This thesis sheds light on differences in health insurance enrolment determinants and uptake barriers between urban and rural areas in the Jirapa district of Ghana. The National Health Insurance Scheme in Ghana has made significant progress in terms of enrolment, which has had a commensurate increase in utilization of health care services. However, there are challenges that pose a threat to the scheme’s transition to universal coverage; enrolment in the scheme has not progressed according to plan, and there are many barriers known to impede uptake of health care. Interestingly, these barriers vary in relation to locality, and rural residents appear to carry a disproportionate portion of the burden. A mixed method approach was employed to collect and analyse the data. On the basis of the primary qualitative and quantitative results, the thesis argues that the costs of enrolling and accessing health care is disproportionately higher for rural residents than it is their urban counterparts. It also highlights that the distribution of service benefits both in terms of the NHIS and health care in the Jirapa district favours urban residents. Lastly, the thesis found that whereas rural residents prefer health care provision to be social in nature, urban residents were more interested in the technical quality aspects of care. These findings suggest that rural residents are not benefitting from, or may not be accessing health services to the extent as their urban counterparts. Affordability, long distance to health facilities, availability and acceptability barriers were found to influence the resultant pro-urban distribution of the overall health care benefit.

Philosophiae Doctor - PhD / The value of accountability as a key feature of strengthening health systems and reducing maternal, newborn and child mortality is increasingly emphasised globally, nationally and locally. Frontline health professionals and managers play a crucial role in promoting maternal, newborn and child health (MNCH) services in an equitable and accountable manner. They are at the interface between higher-level health system management and communities, facing demands from both sides and often expected to perform beyond their available means. Although accountability is a central topic in the governance of MNCH literature, it has mostly been approached at global and national levels, with little understanding of how accountability is integrated into the routine functioning of local health systems.

This thesis sheds light on differences in health insurance enrolment determinants and uptake barriers between urban and rural areas in the Jirapa district of Ghana. The National Health Insurance Scheme in Ghana has made significant progress in terms of enrolment, which has had a commensurate increase in utilization of health care services. However, there are challenges that pose a threat to the scheme’s transition to universal coverage; enrolment in the scheme has not progressed according to plan, and there are many barriers known to impede uptake of health care. Interestingly, these barriers vary in relation to locality, and rural residents appear to carry a disproportionate portion of the burden. A mixed method approach was employed to collect and analyse the data. On the basis of the primary qualitative and quantitative results, the thesis argues that the costs of enrolling and accessing health care is disproportionately higher for rural residents than it is their urban counterparts. It also highlights that the distribution of service benefits both in terms of the NHIS and health care in the Jirapa district favours urban residents. Lastly, the thesis found that whereas rural residents prefer health care provision to be social in nature, urban residents were more interested in the technical quality aspects of care. These findings suggest that rural residents are not benefitting from, or may not be accessing health services to the extent as their urban counterparts. Affordability, long distance to health facilities, availability and acceptability barriers were found to influence the resultant pro-urban distribution of the overall health care benefit. / Ghana Education Trust Fund (GETFund)

Philosophiae Doctor - PhD / The value of accountability as a key feature of strengthening health systems and reducing maternal, newborn and child mortality is increasingly emphasised globally, nationally and locally. Frontline health professionals and managers play a crucial role in promoting maternal, newborn and child health (MNCH) services in an equitable and accountable manner. They are at the interface between higher-level health system management and communities, facing demands from both sides and often expected to perform beyond their available means. Although accountability is a central topic in the governance of MNCH literature, it has mostly been approached at global and national levels, with little understanding of how accountability is integrated into the routine functioning of local health systems. This PhD explores the forms and functioning of accountability at the district level focusing on MNCH as a programmatic area with long-established institutional mechanisms (structures and processes) in South Africa (SA). The thesis is presented in the form of four empirical papers (published or submitted), exploring different dimensions of accountability, which are embedded in a series of narrative chapters. In this thesis, accountability is understood as a set of relations between an accountholder and ‘accountor’ (or duty bearer), in which the latter provides information or justification for actions or decisions taken, and faces the resulting consequences of his/her actions (reward or sanction). Accountability mechanisms are the means to regulate accountability relationships and include broad strategies, interventions or instruments. These mechanisms can take various forms including performance, financial and public accountability, and operate both vertically (accountability inside bureaucratic hierarchies, or towards external stakeholders and/or the community), or horizontally (between peers, ‘neighbour’ units, departments or ministries in a national health system). Drawing conceptually on the field of governance and considering the complexity of the accountability phenomenon, I adopted a case study approach to the PhD research, using a combination of policy document review, interviews (with managers, providers, community representatives and members of labour unions) and field observations, conducted iteratively over 16 months. The study was conducted in Gert Sibande District, one of the three South African health districts in Mpumalanga Province, with an in-depth focus on two of the seven sub-districts in the District. The research found that frontline health professionals have a clear understanding and conceptualisation of accountability in the SA health policy context, despite the reported inability to define accountability by health professionals described in the literature. Respondents referred to accountability as responsibility, answerability and virtue, and also argued for strengthening accountability mechanisms as critical to addressing maternal and child mortality. While deeming accountability as important, frontline professionals experienced the existing accountability mechanisms as ‘too much’ and indicated the desire for the streamlining of existing mechanisms. In this regard, the study documented numerous mechanisms at district level, almost all related to performance accountability in MNCH. These included a performance management system, quality assessment and accreditation processes, quarterly reviews, and death surveillance and response processes. The existence of multiple and overlapping accountability mechanisms engenders operational confusion and ‘accountability overload’ for frontline providers, encouraging empty bureaucratic compliance, while critical gaps – notably in community accountability – remain. In practice, at their best, some mechanisms operate following a reciprocal1 pathway of capacity building with resource provision (from management) and expectation for better performance (from providers). There were, however, contextual variations in the implementation and practice of the mechanisms between sub-district settings. The fieldwork observations and interviews were also able to document how formal institutionalised mechanisms are embedded within a complex system of informal accountability relationships and social norms (‘accountability ecosystem’) that enables or constrains the ability of frontline professionals to fulfil their tasks. In addition, using a Social Network Analysis approach, the research identified key actors and their involved network, which form the relational backdrop to the functioning of accountability mechanisms for MNCH. By revealing complex relationships and collaboration patterns among frontline health professionals, the study was able to show the multi-level action and multiple actors required to achieve MNCH goals.

In this study the researcher attempted to determine the current role expectations of a clinic manager in a primary health care setting, to identify factors determining and influencing the role of a clinic manager, to determine what effect the current role expectations had on the management of primary health care services rendered at the clinic, to establish the developmental needs of clinic managers to enable them to adhere to their role expectations, and to identify and recommend measures to support clinic managers in the execution of their managerial role by addressing the identified deficiencies. The researcher selected a quantitative, exploratory, descriptive and contextual design. Clinic managers of fixed clinics in the Free State province were randomly selected to participate in the study and a questionnaire was utilised as data-collection instrument. The study found that the clinic manager's role is comprehensive and varies from telephonic booking patients to assessment of the quality of primary health care programmes. A number of non-managerial functions were identified, such as consultation of patients, management of medicine, dispensing of medicine and ordering of stock. It was also found that the respondents were not involved in a number of management functions such as financial and human resource management, and adherence to the implementation of standards. Factors that negatively influenced the clinic managers' management role included: * Lack of time due to the large number of patients they had to consult due to the shortage of staff. * Shortage of staff. * The execution of non-managerial tasks. Although it was found that the current role of the clinic manager was confusing as it entailed much more than just clinic management, it is foreseen that the role of the clinic manager could in future be clarified if the recommendations are implemented. / Health Studies / D. Litt. et Phil. (Health Studies)

In this study the researcher attempted to determine the current role expectations of a clinic manager in a primary health care setting, to identify factors determining and influencing the role of a clinic manager, to determine what effect the current role expectations had on the management of primary health care services rendered at the clinic, to establish the developmental needs of clinic managers to enable them to adhere to their role expectations, and to identify and recommend measures to support clinic managers in the execution of their managerial role by addressing the identified deficiencies. The researcher selected a quantitative, exploratory, descriptive and contextual design. Clinic managers of fixed clinics in the Free State province were randomly selected to participate in the study and a questionnaire was utilised as data-collection instrument. The study found that the clinic manager's role is comprehensive and varies from telephonic booking patients to assessment of the quality of primary health care programmes. A number of non-managerial functions were identified, such as consultation of patients, management of medicine, dispensing of medicine and ordering of stock. It was also found that the respondents were not involved in a number of management functions such as financial and human resource management, and adherence to the implementation of standards. Factors that negatively influenced the clinic managers' management role included: * Lack of time due to the large number of patients they had to consult due to the shortage of staff. * Shortage of staff. * The execution of non-managerial tasks. Although it was found that the current role of the clinic manager was confusing as it entailed much more than just clinic management, it is foreseen that the role of the clinic manager could in future be clarified if the recommendations are implemented. / Health Studies / D. Litt. et Phil. (Health Studies)