Promoting good policy for leadership and governance of health related rehabilitation: a realist synthesis

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Abstract

Background

Good governance may result in strengthened performance of a health system. Coherent policies are essential for good health system governance. The overall aim of this research is to provide the best available scientific evidence on principles of good policy related leadership and governance of health related rehabilitation services in less resourced settings. This research was also conducted to support development of the World Health Organization’s (WHO) Guidelines on health related rehabilitation.

Methods

An innovative study design was used, comprising two methods: a systematic search and realist synthesis of literature, and a Delphi survey of expert stakeholders to refine and triangulate findings from the realist synthesis. In accordance with Pawson and Tilley’s approach to realist synthesis, we identified context mechanism outcome pattern configurations (CMOCs) from the literature. Subsequently, these CMOCs were developed into statements for the Delphi survey, whereby 18 expert stakeholders refined these statements to achieve consensus on recommendations for policy related governance of health related rehabilitation.

Results

Several broad principles emerged throughout formulation of recommendations: participation of persons with disabilities in policy processes to improve programme responsiveness, efficiency, effectiveness, and sustainability, and to strengthen service-user self-determination and satisfaction; collection of disaggregated disability statistics to support political momentum, decision-making of policymakers, evaluation, accountability, and equitable allocation of resources; explicit promotion in policies of access to services for all subgroups of persons with disabilities and service-users to support equitable and accessible services; robust inter-sectoral coordination to cultivate coherent mandates across governmental departments regarding service provision; and ‘institutionalizing’ programmes by aligning them with preexisting Ministerial models of healthcare to support programme sustainability.

Conclusions

Alongside national policymakers, our policy recommendations are relevant for several stakeholders, including service providers and service-users. This research aims to provide broad policy recommendations, rather than a strict formula, in acknowledgement of contextual diversity and complexity. Accordingly, our study proposes general principles regarding optimal policy related governance of health related rehabilitation in less resourced settings, which may be valuable across diverse health systems and contexts.

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Most cited references 52

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The Delphi method as a research tool: an example, design considerations and applications

Chitu Okoli, Suzanne Pawlowski (2004)

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Is Open Access

Realist synthesis: illustrating the method for implementation research

Jo Rycroft Malone, Brendan McCormack, Alison Hutchinson … (2012)

Background Realist synthesis is an increasingly popular approach to the review and synthesis of evidence, which focuses on understanding the mechanisms by which an intervention works (or not). There are few published examples of realist synthesis. This paper therefore fills a gap by describing, in detail, the process used for a realist review and synthesis to answer the question ‘what interventions and strategies are effective in enabling evidence-informed healthcare?’ The strengths and challenges of conducting realist review are also considered. Methods The realist approach involves identifying underlying causal mechanisms and exploring how they work under what conditions. The stages of this review included: defining the scope of the review (concept mining and framework formulation); searching for and scrutinising the evidence; extracting and synthesising the evidence; and developing the narrative, including hypotheses. Results Based on key terms and concepts related to various interventions to promote evidence-informed healthcare, we developed an outcome-focused theoretical framework. Questions were tailored for each of four theory/intervention areas within the theoretical framework and were used to guide development of a review and data extraction process. The search for literature within our first theory area, change agency, was executed and the screening procedure resulted in inclusion of 52 papers. Using the questions relevant to this theory area, data were extracted by one reviewer and validated by a second reviewer. Synthesis involved organisation of extracted data into evidence tables, theming and formulation of chains of inference, linking between the chains of inference, and hypothesis formulation. The narrative was developed around the hypotheses generated within the change agency theory area. Conclusions Realist synthesis lends itself to the review of complex interventions because it accounts for context as well as outcomes in the process of systematically and transparently synthesising relevant literature. While realist synthesis demands flexible thinking and the ability to deal with complexity, the rewards include the potential for more pragmatic conclusions than alternative approaches to systematic reviewing. A separate publication will report the findings of the review.

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Framework for assessing governance of the health system in developing countries: gateway to good governance.

Sania Nishtar, Belgacem Sabri, Sheelu Siddiqi … (2009)

Governance is thought to be a key determinant of economic growth, social advancement and overall development, as well as for the attainment of the MDGs in low- and middle-income countries. Governance of the health system is the least well-understood aspect of health systems. A framework for assessing health system governance (HSG) at national and sub-national levels is presented, which has been applied in countries of the Eastern Mediterranean. In developing the HSG framework key issues considered included the role of the state vs. the market; role of the ministries of health vs. other state ministries; role of actors in governance; static vs. dynamic health systems; and health reform vs. human rights-based approach to health. Four existing frameworks were considered: World Health Organization's (WHO) domains of stewardship; Pan American Health Organization's (PAHO) essential public health functions; World Bank's six basic aspects of governance; and United Nations Development Programme (UNDP) principles of good governance. The proposed HSG assessment framework includes the following 10 principles-strategic vision, participation and consensus orientation, rule of law, transparency, responsiveness, equity and inclusiveness, effectiveness and efficiency, accountability, intelligence and information, and ethics. The framework permits 'diagnoses of the ills' in HSG at the policy and operational levels and points to interventions for its improvement. In the case of Pakistan, where the framework was applied, a positive aspect was the growing participation and consensus orientation among stakeholders, while weaknesses were identified in relation to strategic vision, accountability, transparency, effectiveness and efficiency and rule of law. In using the HSG framework it needs to be recognized that the principles are value driven and not normative and are to be seen in the social and political context; and the framework relies on a qualitative approach and does not follow a scoring or ranking system. It does not directly address aid effectiveness but provides insight on the ability to utilize external resources and has the ability to include the effect of global health governance on national HSG as the subject itself gets better crystallized. The improved performance of the ministries of health and state health departments is at the heart of this framework. The framework helps raise the level of awareness among policymakers of the importance of HSG. The road to good governance in health is long and uneven. Assessing HSG is only the first step; the challenge that remains is to carry out effective governance in vastly different institutional contexts.

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Author and article information

Contributors

Joanne McVeigh: jmcveigh@tcd.ie

Malcolm MacLachlan: malcolm.maclachlan@tcd.ie

Brynne Gilmore: gilmorb@tcd.ie

Chiedza McClean: mccleanc@tcd.ie

Arne H. Eide: ArneHenning.Eide@sintef.no

Hasheem Mannan: hasheem.mannan@ucd.ie

Priscille Geiser: pgeiser@handicap-international.org

Antony Duttine: aduttine@handicap-international.us

Gubela Mji: gumji@sun.ac.za

Eilish McAuliffe: eilish.mcauliffe@ucd.ie

Beth Sprunt: b.sprunt@unimelb.edu.au

Mutamad Amin: mutamedamin@gmail.com

Charles Normand: normandc@tcd.ie

Journal

Journal ID (nlm-ta): Global Health

Journal ID (iso-abbrev): Global Health

Title: Globalization and Health

Publisher: BioMed Central (London )

ISSN (Electronic): 1744-8603

Publication date (Electronic): 24 August 2016

Publication date PMC-release: 24 August 2016

Publication date Collection: 2016

Volume: 12

Issue: 1

Electronic Location Identifier: 49

Affiliations

[1 ]Centre for Global Health, Trinity College Dublin, 7-9 Leinster Street South, Dublin 2, Ireland

[2 ]School of Psychology, Trinity College Dublin, College Green, Dublin 2, Ireland

[3 ]Centre for Rehabilitation Studies, Medicine and Health Sciences Faculty, Stellenbosch University, P.O. Box 241, Cape Town, 8000, South Africa

[4 ]SINTEF Technology and Society, P.O. Box 124 Blindern, NO-0314, Oslo, Norway

[5 ]Department of Health Science, Norwegian University of Science and Technology, Tungasletta 2, 7047 Trondheim, Norway

[6 ]School of Nursing, Midwifery and Health Systems, Health Sciences Centre, University College Dublin, Belfield Dublin 4, Ireland

[7 ]Handicap International Fédération, 138, avenue des Frères Lumière, 69008 Lyon, France

[8 ]Handicap International, 8757 Georgia Avenue, Suite 420, Silver Spring, MD 20910 USA

[9 ]Nossal Institute for Global Health, Level 4, Alan Gilbert Building, Melbourne School of Population and Global Health, The University of Melbourne, Victoria, 3010 Australia

[10 ]Ahfad University for Women, P.O. Box 167, Omdurman, Sudan

[11 ]Health Policy & Management, Trinity College Dublin, Room 0.21, 3-4 Foster Place, College Green, Dublin 2, Ireland

Article

Publisher ID: 182

DOI: 10.1186/s12992-016-0182-8

PMC ID: 4997679

PubMed ID: 27558240

SO-VID: 27a6caf1-597e-4159-bf16-2bee5ef7edb1

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 29 January 2016

Date accepted : 1 August 2016

Funding

Funded by: FundRef http://dx.doi.org/10.13039/100004423, World Health Organization;

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ScienceOpen disciplines: Health & Social care

Keywords: health related rehabilitation,leadership,governance,policy,less resourced settings,realist synthesis,delphi study

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ScienceOpen disciplines: Health & Social care

Keywords: health related rehabilitation, leadership, governance, policy, less resourced settings, realist synthesis, delphi study

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Promoting good policy for leadership and governance of health related rehabilitation: a realist synthesis

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Abstract

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Research from Sudan

Most cited references 52

The Delphi method as a research tool: an example, design considerations and applications

Realist synthesis: illustrating the method for implementation research

Framework for assessing governance of the health system in developing countries: gateway to good governance.

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Cited by 21

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