Exploring decision space: a case study of two South African central hospitals

Abstract

Background: The objective of this study is to explore the determinants of decision space and to investigate how it functions within a central hospital in South Africa, where policy proposals regarding the decentralization of management authority are being considered in the context of concerns about poor hospital management, and in terms of planned implementation of the National Health Insurance policy. Methods: Using a mixed methods qualitative approach, the case study methodology involved the purposive selection of two central hospitals as case study sites in the South African province of Gauteng. Nested case studies that focused on the human resources and supply chain management departments involved exploratory and explanatory phases that included document review, work shadow with non-participant observation, and in-depth interviews. Thematic analysis was used to analyse the data and generate findings. Results: Emergent outcomes of the interactions between authority, organisational capacity and accountability were identified and contributed to the development of an analytical decision space framework. The framework outlines the way in which decision space influences the allocation of responsibilities, the responsiveness of decision-making and the use of resources within the organisation or system. Recommendations: In the context of national policy changes regarding the decentralisation of hospital management authorities, this framework can be used to understand how decision space functions in other settings, and to guide implementation of interventions for improved management.