title: Exploring the nature of governance at the level of implementation for health system strengthening: the DIALHS experience.
abstract: Health system governance has been recognized as a critical element of the health system strengthening agenda. To date, health governance research often focuses at national or global levels, adopting a macro-perspective that deals with governance structures, forms and principles. Little attention has been given to a micro-perspective which recognizes the role of health system actors in governance, or to considering the operational level of the health system. This article presents a South African case study of an intervention to address conflict in roles and responsibilities between multiple actors supporting service delivery at the local level, and explores the broader insights this experience generates about the nature of local health system governance. In an embedded case study, action learning and reflection theory were used to design and implement the intervention. Data in this article were drawn from minutes, observations and recorded reflections of the meetings and workshops that comprised the intervention. A theoretical governance framework was used both to understand the context of the intervention and to analyse the dimensions of governance relevant in the experience. The study shows how, through action learning and reflection, local managers in two organizations came to understand how the higher level misalignment of organizational structures and processes imposed governance constraints on them, and to see the impact this had on their organizational relationships. By re-framing the conflict as organizational, they were then able to create opportunities for staff to understand their context and participate in negotiating principles for communication and collaborative work. The result reduced conflict between staff in the two organizations, leading to improved implementation of programme support. Strengthening relationships among those working at local level by building collaborative norms and values is an important part of local health system governance for improved service delivery by multiple actors.
authors.affiliation: School of Public Health, University of the Western Cape, Bellville, South Africa, Metro District Health Services, Provincial Government of the Western Cape, Western Cape, South Africa, City Health, City of Cape Town, South Africa, Health Policy and Systems Division, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa and Health Economics and Systems Analysis Group, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK verascott@mweb.co.za.
authors.forename: Vera
authors.initials: V
authors.lastname: Scott
authors.affiliation: School of Public Health, University of the Western Cape, Bellville, South Africa, Metro District Health Services, Provincial Government of the Western Cape, Western Cape, South Africa, City Health, City of Cape Town, South Africa, Health Policy and Systems Division, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa and Health Economics and Systems Analysis Group, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Nikki
authors.initials: N
authors.lastname: Schaay
authors.affiliation: School of Public Health, University of the Western Cape, Bellville, South Africa, Metro District Health Services, Provincial Government of the Western Cape, Western Cape, South Africa, City Health, City of Cape Town, South Africa, Health Policy and Systems Division, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa and Health Economics and Systems Analysis Group, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Patti
authors.initials: P
authors.lastname: Olckers
authors.affiliation: School of Public Health, University of the Western Cape, Bellville, South Africa, Metro District Health Services, Provincial Government of the Western Cape, Western Cape, South Africa, City Health, City of Cape Town, South Africa, Health Policy and Systems Division, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa and Health Economics and Systems Analysis Group, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Nomsa
authors.initials: N
authors.lastname: Nqana
authors.affiliation: School of Public Health, University of the Western Cape, Bellville, South Africa, Metro District Health Services, Provincial Government of the Western Cape, Western Cape, South Africa, City Health, City of Cape Town, South Africa, Health Policy and Systems Division, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa and Health Economics and Systems Analysis Group, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Uta
authors.initials: U
authors.lastname: Lehmann
authors.affiliation: School of Public Health, University of the Western Cape, Bellville, South Africa, Metro District Health Services, Provincial Government of the Western Cape, Western Cape, South Africa, City Health, City of Cape Town, South Africa, Health Policy and Systems Division, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa and Health Economics and Systems Analysis Group, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK School of Public Health, University of the Western Cape, Bellville, South Africa, Metro District Health Services, Provincial Government of the Western Cape, Western Cape, South Africa, City Health, City of Cape Town, South Africa, Health Policy and Systems Division, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa and Health Economics and Systems Analysis Group, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Lucy
authors.initials: L
authors.lastname: Gilson
mesh_terms: D003695:Delivery of Health Care / Q000458:organization & administration*; D006078:Government Programs / Q000458:organization & administration*; D006801:Humans; D007400:Interprofessional Relations; D007858:Learning; D019982:Organizational Case Studies; D009937:Organizational Objectives; D013019:South Africa
keywords: Action research; case study; governance; health system actors; health system strengthening; implementation; reflective learning; relationships; values and norms