The main results of individual interviews in this study have been grouped according to the four functions proposed by Marchal et al. [8] to assess organizational performance, in this case, the RDHAs in Mauritania. The nature and intensity of interactions and alignment between these functions are studied in more detail.
Goal attainment: the objectives of the RDHAs
The first group of participants stated that the RDHA’s objective is to improve access to and quality of curative, preventive, and promotional health services.
“I see the RDHA as having the objective of providing quality care to the people of the Wilaya. It must bring health services to the most remote areas, ensure the availability of medicines, raise awareness against diseases…” (Staff, RDHA).
The second group of participants, however, considered this objective to be of a more operational nature, and would therefore be within the scope of goals of the level of the Moughataas (i.e. the district level). For this second group, the main objective of RDHA would rather be to ensure the implementation at the regional level of the MOH health policies and coordinate multisectoral action:
“The objective of the RDHA is the execution of the MOH policy in its Wilaya and maybe the collaboration with other sectors that are not health” (Staff, RDHA).
“For us, the RDHA must pilot all health and social actions at the regional level. It represents the Ministry of Health. It is the focal point for health at the regional level” (Hospital Director).
However, some participants felt that this objective was too ambitious. They consider that the RDHAs do not have the levers or the means to achieve this objective.
“This objective is very broad. The RDHA does not have the means to achieve it, which is why they focus on health services and not on the coordination of health action at the regional level, which limits their scope of action.” (TFP).
Service production: delivery of services offered by the RDHAs and operational management
Services offered by the RDHA
The main services identified by most participants were training, supervision and planning of activities.
Staff training
For several participants, the RDHA should play a role in training their own staff and that of the Moughataas. They noted, however, that the RDHA did not have a training plan and that the trainings offered were organised by the central level or by Technical and Financial Partners (TFPs). Some participants mentioned that these training sessions do not always correspond to their priority needs.
“At the RDHAs level, we have a pool of trainers for the various components, whether reproductive health, tuberculosis, nutrition or vaccination, but we do not have the means to capitalise training for the Moughataas to be able to strengthen their skills” (Staff, RDHA).
On the other hand, other participants indicated that:
“The RDHA team is not trained enough; this is a weakness of the RDHA…. And when we ask to do the cascade training it doesn’t go well… Therefore we see this substitution of the RDHA by the central level to provide this training” (Central level).
Furthermore, some participants observeed that even if staff receive training, their low retention rate does not allow them to capitalise sufficiently to benefit the RDHA.
Supervision of activities by the RDHAs
Participants stressed that RDHAs should supervise the Moughataas, their staff, and private (for-profit and not-for-profit) healthcare providers. However, they noted that the integrated supervision of the Moughataas is of poor quality due to the RDHAs’ low competence and insufficient funding and logistics. In addition, supervision reports are very irregular or nonexistent.
“For some time now, there has not been proper supervision. I’m telling you, there were heads of health posts who don’t know about RDHA….” (Staff, RDHA).
“When the RDHA did the supervision, he met with all the heads of service in the Moughataa, but no reports, just a phone call. What is missing, in general, is the documentation…” (CMOM).
On the other hand, participants noted that supervision of vertical programs (such as nutrition, medicines, Covid-19, etc.) is done more regularly, as they are funded by partners.
Participants also mentioned that the supervision of RDHA heads of the department is not done internally or at the national level.
“The RDHA does not formally supervise its heads of department. The staff are left to their own devices… The central level also rarely comes and even if they do it’s quick. Quickly, quickly…”. (Staff, RDHA).
The supervision of the private sector is ensured by a general inspector who operates independently and does not report to the RDHA.
Planning of activities
Several participants noted that the RDHA should plan its activities on the one hand and support planning at the operational (Moughataa) level on the other. However, they mentioned the RDHA’s weak capacity to do so. They also indicated that for the past two years, annual operational activity plans (OAPs) have been developed with the support of the MOH.
“Before there was no planning, it was rather a “copy and paste” of activities, but in any case, since the arrival of this ministry, we have started with the planning for the year… RDHA organises and informs us, sends us the tools beforehand… but RDHA’s capacities are very weak.” (Chef medical officer of moughataa “CMOM”).
Some participants underlined the RDHA’s low ownership of these OAPs. They also indicated that many of the RDHA’s priority activities included in these OAPs are not funded.
Other participants mentioned that the role of the RDHA would also be to support planning at the operational level. However, this support was also seen as weak and very irregular:
“Normally the RDHA should support the Moughataa when they do their planning, but also in the implementation. But this is not done. It is only when the central level comes…. (Central level).
The operational management
Participants identified the management of human resources (HR) and financial resources (FR), the National Health Information System (NHIS)/epidemiological surveillance, equipment/infrastructure, and medicines/inputs as key functions of RDHA.
Human resource management
Several participants noted that the RDHA are supposed to manage (recruitment, retention, motivation, formation, etc.) their HR but also the HR of the Moughataa. They felt that this management was too centralised and inefficient. For example, doctors are assigned directly by the central level to health facilities without going through the RDHA. Paramedics are placed at the disposal of the RDHA, who propose their assignment to the Walis, who are the final decision-makers. Moreover, the reassignment of staff to other regions is done by the central level without consultation of the RDHA, which is only informed a posteriori.
“The power to manage staff is in the hands of the central level and the Wali, not the RDHA. It is the Wali who decides, and sometimes politicians force him to favour their relatives. RDHA only proposes, it cannot impose. But sometimes it depends on the character and leadership of the RDHA too”. (Staff, RDHA).
“Personnel management is quite centralised. Our opinion is not considered…”. (Staff, RDHA).
As far as the RDHA team is concerned, it consists of six heads of service in addition to the RDHA itself, who is, in general, a medical doctor without any further training. Each service is down to a single head of service, a nurse with no job description and limited organisational capacity and skills.
“I find that there is a great lack of human resources at the level of the RDHA because you find services with only one staff member. She can’t do the work of a service in the true sense…” (Staff, RDHA).
In addition, some participants felt that their poor knowledge of public health, particularly of health system management, prevented them from fully playing their roles.
Management of financial resources
Some participants noted that financial management was not very effective or efficient. They mentioned that the financing of the RDHA’s activities is essentially provided by the national budget and the TFPs.
“The RDHA has two sources of funding, essentially the Ministry of Health and the partners. But this funding does not arrive in time to carry out the activities” (Staff, RDHA).
The national budget (of the MoH) finances the functioning of the RDHA. While the RDHA formulates requests for disbursements, the Wali is the authorising officer. This reduces the RDHA’s level of accountability. Furthermore, participants noted a long delay in the availability of these resources, sometimes up to six months. This means that RDHAs must go into debt with suppliers who overcharge them to compensate for the delays in payments.
“It’s complicated if you have a budget of 10 million (MRU), but in fact, you only find 5 million. The other 50% goes to the supplier’s percentage and so on…, what do you want.” (Staff, RDHA).
As for the TFPs, their funding is centralised at the central level before being transferred to an account managed directly by the RDHA. The RDHA has few partners who directly fund their activities.
“The partners send their money to the central level and then it is transferred to a bank account at the level of the RDHA to carry out activities such as vaccination campaigns. This works well except that it is often done at the last minute. There is no planning.” (Staff, RDHA).
Furthermore, some participants emphasised that there is little control over the use of financial resources allocated to the RDHA and that the administrative and financial service plays a minor role in their management.
Management of the National Health Information System (NHIS) and epidemiological surveillance
For the management of the NHIS, some participants mentioned that the DHIS2 (District Health Information Software) is filled in directly by the Moughataas and that the RDHA no longer has the possibility of validating the data before they are transmitted to the central level, as was the case with the previous software (Maurisys). Therefore, the RDHAs currently play a minor role in the management of the NHIS.
“Normally, it is the RDHAs that collects the data at the regional level, it is decentralised. But with the DHIS2 software, the Moughataas send the data directly to the Ministry, which is a step backwards. It kills the RDHAs…”. (Staff, RDHA).
They mention several problems, such as media stockouts and the poor quality of their data collection and reporting. Despite this, they acknowledge that the NHIS is one of the most successful services because of the pressure exerted by the central level to retrieve data.
“The NHIS is one of the best services in the RDHA. They are well trained and follow up with the central level daily. It is not bad.” (Staff, RDHA).
In addition, the RDHA coordinates epidemiological surveillance, with daily telephone data collection and transmission to the central level. It also coordinates case investigations as needed with the central and operational levels.
Management of medicines and consumables
Participants felt that the RDHAs play a minor role in medicine management. They communicate poorly with the Central Purchasing Office for Essential Medicines and Consumables (CAMEC) and have little power to sanction cases of poor drug management at the operational level.
“The availability of and access to medicines at the regional level is the responsibility of the RDHA. But it is the CAMEC that manages the medicines… We don’t know what’s going on there. We don’t know what happens there. But the RDHAs supervise the pharmaceutical depots in the health posts and centres.” (Central level).
For the Brakna region, a CAMEC branch located within the RDHA office is responsible for supplying the Moughataas and (regional) hospitals. For Nouakchott-North, supplies are made directly to the central CAMEC or private depots. The role of the heads of the RDHA medicine departments is minor and is limited to supervising the health facilities’ pharmacies to make inventories. This supervision is also irregular.
“We can’t control what happens to the medicines because the supervision is not regular. There is a lot of mismanagement at the level of the health posts or centres, but we don’t have the means to monitor… (Staff, RDHA).
Therefore, the heads of the RDHA services manage only free medicines and consumables to ensure their delivery to the health facilities.
Management of equipment and infrastructure
For several participants, the RDHA’s involvement in managing equipment and infrastructure is minor and limited to expressing needs.
“The RDHA should regularly make an exact situation of the equipment and infrastructure of the Moughataa, but nothing is done. Even at the RDHA level, there is no up-to-date inventory of materials and equipment.” (Central level).
In addition, participants indicated that the maintenance of available equipment is not ensured.
“There is a problem in all the Moughataas for the maintenance of equipment. Normally the RDHA should take care of it. Expensive equipment is bought and then it is not maintained and with small breakdowns, it is abandoned. This is not good.” (TFP).
Culture and values maintaining: the organizational culture and values of the RDHA
Several participants noted that RDHA’s organisational culture is imbued with Mauritanian social values (practices, habits, or characteristics). As a result, it is not structured or sufficiently formalised and hampers the achievement of the organisation’s objectives.
“The culture of RDHA is dependent on certain values in society. In Mauritania, a lot of things in everyday life are taken lightly and everything is put into perspective… For RDHA, this means that many things are done more often in an informal or unstructured way.” (TFP).
Some participants see this as an opportunity, as it offers certain flexibility so that, thanks to the reforms underway, the RDHA can develop its own identity and become an organisation that plays its role fully.
On the other hand, some participants refer to certain practices such as clientelistic relationships that guide the organisation of work within the RDHA. Indeed, they mention that some heads of service enjoy more trust from the directors than others. They are therefore given more responsibilities, carry out tasks that should be carried out by their colleagues, or receive benefits, which are sources of frustration.
“Sometimes the work is distributed among the heads of the department according to the personal relationship with the director. People who are well considered will get more benefits like training and activities… This is not good.” (Staff, RDHA).
Although several participants considered the subject to be sensitive, they felt that ethnicity would influence decisions about appointments to key positions or the allocation of work at the expense of actual skills.
“Ethnicity interferes with management at the RDHA level. Relatives may be privileged over others and their wrongdoing tolerated. But this is a very sensitive issue in Mauritania…” (TFP).
Furthermore, the existence of a strong hierarchical culture was also recognised by most participants. However, when the directives given are in contradiction with the regulations and standards, this compromises the achievement of objectives.
“Staff are expected to carry out the orders of their superior. Sometimes it’s good if it’s part of our job. But sometimes the orders are not correct, and the superior imposes himself, it influences negatively…” (Staff, RDHA).
On a completely different level, participants mentioned that respect for women and the elderly have implications for the RDHA’s organizational culture. For example, it would not be acceptable to impose a certain work pace on them. However, participants noted that many officers abuse this.
“We always want to help the elderly or the woman, if they have work that is tiring, we can take some of it to relieve them.” (Staff, RDHA).
On the other hand, participants indicate that there is a certain amount of multi-tasking of staff which appears to improve their performance. However, some participants acknowledged that this serves the personal interests of staff who are often absent without having to justify themselves. Similarly, it leads to an overload of work for the most conscientious officers.
“Multi-skilling is compulsory because there are not many of us. If this man is absent or on leave, if I know his role, it’s better. I can help. But I tell you, it depends on the mentality. Some exaggerate and don’t work.”(Staff, RDHA).
Adaptation to the environment: stakeholder interactions and health coordination
Participants identified two main categories of actors or stakeholders (internal and external) and classified them according to their level of power and legitimacy. They also noted the interactions between stakeholders and their own perceptions of how health action is coordinated at the regional level.
Internal actors
These were defined as those who are under the RDHA’s hierarchy and are more closely aligned with its goal:
“These are the regional hospitals, the health facilities and the private healthcare sector (profit and non-profit).” (Staff, RDHA).
About hospitals, in particular, some participants mentioned inconsistencies in their status that create a source of confusion and sometimes even tensions that would be detrimental to the proper functioning of the RDHA:
“On the organisational level, hierarchically, the RDHA is the supervisor of the hospitals at the regional level. The RDHA represents the Ministry of Health. But in addition to that, the hospitals have an autonomous management. Moreover, the hospitals and the RDHA depend on two different directorates. This creates confusion…” (Hospital Director).
“The problem we have at the RDHA is a problem of institutional anchoring, i.e. the RDHA is appointed by our ministry, the director of a hospital is appointed by a decree taken in the council of ministers…” (Central level).
For several participants, these inconsistencies resulted in weak articulation between the RDHA and the hospitals. However, in the Brakna region, the RDHA is a member of the hospital’s board of directors, which gives it greater visibility. This is not the case for the RDHA in Nouakchott-North.
External actors
External actors have been defined as those who are not under the direct hierarchy of the RDHA. These are the central level of the MOH and its attached directorates; the Wilaya and other regional directorates (hydraulics, education, etc.); the TFPs; civil society (NGOs, associations, etc.); the regional health development council (RHDC) or professional orders. Among these, the Wali and the Minister of Health were recognised as the most legitimate and powerfull, which makes them more influential in the functioning of the RDHA.
“The RDHA is under the direct hierarchy of the Wali (representative of the President of the Republic) and the Directorate General of Health for the MOH. But functionally, all the directorates of the ministry must work with the RDHA. So, for us, the RDHA is the small MOH in each region.” (Central level).
As for the TFPs, they are generally aligned with the objectives of the RDHA but can easily influence priorities because of the funding they provide. Their interventions are largely centralised at the level of the MOH with a few exceptions:
“We don’t have many direct partners. I see ACF supporting us through UNICEF about inputs for nutrition. For the big partners, they are managed directly by the ministry.” (Staff, RDHA).
The participants mentioned the role that the RHDC should play in coordinating health action at the regional level. However, these RHDCs are new actors whose capacities are still very weak.
Interactions between stakeholders and coordination of regional health action
Several participants agreed that the interactions between stakeholders in health action at the regional level remain weak. This is reflected in the absence of a functional and structured regional consultation framework.
“Well, there is no real coordination of actions except in the case of epidemics such as COVID, because it is a national or international problem. It is the Wali who coordinates this with the RDHA…” (Staff, RDHA).
For the participants, this weak coordination is also reflected in the numerous urgent instructions or requests made to the RDHA by the central level and the international partners. They impose on the RDHA the pace of work and priorities.
On the other hand, coordination with the chief medical officers of the Moughataas (CMOM) seems to be more effective, yet is often done by telephone on an adhoc base. Only in Brakna attempts are made to have monthly meetings with the CMOM.
“We have good coordination with the RDHAs. We can’t go two days without calling each other… Well, there is the monthly meeting where all the chief doctors are invited to coordinate together.” (CMOM).
As far as the coordination of activities is concerned, participants noted that teamwork is weak and synergies between the heads of services are rare. It is common for the RDHA to approach the heads of departments individually to give them assignments or files according to their affinities, which is often a source of tension.
