Topp Stephanie M, Chipukuma Julien M, Hanefeld Johanna
Health Systems Adviser & Research Associate, Centre for Infectious Disease Research in Zambia (CIDRZ), Schools of Medicine, University of Alabama at Birmingham (UAB), Nossal Institute for Global Health, University of Melbourne, Student, University of Lusaka, Zambia Lecturer in Health Systems Economics, Department of Global Health and Development, Faculty of Public Health and Policy London School of Hygiene and Tropical Medicine
Health Systems Adviser & Research Associate, Centre for Infectious Disease Research in Zambia (CIDRZ), Schools of Medicine, University of Alabama at Birmingham (UAB), Nossal Institute for Global Health, University of Melbourne, Student, University of Lusaka, Zambia Lecturer in Health Systems Economics, Department of Global Health and Development, Faculty of Public Health and Policy London School of Hygiene and Tropical Medicine.
Health Policy Plan. 2015 May;30(4):485-99. doi: 10.1093/heapol/czu029. Epub 2014 May 14.
Despite being central to achieving improved population health outcomes, primary health centres in low- and middle-income settings continue to underperform. Little research exists to adequately explain how and why this is the case. This study aimed to test the relevance and usefulness of an adapted conceptual framework for improving our understanding of the mechanisms and causal pathways influencing primary health centre performance.
A theory-driven, case-study approach was adopted. Four Zambian health centres were purposefully selected with case data including health-care worker interviews (n = 60); patient interviews (n = 180); direct observation of facility operations (2 weeks/centre) and key informant interviews (n = 14). Data were analysed to understand how the performance of each site was influenced by the dynamic interactions between system 'hardware' and 'software' acting on mechanisms of accountability.
Structural constraints including limited resources created challenging service environments in which work overload and stockouts were common. Health workers' frustration with such conditions interacted with dissatisfaction with salary levels eroding service values and acting as a catalyst for different forms of absenteeism. Such behaviours exacerbated patient-provider ratios and increased the frequency of clinical and administrative shortcuts. Weak health information systems and lack of performance data undermined providers' answerability to their employer and clients, and a lack of effective sanctions undermined supervisors' ability to hold providers accountable for these transgressions. Weak answerability and enforceability contributed to a culture of impunity that masked and condoned weak service performance in all four sites.
Health centre performance is influenced by mechanisms of accountability, which are in turn shaped by dynamic interactions between system hardware and system software. Our findings confirm the usefulness of combining Sheikh et al.'s (2011) hardware-software model with Brinkerhoff's (2004) typology of accountability to better understand how and why health centre micro-systems perform (or under-perform) under certain conditions.
尽管对于改善人群健康状况至关重要，但低收入和中等收入地区的初级卫生保健中心的表现仍持续不佳。几乎没有研究能够充分解释情况为何如此以及如何发生。本研究旨在检验一个经过调整的概念框架的相关性和实用性，以增进我们对影响初级卫生保健中心绩效的机制和因果途径的理解。
采用理论驱动的案例研究方法。有目的地选择了赞比亚的四个卫生中心，案例数据包括对医护人员的访谈（n = 60）；对患者的访谈（n = 180）；对机构运营的直接观察（每个中心2周）以及对关键知情者的访谈（n = 14）。对数据进行分析，以了解每个场所的绩效如何受到作用于问责机制的系统“硬件”和“软件”之间动态相互作用的影响。
包括资源有限在内的结构性制约因素造成了具有挑战性的服务环境，工作负担过重和库存短缺情况普遍存在。医护人员对这种状况的不满与对薪资水平的不满相互作用，侵蚀了服务价值，并成为不同形式旷工的催化剂。此类行为加剧了医患比例，并增加了临床和行政捷径的频率。薄弱的卫生信息系统和缺乏绩效数据削弱了提供者对雇主和客户的问责性，而缺乏有效的制裁措施则削弱了监督者要求提供者对这些违规行为负责的能力。薄弱的问责性和可执行性助长了有罪不罚的文化，掩盖并纵容了所有四个场所的薄弱服务表现。
卫生中心的绩效受到问责机制的影响，而问责机制又受到系统硬件和系统软件之间动态相互作用的影响。我们的研究结果证实，将谢赫等人（2011年）的硬件 - 软件模型与布林克霍夫（2004年）的问责类型学相结合，有助于更好地理解卫生中心微观系统在特定条件下表现（或表现不佳）的方式和原因。
