PONE-D-22-22471Opening decision spaces: a case study on the opportunities and constraints in the public health sector of Mpumalanga Province, South AfricaPLOS ONE

Dear Dr. Lucia D'Ambruoso,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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ACADEMIC EDITOR:The authors are to be congratulated for this pertinent body of work. However, there are a few minor changes that will need to be addressed.In the abstract, Line 18. Locally informed and locally relevant. Locally doesn't need to be repeated.Abstract results. Although capacity exists. Capacity for what. Add capacity for decision making.Introduction, line 61. VAPAR is mentioned for the first time. Put a reference.Data sources, line 200. Spell out VA and PAR before abbreviating. Go through the entire manuscript and fully spell out all abbreviations used for the first time e.g. Line 226 NGOs.Study limitations should come after the discussion.Footnotes are not permitted. If your manuscript contains footnotes, move the information into the main text or the reference list, depending on the content.Provide full references for references 2, 9, 17, 19, 56 and 57

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Academic Editor

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Comments to the Author

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Reviewer #1: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

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3. Have the authors made all data underlying the findings in their manuscript fully available?

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Reviewer #1: No

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #1: Yes

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5. Review Comments to the Author

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Reviewer #1: Opening decision spaces: a case study on the opportunities and constraints in the public health sector of Mpumalanga Province, South Africa

Reveiwer comments

General comments

This is a well written paper on a very important issue for federating low and middle income countries where the subnational level are mandated to implement health policies. Below are specific comments and suggestions for minor revisions

Specific comments

Abstract

Line 25..remove the, and leave as ....three core domains

Key words... Iw ould have expected to see ‘ Decentralisation’ as a key word, since it’s the principle at the core of subnational decision making

Introduction

I suggest that it nay be necessary to further explain ( in a few swntences), the model of decentralization ( deconcentration, devolution etc.) that is in practice as this may have resonance for the findings. And sometimes actors, in practice, deviate from the model prescribed by their constitution, especially in LMICs

Methods

I commend the detailed writing in this section and suggest a few revisions, as follows:

Lines 160-165

It will be good to rank the socio-economic status of Mpumalaga among the other provinces, for the wider readership to fully appreciate the context, especially as Capacity ( resource... financial etc.) is one of your key study domains. The impact of resource capacity on the decision space may well differ in a better resourced provice, like the Western Cape, for instance.

Line 195....... remove one ‘from’

Line 202...Edit sentence

Line 211..... Though referenced, I think a sentence on the purpose of selecting these particular three villages can be included here, without the reader going to seek out the Reference.

Results

Findings have also been reported in a detailed manner

Given the long study period, (2015-2020), albeit retrospective, were there fluctuations observed in the decision spaces at the various levels and what factors (political, economic, change in actors) may have accounted for these?

Discussion

You now bring in Decentralisation literature here, which is apt, but not adequately introduced at the beginning.

I also wonder if some street level bureaucracy literature can be used to explain the facility staff coping mechanism (positive or negative).

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PONE-D-22-22471R1Opening decision spaces: a case study on the opportunities and constraints in the public health sector of Mpumalanga Province, South AfricaPLOS ONE

Dear Dr. D'Ambruoso,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please address comments raised by Reviewer 4.

Please submit your revised manuscript by Mar 14 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

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We look forward to receiving your revised manuscript.

Kind regards,

Sogo France Matlala, PhD

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: (No Response)

Reviewer #3: All comments have been addressed

Reviewer #4: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Partly

Reviewer #3: Yes

Reviewer #4: Partly

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: N/A

Reviewer #3: N/A

Reviewer #4: N/A

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: No

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: No

Reviewer #3: Yes

Reviewer #4: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: The main issue is that the manuscript involve two things which could have led to two separate manuscripts: (1) application of the concept framework in decison making space, and also (2) assessment of decision making space using participatory approach.

As such this has impacted your background, methodology, results and discussions.

generate two manuscript from this submission

Reviewer #3: The manuscript is recommended for publication. The authors to justify as to why the three villages were selcted above all other available villages. Also, attend to the referencing of government documents as per given example in the manuscript.

Reviewer #4: Thank you for submitting this interesting paper to review. You use an interesting methodology using PAR to unpack the decision-making space issue. I have a number of overarching comments and questions as well as specific ones related to the text.

You highlight the importance of the decentralised health system in South Africa – which is administratively decentralised to the district level. You introductory paragraph remarks that the health system is operationalised by the districts in line (line 57-8) with standards and set targets for population level indicators. Who does the target setting? National? Provinces? To what extent is this determined at a district level in Mpumalanga? What is the target setting process/consultation process? How does local evidence impact on target setting and therefore resource allocation? Unpacking some of this could assist with understanding the gaps in ownership of decisions, and the architecture of the decision space. You conclude the article with a discussion about making spaces. Not much mention is made about the absence of these in the current district functioning.

In addition, the issue of adequate information for astute decision making is not explicitly highlighted. Poor information management and reporting of metrics that span the whole province with little drilling down to district or facility level surely constrains decision making and resource allocation, particularly in a resource constrained environment.

For some specific comments:

1. Line 91 mentions resource capacities – are these technical (is this where data comes in as well as the ability to make sense of data – i.e. information)? You mention the provincial M&E office but do not draw this into the research or discussion. This is important as poor access to valid information informs resource decision-making.

2. You point to the implications of inadequate resource capacities – with reverting to informal decision-making strategies. Do you mean that for example if there is little information available informal decision-making emerges?

3. You mention (line 109-110) that leadership should enable front line staff to make decisions about delivery to meet needs. However, your phrasing indicates that you see in the SA context that this is for service delivery that fulfils policy mandates.

4. The accountability paragraph reviews horizontal and vertical decision making. Community accountability through structures are the only ones mentioned in horizontal accountability. However there could be on-line forums that promote discussion and problem solving that are not decision-making forums that are now used in some provincial health departments, e,g, the Western Cape. These are designed for district and provincial managers to touch sides about mutual problems, highlighting conundrums, how they have managed them, promoting innovation and spreading good practice. This has engendered more trusting relationships and less of compliance culture. Your consideration of opportunities brought about by digital resources would be useful.

5. Line 143: What do you mean by “affirmative student recruitment”? Is this purposefully recruiting local students to work in a rural province? Other?

6. Line 144: your use of ‘public health workforce”. Is this a public sector health workforce”, or staff with public health skills (epidemiology, management etc)?

7. Line 163 – suggest you replace ‘it’ with ‘this’.

8. In your methods you mention that the data was obtained through team observations (TO). However it is not clear if the opportunities for review of data, and mutual support by managers at a provincial, district or local level were probed by the team.

9. Line 321. The mention of ‘scripts’: Is this scripts to be used to conduct consultations or decision tree/algorithmic/ protocols as to what the indications are for various conditions e.g. the PACK guidelines that the Knowledge Translation Unit design.

10. The initiatives (line 323) that ‘lacking local relevance” is interesting, and could be unpacked in more detail. Are there diseases/conditions that are not covered or management protocols that are not possible or relevant?

11. You make mention that the relationships between the hospitals and CHCs are no longer direct. How do the Paediatricians instituted by the WBOTS function ito supervision? How do they relate to hospital clinicians? In line 403 you mention that there ‘may’ be confusion over mandates? Is there confusion? Was this not probed? This is key to an exploration of decision spaces. If there is no WBOTs or discipline specialists are there any other clinical supervision plans made? The PHC supervisors, are they clinically trained experienced clinical nurse practitioners?

12. You give figures for anticipated attrition (line 349-350). Was there a correlation between the clinics with high levels of staff dissatisfaction and high proportions of staff intending to leave?

13. Line 355 – “area was a homeland” – this needs more contextual explanation, as only those familiar with apartheid implementation would know anything about this. You only raise homelands in the discussion. I think this should come earlier.

14. The link between capacity, decision spaces and long waiting times needs to be made clearer. Do clinic managers have the mandate, information and tools to make decisions about implementing booking systems for patient consultations that would reduce patient waiting times ?

15. Why do you think the proportion of clinics have met Ideal Clinic standards, compared to the national average, are so low (line375-376). Surely all provinces have the same constraints and consequently procurement constraints cannot be the problem.

16. The report on deficiencies in the use of data to determine causes of death via the DHIS merits further discussion. Are the underlying causes of hospital deaths not recorded in the hospital information system? In addition, are there not M&M meetings to discuss hospital deaths? Also unexplained deaths should be investigated by the Forensic pathology services. Surly there are some avenues open to obtain some sense of leading causes of death in children in the district?

17. Line 397. It would be helpful to have more detail about the PHC director who “sits under the MCWYH&N programme coordinator”. Is the MCWYH&N person a director as well? Are they located in the provincial office? The job description for accountabilities would be useful. While this may seem pernickety, I think this is pertinent as decision making, accountability and lines of authority are the subject of the paper.

18. The perspectives of the district authority about the roles and reporting lines of the DCST would be useful as clinical governance is not independent of service targets. Perhaps the DCSTs were imposed on the district who had little control over their activities?

19. Lines 412-422: The district accountability upward and downward accountability mechanisms seem to be in the form of written reports? Besides the VAPAR forum (a district level meeting?), are there any discussion forums within the district – such as monthly district / sub-district meetings where issues can be raised? What is the level of understanding of information derived from data that is reported which may lend itself to identifying gaps in ?training ?procurement ?staffing.

20. Line 427: You assert that the system is dysfunctional. That is a sweeping comment. It would be useful to have better precision here, e.g. people management/HR problems with the detail. Was the recentralisation to the provincial level? How were the irregularities managed?

21. Line 434-438: I think there should be a full-stop Line 435 “duties”. The “however” sentence is grammatically problematic.

22. The “equitable share” comment should include what was funded? Only the HR component?

23. The lack of ownership by districts of provincial targets points to a top-down imposition of targets. This may point to inadequate forums for decision making and/or a provincial office that is resource constrained or has inadequate management practice.

24. The people management systems at an individual level are highlighted as problematic. How do performance appraisals (6 monthly and annual) work. Surely each individual is appraised by their line manager at least annually? Or is this not currently functioning?

25. You point out that those suspended continue to draw salaries, with an implied criticism. Do you think they should not? Surely the issue here is the quicker resolution of such cases? The onus of proof should be on the complainant’s strong case.

26. You point to the damning Auditor General’s 2013/14 report (line 501). This is long out of date. I see that you do quote the 2017/18 report (line552). Can you identify if there have been improvements/changes in the AG’s assessment. It may be useful to understand the trajectory. I see that in the Discussion, you say that you did not analyse changes over time. How did you assess that “these features appear to be relatively constant over time” (line 577-8)?

27. Line 545 suggest that “intends” should be ‘intend”. Does the new University host the Wits/MRC Unit currently? How is it intended that this will work?

28. The ‘end users’ referred to (line 548): are these district or hospital or facility managers.

29. Table 3: This is a useful summary of findings. The comment on reporting – quantitative data as a limitation is only compared to social factors. Are there not other quantitative data that could be elicited that are not, e.g. retention in care or transfers between levels of care for a myriad of health conditions?

30. In the discussion, you raise that political and personal factors are identified across provinces. You do not discuss this in the results, and it is unclear where there is evidence for this. Relevant in this context?

31. You raise the enabling of learning and exchange that are critical to the development of decision-space. What kinds of decision spaces would facilitate this? Is it a matter of capacity such as developing leadership skills among middle and senior managers?

32. The contextual factors raised in the discussion – apartheid legacy issues, could be raised in the introduction which would give the reader more background and inform their understanding of the research findings.

33. It is unclear what is meant by (line 610) “public health employment market”. Do you mean that the public sector is a key employer for aspirant job seekers?

34. Line 611-12 could be clearer: “perceptions of higher-level distortions and state capture” – be more explicit - are you talking about national government? About political interference in the administration? About external organisations wishing to take control of state assets? The assertions are too sweeping with little detail. Whose perceptions? I think rephrase.

35. The explanation of Gatekeeper politics related to ward counsellors point to local government, and local government is NOT the custodian of health service delivery. It is unclear why this is raised here.

36. Line 623. “The difference between responsibility and financial resources …” is unclear Are you saying there is a mismatch, and what are the implications?

37. You seem to indicate that authority, accountability and capacities are aligned (line 628 & line637). Is this the case? What do you mean by aligned? Are the WBOTs aligned with district functions? And are there decision spaces such as regular district or provincial meetings that are functional?

38. You point out that there are insufficient management skills (line 643),. Is this not a deficit at a ‘capacity’ level? Does this not indicate poor alignment between capacity, authority and accountability?

39. The conclusion summarises the findings which is helpful. However could you be clearer as to what you are saying about lines of authority. Although they may be well defined are they functional? And if they were functional would there be a need for local ingenuity?

40. Your concluding commentary – the creation of spaces for constructive dialogue and decision making – is ‘spot on’ and more could be unpacked about this in the course of the results and discussion.

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Reviewer #2: No

Reviewer #3: No

Reviewer #4: No

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

PONE-D-22-22471R2

Dear Dr. Lucia D'Ambruoso

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #4: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #4: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #4: N/A

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #4: No

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #4: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #4: Thank you for addressing comments so comprehensively. The changes to the document have dealt with the concerns.

Congratulations for producing such an interesting article.

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Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #4: Yes: Virginia Zweigenthal

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