The organisational determinants and challenges of integrated, coordinated and decentralised primary health care programmes

This thesis covers the organisational factors affecting the integration and implementation of primary health care programmes of a provincial public sector health department in South Africa. It responds to the problems of district-level management structures and front-line health care providers being inundated and undermined by the implementation of uncoordinated and fragmented PHC programme activities and strategies. The organisational factors assessed included structural factors such as the interaction between line authority and staff authority, the relationship between divisions located at the centre and periphery of the department and the complementarity between positions and their ranks; management style and leadership; the variables inherent within different PHC programme areas that should influence organisational design; and relevant contextual factors. The thesis is a single case study. Data is mostly qualitative in nature, based mainly on participant observation, interview and document review. The thesis discusses the methodological and epistemological challenges to conducting in-depth research into the functioning of health departments, and illustrates the potential of such research for the strengthening of public health systems in developing countries. One of the main conclusions of the research was that the structural design of a health department can be very significant to its functioning. Some of the structural design faults identified by this research were the inadequate definition of the roles, functions and inter-relationships of several positions with the department; and the lack of congruence between the distribution of rank and the structural configuration of the department. The thesis suggests certain generalisable lessons that could be applied to the design of a developing country public health sector organogram. The study also confirmed that the contribution of management leadership to effective organisational cohesion and inter-divisional coordination is very important in the context of PHC programme coordination. Of particular note was the importance of providing a clear and appropriate strategic framework for planning, which would include the use of planning as a strategy to enhance organisational cohesion and coordination. Finally, the thesis describes the fundamental importance of adequately skilled human personnel within health departments to the effective integration and implementation of PHC programmes.