Dr Ben Tsofa examines the effects of political decentralisation in Kenya, on sub-national level health sector governance and accountability.
The KEMRI-Wellcome Trust Research Programme is a major Wellcome Trust’s overseas programmes. Its work has had a major influence on national and international health policy. Research spans a wide variety of topics and disciplines including research on malaria and bacterial and viral infectious diseases, work to map disease risk and intervention coverage and work on research ethics and health systems strengthening.
I have had a bit of a convoluted background, really. I started off as a clinical dentist. I worked a bit, for about 3 years, as a clinical dentist and then went in to public health management and I am currently doing health systems and health policy research.
My current area of research is health system governance. Specifically within the health system governance I am looking at the role of health system decentralisation in enhancing good governance within the health systems.
It is an important area in my understanding and especially a lot to do with my previous experience as a public health manager. I came to experience a lot of challenges fast at the operational level. Ensuring that you work in delivering your role as a health manager and understanding governance is one of the probably least understood issues. That is what drove me in to wanting to be part and parcel of addressing the challenges and the questions that faces health system managers.
Largely it is because particularly at the middle management level in the health care systems, the middle managers are charged with responsibility of interpreting policies which are set at the national level and translating them in to day-to day management activities. And they are the ones also that interface with the service providers and the service seekers and there is always a lot of tension between what you are understanding and the interpretation of the policies coming from above and what you can realistically do at a middle level management. It is that tension, or the experience of going through that tension that actually led me in to wanting to understand more, particularly the process by which middle level managers go about making decisions and go about balancing issues that come in from above and also addressing challenges and expectations that come from both service providers and service seekers at the lower level.
It is an important area of study because for me I find that the managers at the middle level are the most important arm, or element, in ensuring quality of care or delivery of desired good policies. It is because how they interpret and implement those desired good policies that actually lead to quality of care and general better health outcome. My view is that understanding of the issues, challenges and processes that middle level management undertake in going about making decisions and choices and priorities at that level that really have a big influence in ensuring quality of care.
In my research area I largely use qualitative methods, basically lots of participatory observation. As much as I see myself as a researcher as also see myself as an implementer in the role as I am interacting quite actively with policy makers both at middle level and at national level. I use a lot of what I call participatory observation methods and lots of other qualitative methods such as interviews and discussions with participants.
My data is not really quantitative, dealing with statistics, but rather qualitative, dealing with perceptions and realities. What I come across as interesting discoveries or processes in my research are what I call the 'coping mechanisms' middle level managers undertake to ensure that they strike a balance between instructions from above and the realities with the day-to-day challenges when it comes to interpreting that. Different ranges of managers have different coping mechanisms in terms in to trying to please superiors at the national level and to be able to meet the desires and expectations of the people that they are managing.
What I find as the contribution, or impact, of my research work in to the health system, particularly where we are working in the health care system in Kenya is first that my type of research is really at the operational level and in the real-time is feeding back to the system, particularly in working with managers and helping them to make decisions. I am involved a lot, as part of my research, on working on ways of enhancing decision making at a middle management level. Helping health workers to devise ways and means of maximising their decisions based on different ranges of choices that they would have. So, in that way, yes, I do feel that I am making a big, real-time contribution to the range of choices and decisions that middle managers do undertake to perform their duties in managing the health care system at that level.
I have a dual role in my current position. I am in fact principally an employee of the ministry of health in Kenya but have been seconded to a research programme and part of my role around which my body of research is focused also on facilitating the translation evidence of decision making both at policy level and that then my own research work fits around that and how managers can use this and harness it for decision making.
If you had asked me ten years ago if I wanted to be a researcher I would probably have said no. But clearly when I was in the medical school I wanted to be a clinician. I went out there with a lot of enthusiasm and interest to be a clinician. But the reality and experiences that I first encountered working in the public sector was when I first started asking questions. How best can we working in this type of environment and the knowledge that I got from training, how can I help in enhancing and ensuring that other health workers and clinicians can deliver their mandate better? My research career was influenced by my own experiences but as a front-line clinician and also as a public health manager.