Deconcentrating regulation in low- and middle-income country health systems: a proposed ambidextrous solution to problems with professional regulation for doctors and nurses in Kenya and Uganda.

BACKGROUND: Regulation can improve professional practice and patient care, but is often weakly implemented and enforced in health systems in low- and middle-income countries (LMICs). Taking a de-centred and frontline perspective, we examine national regulatory actors' and health professionals' views and experiences of health professional regulation in Kenya and Uganda and discuss how it might be improved in LMICs more generally. METHODS: We conducted large-scale research on professional regulation for doctors and nurses (including midwives) in Uganda and Kenya during 2019-2021. We interviewed 29 national regulatory stakeholders and 47 subnational regulatory actors, doctors, and nurses. We then ran a national survey of Kenyan and Ugandan doctors and nurses, which received 3466 responses. We thematically analysed qualitative data, conducted an exploratory factor analysis of survey data, and validated findings in four focus group discussions. RESULTS: Kenyan and Ugandan regulators were generally perceived as resource-constrained, remote, and out of touch with health professionals. This resulted in weak regulation that did little to prevent malpractice and inadequate professional education and training. However, interviewees were positive about online licencing and regulation where they had relationships with accessible regulators. Building on these positive findings, we propose an ambidextrous approach to improving regulation in LMIC health systems, which we term deconcentrating regulation. This involves developing online licencing and streamlining regulatory administration to make efficiency savings, freeing regulatory resources. These resources should then be used to develop connected subnational regulatory offices, enhance relations between regulators and health professionals, and address problems at local level. CONCLUSION: Professional regulation for doctors and nurses in Kenya and Uganda is generally perceived as weak. Yet these professionals are more positive about online licencing and regulation where they have relationships with regulators. Building on these positive findings, we propose deconcentrating regulation as a solution to regulatory problems in LMICs. However, we note resource, cultural and political barriers to its effective implementation.

Hybrid clinical-managers in Kenyan hospitals.

PURPOSE: The purpose of this paper is to explore the way "hybrid" clinical managers in Kenyan public hospitals interpret and enact hybrid clinical managerial roles in complex healthcare settings affected by professional, managerial and practical norms. DESIGN/METHODOLOGY/APPROACH: The authors conducted a case study of two Kenyan district hospitals, involving repeated interviews with eight mid-level clinical managers complemented by interviews with 51 frontline workers and 6 senior managers, and 480 h of ethnographic field observations. The authors analysed and theorised data by combining inductive and deductive approaches in an iterative cycle. FINDINGS: Kenyan hybrid clinical managers were unprepared for managerial roles and mostly reluctant to do them. Therefore, hybrids' understandings and enactment of their roles was determined by strong professional norms, official hospital management norms (perceived to be dysfunctional and unsupportive) and local practical norms developed in response to this context. To navigate the tensions between managerial and clinical roles in the absence of management skills and effective structures, hybrids drew meaning from clinical roles, navigating tensions using prevailing routines and unofficial practical norms. PRACTICAL IMPLICATIONS: Understanding hybrids' interpretation and enactment of their roles is shaped by context and social norms and this is vital in determining the future development of health system's leadership and governance. Thus, healthcare reforms or efforts aimed towards increasing compliance of public servants have little influence on behaviour of key actors because they fail to address or acknowledge the norms affecting behaviours in practice. The authors suggest that a key skill for clinical managers in managers in low- and middle-income country (LMIC) is learning how to read, navigate and when opportune use local practical norms to improve service delivery when possible and to help them operate in these new roles. ORIGINALITY/VALUE: The authors believe that this paper is the first to empirically examine and discuss hybrid clinical healthcare in the LMICs context. The authors make a novel theoretical contribution by describing the important role of practical norms in LMIC healthcare contexts, alongside managerial and professional norms, and ways in which these provide hybrids with considerable agency which has not been previously discussed in the relevant literature.

Examining clinical leadership in Kenyan public hospitals through the distributed leadership lens.

Clinical leadership is recognized as a crucial element in health system strengthening and health policy globally yet it has received relatively little attention in low and middle income countries (LMICs). Moreover, analyses of clinical leadership tend to focus on senior-level individual leaders, overlooking a wider constellation of middle-level leaders delivering health care in practice in a way affected by their health care context. Using the theoretical lens of 'distributed leadership', this article examines how middle-level leadership is practised and affected by context in Kenyan county hospitals, providing insights relevant to health care in other LMICs. The article is based on empirical qualitative case studies of clinical departmental leadership in two Kenyan public hospitals, drawing on data gathered through ethnographic observation, interviews and focus groups. We inductively and iteratively coded, analysed and theorized our findings. We found the distributed leadership lens useful for the purpose of analysing middle-level leadership in Kenyan hospitals, although clinical departmental leadership was understood locally in more individualized terms. Our distributed lens revealed medical and nursing leadership occurring in parallel and how only doctors in leadership roles were able to directly influence behaviour among their medical colleagues, using inter-personal skills, power and professional expertize. Finally, we found that Kenyan hospital contexts were characterized by cultures, norms and structures that constrained the way leadership was practiced. We make a theoretical contribution by demonstrating the utility of using distributed leadership as a lens for analysing leadership in LIMC health care contexts, revealing how context, power and inter-professional relationships moderate individual leaders' ability to bring about change. Our findings, have important implications for how leadership is conceptualized and the way leadership development and training are provided in LMICs health systems.

'Pastoral practices' for quality improvement in a Kenyan clinical network.

We explain social and organisational processes influencing health professionals in a Kenyan clinical network to implement a form of quality improvement (QI) into clinical practice, using the concept of 'pastoral practices'. Our qualitative empirical case study, conducted in 2015-16, shows the way practices constructing and linking local evidence-based guidelines and data collection processes provided a foundation for QI. Participation in these constructive practices gave network leaders pastoral status to then inscribe use of evidence and data into routine care, through championing, demonstrating, supporting and mentoring, with the support of a constellation of local champions. By arranging network meetings, in which the professional community discussed evidence, data, QI and professionalism, network leaders also facilitated the reconstruction of network members' collective professional identity. This consequently strengthened top-down and lateral accountability and inspection practices, disciplining evidence and audit-based QI in local hospitals. By explaining pastoral practices in this way and setting, we contribute to theory about governmentality in health care and extend Foucauldian analysis of QI, clinical networks and governance into low and middle income health care contexts.

Infectious disease and health systems modelling for local decision making to control neglected tropical diseases.

Most neglected tropical diseases (NTDs) have complex life cycles and are challenging to control. The "2020 goals" of control and elimination as a public health programme for a number of NTDs are the subject of significant international efforts and investments. Beyond 2020 there will be a drive to maintain these gains and to push for true local elimination of transmission. However, these diseases are affected by variations in vectors, human demography, access to water and sanitation, access to interventions and local health systems. We therefore argue that there will be a need to develop local quantitative expertise to support elimination efforts. If available now, quantitative analyses would provide updated estimates of the burden of disease, assist in the design of locally appropriate control programmes, estimate the effectiveness of current interventions and support 'real-time' updates to local operations. Such quantitative tools are increasingly available at an international scale for NTDs, but are rarely tailored to local scenarios. Localised expertise not only provides an opportunity for more relevant analyses, but also has a greater chance of developing positive feedback between data collection and analysis by demonstrating the value of data. This is essential as rational program design relies on good quality data collection. It is also likely that if such infrastructure is provided for NTDs there will be an additional impact on the health system more broadly. Locally tailored quantitative analyses can help achieve sustainable and effective control of NTDs, but also underpin the development of local health care systems.

A new mode of organizing in health care? Governmentality and managed networks in cancer services in England.

We explore the argument that a new mode of health care organizing is emerging which moves beyond the established professional dominance versus New Public Management (NPM) debate. We review Foucault's work on 'governmentality', as applied to health care organizations. We specify two specific Foucauldian themes (the power/knowledge nexus in Evidence Based Medicine (EBM); and the technologies of the clinical managerial self) to analyse organizing in the English cancer services field. We introduce two qualitative case studies of Managed Cancer Networks. We suggest their governance can be fruitfully seen through a 'governmentality' lens. We consider implications for developing Foucauldian analysis of health care organizations.

Reactivity and reactions to regulatory transparency in medicine, psychotherapy and counselling.

We explore how doctors, psychotherapists and counsellors in the U.K. react to regulatory transparency, drawing on qualitative research involving 51 semi-structured interviews conducted during 2008-10. We use the concept of 'reactivity mechanisms' (Espeland & Sauder, 2007) to explain how regulatory transparency disrupts practices through simplifying and decontextualizing them, altering practitioners' reflexivity, leading to defensive forms of practice. We make an empirical contribution by exploring the impact of transparency on doctors compared with psychotherapists and counsellors, who represent an extreme case due to their uniquely complex practice, which is particularly affected by this form of regulation. We make a contribution to knowledge by developing a model of reactivity mechanisms, which explains how clinical professionals make sense of media and professional narratives about regulation in ways that produce emotional reactions and, in turn, defensive reactivity to transparency.

Medical regulation, spectacular transparency and the blame business.

PURPOSE: The purpose of this paper is to explore general practitioners' (GPs') and psychiatrists' views and experiences of transparent forms of medical regulation in practice, as well as those of medical regulators and those representing patients and professionals. DESIGN/METHODOLOGY/APPROACH: The research included interviews with GPs, psychiatrists and others involved in medical regulation, representing patients and professionals. A qualitative narrative analysis of the interviews was then conducted. FINDINGS: Narratives suggest rising levels of complaints, legalisation and blame within the National Health Service (NHS). Three key themes emerge. First, doctors feel "guilty until proven innocent" within increasingly legalised regulatory systems and are consequently practising more defensively. Second, regulation is described as providing "spectacular transparency", driven by political responses to high profile scandals rather than its effects in practice, which can be seen as a social defence. Finally, it is suggested that a "blame business" is driving this form of transparency, in which self-interested regulators, the media, lawyers, and even some patient organisations are fuelling transparency in a wider culture of blame. RESEARCH LIMITATIONS/IMPLICATIONS: A relatively small number of people were interviewed, so further research testing the findings would be useful. PRACTICAL IMPLICATIONS: Transparency has some perverse effects on doctors' practice. SOCIAL IMPLICATIONS: Rising levels of blame has perverse consequences for patient care, as doctors are practicing more defensively as a result, as well as significant financial implications for NHS funding. ORIGINALITY/VALUE: Transparent forms of regulation are assumed to be beneficial and yet little research has examined its effects in practice. In this paper we highlight a number of perverse effects of transparency in practice.

Networking to improve end of life care.

Network organisations are increasingly common in healthcare. This paper describes an example of clinically led networking, which improved end of life care (EOLC) in care homes, differentiating between a 'network' as a formal entity and the more informal process of 'networking'. The paper begins with a brief discussion of networks and their development in healthcare, then an overview of EOLC policy, the case setting and methods. The paper describes four key features of this networking; (1) how it enabled discussions and implemented processes to help people address difficult taboos about dying; (2) how personal communication and 'distributed leadership' facilitated learning; (3) how EOLC occasionally lapsed during the handover of patient care, where personal relationship and communication were weaker; and (4) how successful learning and sharing of best practice was fragile and could be potentially undermined by wider financial pressures in the NHS.

Change capacity: the route to service improvement in primary care.

BACKGROUND: This paper draws on data from five English primary care trust (PCT) case studies which formed part of a larger research project that explored the roles and relationships of clinical managers and their colleagues in periods of change within different healthcare organisations. AIMS: This article uses empirical data to further our understanding of how primary care organisations can successfully implement service improvements. METHOD: Qualitative methods were used to compare across multiple cases. Three methods were utilised comprising semi-structured interviews, document analysis and observation at meetings. Through an iterative process of data coding using the NVivo data analysis software, final conclusions developed and became more explicit. Data were collected between mid-2002 and 2005. RESULTS: Our analysis demonstrates the important influence of context on the change process. The case studies provide evidence of the nature of the relationships between context and progress in organisational change. We identified three interrelated dimensions of organisational context that played a crucial role in the progress or otherwise of service improvement. CONCLUSION: We conclude that primary care organisations need to have three key features in combination to successfully implement service improvements. These are (i) the presence of change leaders, at several levels throughout the organisation; (ii) a coherent change strategy; and (iii) a sound foundation of relationships between managers and clinical professional groups.