Opening decision spaces: a case study on the opportunities and constraints in the public health sector of Mpumalanga Province, South Africa

Abstract Background Decentralised and evidence-informed health systems rely on managers and practitioners at all levels having sufficient ‘decision space’ to make timely locally informed and locally relevant decisions. Our objectives were to: (a) understand decision spaces in terms of constraints and enablers (using a framework focused on authority, accountability and capacity and the interrelationships between these domains); and (b) outline opportunities through which to expand and enhance them in an understudied rural context in South Africa. Methods This study examined decision spaces within Mpumalanga Province, using data and insights generated through a participatory action research process with local communities and health system stakeholders since 2015, which was triangulated with published documents and research team participant observation to produce findings on the three core domains at three levels of the health system. Results There is significant capacity in the system, which is delivering on many of its goals, with areas of high achievement. While lines of authority are generally well-defined, personal networks take on an important dimension in how stakeholders can act. This is expressed through marked ingenuity and a range of informal coping strategies built on local relationships. There are constraints in terms of limited formal external accountability to communities and internal accountability which is weak in places for individuals and focused more on meeting performance targets set at higher levels and less on enabling effective local leadership. More generally, political and personal factors are clearly identified at higher levels of the system, whereas at sub-district and facility levels, the dominant theme was constrained capacity, affecting all health system components. Conclusions Decision space can be opened up through supporting leadership and organisational culture changes. In this scenario, the real resources in the system, which are human, technical and financial, can be empowered to realise potential more fully. The article adds to existing literature by applying a decision space lens at multiple levels of a decentralised health care system, focusing on a broad range of capacities, and providing future directions to support and expand existing capacity.