Browsing by Author "Lehmann, Uta"
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Item Action learning for health system governance: the reward and challenge of co-production(Oxford University Press, 2014-08-26) Lehmann, Uta; Gilson, LucyHealth policy and systems research (HPSR) is centrally concerned with people, their relationships and the actions and practices they can implement towards better health systems. These concerns suggest that HPS researchers must work in direct engagement with the practitioners and practice central to the inquiry, acknowledging their tacit knowledge and drawing it into generating new insights into health system functioning. Social science perspectives are of particular importance in this field because health policies and health systems are themselves social and political constructs. However, how can social science methodologies such as action research and narrative and appreciative enquiry enable such research, and how can methodologies from different disciplines be woven together to construct and make meaning of evidence for 'this' field? This article seeks to present 'methodological musings' on these points, to prompt wider discussion on the practice of HPSR. It draws on one long-term collaborative action learning research project being undertaken in Cape Town, South Africa. The District Innovation and Action Learning for Health System Development project is an action research partnership between two South African academic institutions and two health authorities focused, ultimately, on strengthening governance in primary health care. Drawing on this experience, the article considers three interrelated issues: The diversity and complexities of practitioner and research actors involved in co-producing HPSR; The nature of co-production and the importance of providing space to grapple across different systems of meaning; The character of evidence and data in co-production. There is much to be learnt from research traditions outside the health sector, but HPSR must work out its own practices-through collaboration and innovation among researchers and practitioners. In this article, we provide one set of experiences to prompt wider reflection and stimulate engagement on the practice of HPSR for people-centred health systems.Item Advancing the application of systems thinking in health: South African examples of a leadership of sensemaking for primary health care(Biomed Central, 2014) Gilson, Lucy; Elloker, Soraya; Olckers, Patti; Lehmann, UtaBACKGROUND: New forms of leadership are required to bring about the fundamental health system changes demanded by primary health care (PHC). Using theory about complex adaptive systems and policy implementation, this paper considers how actors' sensemaking and the exercise of discretionary power currently combine to challenge PHC re-orientation in the South African health system; and provides examples of leadership practices that promote sensemaking and power use in support of PHC. METHODS: The paper draws on observational, interview, and reflective data collected as part of the District Innovation and Action Learning for Health Systems Development (DIALHS) project being implemented in Cape Town, South Africa. Undertaken collaboratively between health managers and RESEARCHERS, the project is implemented through cycles of action-learning, including systematic reflection and synthesis. It includes a particular focus on how local health managers can better support front line facility managers in strengthening PHC. RESULTS: The results illuminate how the collective understandings of staff working at the primary level - of their working environment and changes within it - act as a barrier to centrally-led initiatives to strengthen PHC. Staff often fail to take ownership of such initiatives and experience them as disempowering. Local area managers, located between the centre and the service frontline, have a vital role to play in providing a leadership of sensemaking to mediate these challenges. Founded on personal values, such leadership entails, for example, efforts to nurture PHC-aligned values and mind-sets among staff; build relationships and support the development of shared meanings about change; instil a culture of collective inquiry and mutual accountability; and role-model management practices, including using language to signal meaning. CONCLUSIONS: PHC will only become a lived reality within the South African health system when frontline staff are able to make sense of policy intentions and incorporate them into their everyday routines and practices. This requires a leadership of sensemaking that enables front line staff to exercise their collective discretionary power in strengthening PHC. We hope this theoretically-framed analysis of one set of experiences stimulates wider thinking about the leadership needed to sustain primary health care in other settings.Item Analysis of aid coordination in a post-conflict country : the case of Burundi and HRH policies(University of the Western Cape, 2015) Cailhol, Johann; Lehmann, Uta; Gilson, LucyAid coordination in the health sector is known to be challenging in general, but even more in post-conflict settings, due to the multiplicity of actors of development, to the sense of emergency in providing health services, combined with the so-called weak institutional capacities‘ at local level, resulting from the conflict. This study sought to analyze broad determinants of aid coordination using the example of HRH policies in Burundi, during the post-conflict period. Burundi is a country in Central Africa, which experienced cyclic ethnic conflicts since its independence in 1962, the last conflict being the longest (1993-2006).Determinants of coordination were analyzed using the policy-analysis triangle (Gilson et Walt), using data from documents and semi-structured interviews, conducted in 2009 and in 2011, at national, provincial and facility-levels. A conceptual framework, combining organizational and social sciences theories, was devised in order to assess the organizational power of MoH, the one supposed to act as coordinator in the health sector. Findings showed a lack of coordination due to post-conflict specific context, to competition over scarce resources between both donor and recipient organizations and to an insufficiently incentivized and complex coordination process in practical. Most importantly, this research demonstrated the crucial role of post-conflict habitus and mistrust in the behavior of MoH and their influence on organizational power, and, in turn on their capacity to coordinate and exert an appropriate leadership. These findings, together with the growing body of literature on organizational sociology and collective trust, point at the crucial need to rebuild some of the wounded collective trust and organizational leadership in Burundi and in other fragile states.Item Analysis of human resources for health strategies and policies in 5 countries in Sub-Saharan Africa, in response to GFATM AND Pepfar-funded HIV-activities(BioMed Central -The Open Access Publisher, 2013) Cailhol, Johann; Craveiro, Isabel; Mathole, Thubelihle; Parsons, Ann Neo; Lehmann, Uta; Sanders, David; Madede, Tavares; Makoa, Elsie; Van Leemput, Luc; Biesma, Regien; Brugha, Ruairi; Chilundo, Baltazar; Dussault, Gilles; Van Damme, WimBACKGROUND: Global Health Initiatives (GHIs), aiming at reducing the impact of specific diseases such as Human Immunodeficiency Virus (HIV), have flourished since 2000. Amongst these, PEPFAR and GFATM have provided a substantial amount of funding to countries affected by HIV, predominantly for delivery of antiretroviral therapy (ARV) and prevention strategies. Since the need for additional human resources for health (HRH) was not initially considered by GHIs, countries, to allow ARV scale-up, implemented short-term HRH strategies, adapted to GHI-funding conditionality. Such strategies differed from one country to another and slowly evolved to long-term HRH policies. The processes and content of HRH policy shifts in 5 countries in Sub-Saharan Africa were examined. METHODS: A multi-country study was conducted from 2007 to 2011 in 5 countries (Angola, Burundi, Lesotho, Mozambique and South Africa), to assess the impact of GHIs on the health system, using a mixed methods design. This paper focuses on the impact of GFATM and PEPFAR on HRH policies. Qualitative data consisted of semi-structured interviews undertaken at national and sub-national levels and analysis of secondary data from national reports. Data were analysed in order to extract countries’ responses to HRH challenges posed by implementation of HIV-related activities. Common themes across the 5 countries were selected and compared in light of each country context. RESULTS: In all countries successful ARV roll-out was observed, despite HRH shortages. This was a result of mostly short-term emergency response by GHI-funded Non-Governmental Organizations (NGOs) and to a lesser extent by governments, consisting of using and increasing available HRH for HIV tasks. As challenges and limits of short-term HRH strategies were revealed and HIV became a chronic disease, the 5 countries slowly implemented mid to long-term HRH strategies, such as formalisation of pilot initiatives, increase in HRH production and mitigation of internal migration of HRH, sometimes in collaboration with GHIs. CONCLUSION: Sustainable HRH strengthening is a complex process, depending mostly on HRH production and retention factors, these factors being country-specific. GHIs could assist in these strategies, provided that they are flexible enough to incorporate country-specific needs in terms of funding, that they coordinate at global-level and minimise conditionality for countries.Item Building capacity to develop an African teaching platform on health workforce development: a collaborative initiative of universities from four sub Saharan countries(BioMed Central, 2014) Amde, Woldekidan Kifle; Sanders, David; Lehmann, UtaINTRODUCTION: Health systems in many low-income countries remain fragile, and the record of human resource planning and management in Ministries of Health very uneven. Public health training institutions face the dual challenge of building human resources capacity in ministries and health services while alleviating and improving their own capacity constraints. This paper reports on an initiative aimed at addressing this dual challenge through the development and implementation of a joint Masters in Public Health (MPH) programme with a focus on health workforce development by four academic institutions from East and Southern Africa and the building of a joint teaching platform. METHODS: Data were obtained through interviews and group discussions with stakeholders, direct and participant observations, and reviews of publications and project documents. Data were analysed using thematic analysis. CASE DESCRIPTION: The institutions developed and collaboratively implemented a ‘Masters Degree programme with a focus on health workforce development’. It was geared towards strengthening the leadership capacity of Health ministries to develop expertise in health human resources (HRH) planning and management, and simultaneously build capacity of faculty in curriculum development and innovative educational practices to teach health workforce development. The initiative was configured to facilitate sharing of experience and resources. DISCUSSION: The implementation of this initiative has been complex, straddling multiple and changing contexts, actors and agendas. Some of these are common to postgraduate programmes with working learners, while others are unique to this particular partnership, such as weak institutional capacity to champion and embed new programmes and approaches to teaching. CONCLUSIONS: The partnership, despite significant inherent challenges, has potential for providing real opportunities for building the field and community of practice, and strengthening the staff and organizational capacity of participant institutions. Key learning points of the paper are: *the need for long-term strategies and engagement; *the need for more investment and attention to developing the capacity of academic institutions; *the need to invest specifically in educational/teaching expertise for innovative approaches to teaching and capacity development more broadly; and *the importance of increasing access and support for students who are working adults in public health institutions throughout Africa.Item Decentralised human resource management in a district health system: case studies in the Western Cape Province, South Africa(University of the Western Cape, 2017) Mathews, Verona Elizabeth; Lehmann, UtaThe effective management of the public health workforce, in the context of decentralisation and the District Health System, is pivotal to the delivery of primary health care and, ultimately, improved health. This research investigates the phenomena of human resource management in the public health sector, focussing on the factors influencing human resource management (HRM), the internal alignment within the HRM Programme and external alignment with the strategic objectives of the organisation. It takes a frontline perspective to understand how the phenomenon is experienced in a decentralised District Health System.Item Emerging roles and competencies of district and sub-district pharmacists: a case study from Cape Town(BioMed Central, 2015) Bradley, Hazel A.; Lehmann, Uta; Butler, NadineDistrict and sub-district pharmacist positions were created during health sector reform in South Africa. High prevalence of HIV/AIDS, tuberculosis and increasing chronic non-communicable diseases have drawn attention to their pivotal roles in improving accessibility and appropriate use of medicines at the primary level. This research describes new roles and related competencies of district and sub-district pharmacists in Cape Town. Between 2008 and 2011, the author (HB) conducted participatory action research in Cape Town Metro District, an urban district in the Western Cape Province of South Africa, partnering with pharmacists and managers of the two government primary health care (PHC) providers. The two providers function independently delivering complementary PHC services across the entire geographic area, with one provider employing district pharmacists and the other sub-district pharmacists. After an initiation phase, the research evolved into a series of iterative cycles of action and reflection, each providing increasing understanding of district and sub-district pharmacists’ roles and competencies. Data was generated through workshops, semi-structured interviews and focus groups with pharmacists and managers which were recorded and transcribed. Thematic analysis was carried out iteratively during the 4-year engagement and triangulated with document reviews and published literature. Five main roles for district and sub-district pharmacists were identified: district/sub-district management; planning, co-ordination and monitoring of pharmaceuticals; information and advice; quality assurance and clinical governance; and research (district pharmacists)/dispensing at clinics (sub-district pharmacists). Although the roles looked similar, there were important differences, reflecting the differing governance and leadership models and services of each provider. Five competency clusters were identified: professional pharmacy practice; health system and public health; management; leadership; and personal, interpersonal and cognitive competencies. Whilst professional pharmacy competencies were important, generic management and leadership competencies were considered critical for pharmacists working in these positions. Similar roles and competencies for district and sub-district pharmacists were identified in the two PHC providers in Cape Town, although contextual factors influenced precise specifications. These insights are important for pharmacists and managers from other districts and sub-districts in South Africa and inform health workforce planning and capacity development initiatives in countries with similar health systems.Item Evidence of past and current collaborations between traditional health practitioners and biomedical health practitioners: A scoping review protocol(BMJ PUBLISHING GROUP, 2021) Jama, Ngcwalisa Amanda; Nyembezi, Anam; Lehmann, UtaHealthcare seekers around the globe use more than one healthcare system, with most using the traditional and the Western approaches concurrently. To date, little collaboration between the two systems has taken place within the mental health space compared with other areas of medicine. In order to inform integrating plans for traditional health practitioners and biomedical health practitioners in the South African mental health system, it is important to know which models of collaboration are used in other medical settings and contexts. This study aims to document global evidence on collaboration practices between traditional health practitioners and biomedical professionals when working with various health conditions.Item Exploring multiple job holding practices of academics in public health training institutions from three sub-Saharan Africa countries: drivers, impact, and regulation(Taylor & Francis, 2018) Amde, Woldekidan Kifle; Sanders, David; Chilundo, Baltazar; Rugigana, Etienne; Mariam, Damen Haile; Lehmann, UtaBACKGROUND: The paper examines external multiple job holding practices in public health training institutions based in prominent public universities in three sub-Saharan Africa countries (Rwanda, Ethiopia, Mozambique). OBJECTIVE: The study aims to contribute to broadening understanding about multiple job holding (nature and scale, drivers and reasons, impact, and efforts to regulate) in public health training schools in public universities. METHODS: A qualitative multiple case study approach was used. Data were collected through document reviews and in-depth interviews with 18 key informants. Data were then triangulated and analyzed thematically. RESULTS: External multiple job holding practices among faculty of the three public health training institutions were widely prevalent. Different factors at individual, institutional, and national levels were reported to underlie and mediate the practice. While it evidently contributes to increasing income of academics, which many described as enabling their continuing employment in the public sector, many pointed to the negative effects as well. Similarities were found regarding the nature and drivers of the practice across the institutions, but differences exist with respect to mechanisms for and extent of regulation. Regulatory mechanisms were often not clear or enforced, and academics are often left to self-regulate their engagement. Lack of regulation has been cited as allowing excessive engagement in multiple job holding practice among academics at the expense of their core institutional responsibility. This could further weaken institutional capacity and performance, and quality of training and support to students. CONCLUSION: The research describes the complexity of external multiple job holding practice, which is characterized by a cluster of drivers, multiple processes and actors, and lack of consensus about its implication for individual and institutional capacity. In the absence of a strong accountability mechanism, the practice could perpetuate and aggravate the fledgling capacity of public health training institutions.Item The first thousand days within the Western Cape whole of society approach: Lessons for the collaborative governance of intersectoral action for health(Researchgate, 2020-11) Okeyo, Ida; Lehmann, Uta; Schneider, HelenThis report is a case study of the Western Cape’s Whole of Society Approach (WoSA) through the lens of the First Thousand Days (FTD) of childhood initiative, focusing in particular on its implementation in Saldanha Bay and to a limited extent the Drakenstein municipal areas/sub-districts. The case study reports on data collected by Ida Okeyo as part of her PhD, which has examined the emergence and implementation of FTD in the Province as a whole over the last 3-4 years. Experiences in Saldanha Bay and Drakenstein stand in contrast to elsewhere in the Province, where, despite original intentions, the FTD strategy has failed to take root as a cohesive intersectoral response to this critical moment in the lifecourse. This case study examines how WoSA (and the Better Spaces initiative before that), created an enabling context for intersectoral action within which FTD found a natural home. We spell out the elements of this enabling environment using a framework of ‘collaborative governance’, concluding that these elements are the necessary pre-conditions for advancing any intersectoral initiative more widely in the Western Cape Province and elsewhere. In this way, we aim to document and affirm lessons learnt through WoSA, and provide the case for its further development and institutionalisation in the Province.Item The global pendulum swing towards community health workers in low- and middle-income countries: A scoping review of trends, geographical distribution and programmatic orientations, 2005 to 2014(BioMed Central, 2016) Schneider, Helen; Okello, Dickson; Lehmann, UtaBACKGROUND: There has been a substantial increase in publications and interest in community health workers (CHWs) in low- and middle-income countries (LMIC) over the last years. This paper examines the growth, geographical distribution and programmatic orientations of the indexed literature on CHWs in LMIC over a 10-year period. METHODS: A scoping review of publications on CHWs from 2005 to 2014 was conducted. Using an inclusive list of terms, we searched seven databases (including MEDLINE, CINAHL, Cochrane) for all English-language publications on CHWs in LMIC. Two authors independently screened titles/abstracts, downloading full-text publications meeting inclusion criteria. These were coded in an Excel spreadsheet by year, type of publication (e.g. review, empirical), country, region, programmatic orientation (e.g. maternal-child health, HIV/AIDS, comprehensive) and CHW roles (e.g. prevention, treatment) and further analysed in Stata14. Drawing principally on the subset of review articles, specific roles within programme areas were identified and grouped. FINDINGS: Six hundred seventy-eight publications from 46 countries on CHWs were inventoried over the 10-year period. There was a sevenfold increase in annual number of publications from 23 in 2005 to 156 in 2014. Half the publications were reporting on initiatives in Africa, a third from Asia and 11 % from the Americas (mostly Brazil). The largest single focus and driver of the growth in publications was on CHW roles in meeting the Millennium Development Goals of maternal, child and neonatal survival (35 % of total), followed by HIV/AIDS (16 %), reproductive health (6 %), non-communicable diseases (4 %) and mental health (4 %). Only 17 % of the publications approached CHW roles in an integrated fashion. There were also distinct regional (and sometimes country) profiles, reflecting different histories and programme traditions. CONCLUSIONS: The growth in literature on CHWs provides empirical evidence of ever-increasing expectations for addressing health burdens through community-based action. This literature has a strong disease- or programme-specific orientation, raising important questions for the design and sustainable delivery of integrated national programmes.Item A health system perspective on factors influencing the use of health information for decision-making in a district health system(University of the Western Cape, 2016) Scott, Vera Eileen; Lehmann, Uta; Schneider, HelenThis research explores a poorly understood area of health systems: the nature of managerial decision-making in primary healthcare facilities, and the information that informs decision-making at this level. Located in the emerging field of Health Policy and System Research, this research draws on constructivist and participatory perspectives to understand the role of information and, more broadly, learning and knowledge in decisions that primary healthcare managers make, and the systemic factors influencing this. Using a multiple case study design with iterative cycles of in-depth data collection and analysis over a three year period, it examined the decision-making and information use in three cases of managerial responsibility in 17 primary healthcare facilities in a sub-district in Cape Town. The cases were: improving efficiency of service delivery, implementing programme priorities and managing leave of absence. Using multiple strategies for engaging primary healthcare facility managers, often as co-researchers of their own practice, the research sought to elicit both their explicit and tacit, experience-based knowledge on these phenomena. Key insights gained in the research are that firstly, operational health management at facility level is less linear and simple than policy-makers and planners often assume, and is, instead, characterised by considerable on-the-spot problem solving and people management to meet multiple agendas, which can be surprisingly complex. Secondly, contrary to prevailing views, managers do actively use information in decision-making, but require a wide range of information which is outside of the current, and indeed the globally-advocated, health information system (HIS). Thirdly, they not only use, but generate, information in their management routines and practices, and must learn from experience in order to adapt new interventions for successful implementation in their facilities and communities. This research thus makes explicit the value and use of informal information and knowledge in decision-making. It demonstrates, amongst others, a relationship of functional interdependence between the use of formal information in the HIS, and informal information and knowledge, suggesting that the latter has the potential to improve the use and utility of formal health information by making sense of it within the local context. Furthermore, building on the public policy literature on governance, this research develops a model to understand the multiple contextual influences on decision-making and information use, showing the central role of values and relationships across the health system. It proposes a causal mechanism for strengthening the use of information in decision-making. Finally, in giving priority to the informational needs of facility managers, this research offers a bottom-up perspective which argues for an integrated approach to health system strengthening which moves beyond atomised treatment of HIS strengthening. It suggests the need to re-think how to support facility managers by re-positioning the HIS relative to organisational learning, and leadership and management development.Item The impact of differing frames on early stages of intersectoral collaboration: The case of the first 1000 days initiative in the Western Cape Province(Springer Nature, 2020) Okeyo, Ida L.A.; Lehmann, Uta; Schneider, HelenWhile intersectoral collaboration is considered valuable and important for achieving health outcomes, there are few examples of successes. The literature on intersectoral collaboration suggests that success relies on a shared understanding of what can be achieved collectively and whether stakeholders can agree on mutual goals or acceptable trade-offs. When health systems are faced with negotiating intersectoral responses to complex issues, achieving consensus across sectors can be a challenging and uncertain process. Stakeholders may present divergent framings of the problem based on their disciplinary background, interests and institutional mandates. This raises an important question about how different frames of problems and solutions affect the potential to work across sectors during the initiating phases of the policy process. Methods: In this paper, this question was addressed through an analysis of the case of the First 1000 Days (FTD) Initiative, an intersectoral approach targeting early childhood in the Western Cape Province of South Africa. We conducted a documentary analysis of 34 policy and other documents on FTD (spanning global, national and subnational spheres) using Schmidt's conceptualisation of policy ideas in order to elicit framings of the policy problem and solutions.Item Lay health workers and HIV programmes: Implications for health systems(Routledge, 2010) Schneider, Helen; Lehmann, UtaOne of the consequences of massive investment in antiretroviral access and other AIDS programmes has been the rapid emergence of large numbers of lay workers in the health systems of developing countries. In South Africa, government estimates are 65,000, mostly HIV/TB care-related lay workers contribute their labour in the public health sector, outnumbering the main front-line primary health care providers and professional nurses. The phenomenon has grown organically and incrementally, playing a wide variety of care-giving, support and advocacy roles. Using South Africa as a case, this paper discusses the different forms, traditions and contradictory orientations taken by lay health work and the system-wide effects of a large lay worker presence. As pressures to regularise and formalise the status of lay health workers grow, important questions are raised as to their place in health systems, and more broadly what they represent as a new intermediary layer between state and citizen. It argues for a research agenda that seeks to better characterise types of lay involvement in the health system, particularly in an era of antiretroviral therapy, and which takes a wider perspective on the meanings of this recent re-emergence of an old concept in health systems heavily affected by HIV/AIDS.Item Looking back to look forward: a review of human resources for health governance in South Africa from 1994 to 2018(Springer Nature, 2020) van Ryneveld, Manya; Schneider, Helen; Lehmann, UtaWhile South Africa has had a fairly consistent record of producing national-level strategic plans for human resources for health in the past 25 years, the country continues to face major problems of affordability, availability, distribution and management of its health workforce. There are several factors contributing to the state of health human resources in the country, but problems with governance stand out as one area requiring further research, analysis and critique. This paper presents a retrospective analysis of the historical patterns in national health human resources governance in South Africa, based on a desktop policy review spanning 25 years after democracy. The authors took a multi-pronged, iterative approach, reviewing policy documents alongside grey and published literature. This led to a timeline showing key legislation, relevant health system and human resource policies, interventions, reviews and evaluations from 1994 to 2018. The review identified three distinct periods that help to characterise the terrain of human resources for health governance over the concerned 25 years. Firstly, a foundational period, in which much of the constitutional and legislative groundwork was laid. Secondly, the HIV epidemic period, which presented a major disruption to the development of system wide governance interventions and improvements.Item Organizational change and everyday health system resilience: Lessons from Cape Town, South Africa(Elsevier, 2020) Gilson, Lucy L.; Lehmann, Uta; Ellokor, SorayaThis paper reports a study from Cape Town, South Africa, that tested an existing framework of everyday health system resilience (EHSR) in examining how a local health system responded to the chronic stress of large-scale organizational change. Over two years (2017–18), through cycles of action-learning involving local managers and researchers, the authorial team tracked the stress experienced, the response strategies implemented and their consequences. The paper considers how a set of micro-governance interventions and mid-level leadership practices supported responses to stress whilst nurturing organizational resilience capacities. Data collection involved observation, in-depth interviews and analysis of meeting minutes and secondary data. Data analysis included iterative synthesis and validation processes.Item A participatory approach to the design of a child-health community-based information system for the care of vulnerable children(University of the Western Cape, 2004) Byrne, Elaine; Lehmann, Uta; Sahay, Sundeep; School of Public Health; Faculty of Community and Health SciencesThe existing District Health Information System in South Africa can be described as a facility based Information System, focusing on the clinics and hospitals and not on the community. Consequently, only those who access health services through these facilities are included in the system. Many children do not have access to basic health and social services and consequently, are denied their right to good health. Additionally, they are excluded from the routine Health Information System. Policy and resource decisions made by the District Managers, based on the current health facility information, reinforces the exclusion of these already marginalised children. The premise behind this research is that vulnerability of children can be tackled using two interconnected strategies. The first is through the creation of awareness of the situation of children and the second through mobilising the commitment and action of government and society to address this situation. These strategies can be supported by designing an Information System for action; an Information System that can be used to advocate and influence decisions and policies for the rights of these children; an Information System that includes all children. An interpretive participatory action research approach, using a case study in a rural municipality in South Africa, was adopted for the study of a child-health Community-Based Information System. The context in which the community is placed, as well as the structures which are embedded in it, was examined using Structuration Theory. This theory also influenced the design of the Information System. As the aim of the research is to change the Information System to include vulnerable children, a Critical Social Theoretical and longitudinal perspective was adopted. In particular, concepts from Habermas, such as the creation of a public sphere and the ’Ideal Speech Situation’, informed the methodology chosen and were used to analyse the research undertaken. Based on the research conducted in this municipality, four main changes to the Health Information System were made. These were: • determination of the community’s own indicators; • changes in data collection forms; • creation of forums for analysis and reflection, and; • changes in the information flows for improved feedback. Other practical contributions of the research are the development of local capacities in data collection and analysis, the development of practical guidelines on the design of a child-health Community-Based Information System, and the development of strategies for enabling participation and communication. In line with the action research approach adopted, and the desire to link theory and practice, the research also contributed on a theoretical level. These contributions include extending the use of Structuration Theory, in conjunction with Habermas’ Critical Social Theory, to the empirical context of South Africa; addressing the gap of Community-Based Information Systems in Information System design; extending the debate on participation and communication in Information Systems to ’developing’ countries, and developing generalisations from a qualitative case study.Item Policy adoption and the implementation woes of the intersectoral first 1000 days of childhood initiative, in the Western Cape province of South Africa(Kerman University of Medical Sciences, 2021) Okeyo, Ida; Lehmann, Uta; Schneider, HelenThere is a growing interest in implementing intersectoral approaches to address social determinants especially within the Sustainable Development Goals (SDGs) era. However, there is limited research that uses policy analysis approaches to understand the barriers to adoption and implementation of intersectoral approaches. In this paper we apply a policy analysis lens in examining implementation of the first thousand days (FTD) of childhood initiative in the Western Cape province of South Africa. This initiative aims to improve child outcomes through a holistic intersectoral approach, referred to as nurturing care.Item Practicing governance towards equity in health systems: LMIC perspectives and experience(BMC, 2017) Gilson, Lucy; Lehmann, Uta; Schneider, HelenThe unifying theme of the papers in this series is a concern for understanding the everyday practice of governance in low- and middle-income country (LMIC) health systems. Rather than seeing governance as a normative health system goal addressed through the architecture and design of accountability and regulatory frameworks, these papers provide insights into the real-world decision-making of health policy and system actors. Their multiple, routine decisions translate policy intentions into practice – and are filtered through relationships, underpinned by values and norms, influenced by organizational structures and resources, and embedded in historical and socio-political contexts. These decisions are also political acts – in that they influence who accesses benefits and whose voices are heard in decisionmaking, reinforcing or challenging existing institutional exclusion and power inequalities. In other words, the everyday practice of governance has direct impacts on health system equity. The papers in the series address governance through diverse health policy and system issues, consider actors located at multiple levels of the system and draw on multi-disciplinary perspectives. They present detailed examination of experiences in a range of African and Indian settings, led by authors who live and work in these settings. The overall purpose of the papers in this series is thus to provide an empirical and embedded research perspective on governance and equity in health systems.Item Practicing governance towards equity in health systems: LMIC perspectives and experience(BioMed Central, 2017) Gilson, Lucy; Lehmann, Uta; Schneider, HelenThe unifying theme of the papers in this series is a concern for understanding the everyday practice of governance in low- and middle-income country (LMIC) health systems. Rather than seeing governance as a normative health system goal addressed through the architecture and design of accountability and regulatory frameworks, these papers provide insights into the real-world decision-making of health policy and system actors. Their multiple, routine decisions translate policy intentions into practice – and are filtered through relationships, underpinned by values and norms, influenced by organizational structures and resources, and embedded in historical and socio-political contexts. These decisions are also political acts – in that they influence who accesses benefits and whose voices are heard in decisionmaking, reinforcing or challenging existing institutional exclusion and power inequalities. In other words, the everyday practice of governance has direct impacts on health system equity. The papers in the series address governance through diverse health policy and system issues, consider actors located at multiple levels of the system and draw on multi-disciplinary perspectives. They present detailed examination of experiences in a range of African and Indian settings, led by authors who live and work in these settings. The overall purpose of the papers in this