 7HT, UK. E-mail: bilal.avan@ 123456lshtm.ac.uk
                Article
                czv124
                10.1093/heapol/czv124
                5009221
                27591202
                f3f4fbad-9ec8-4a04-a1a4-852edd30b408
                © The Author 2016. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 13 November 2015
                Page count
                Pages: 13
                Categories
                Original Articles

                Social policy & Welfare
                decision-making,evidence-based policy,low-income,health systems,decentralization,health planning

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