A participatory action research approach to strengthening health managers’ capacity at district level in Eastern Uganda

Abstract

BackgroundMany approaches to improving health managers’ capacity in poor countries, particularly those pursued by external agencies, employ non-participatory approaches and often seek to circumvent (rather than strengthen) weak public management structures. This limits opportunities for strengthening local health managers’ capacity, improving resource utilisation and enhancing service delivery. This study explored the contribution of a participatory action research approach to strengthening health managers’ capacity in Eastern Uganda.MethodsThis was a qualitative study that used open-ended key informant interviews, combined with review of meeting minutes and observations to collect data. Both inductive and deductive thematic analysis was undertaken. The Competing Values Framework of organisational management functions guided the deductive process of analysis and the interpretation of the findings. The framework builds on four earlier models of management and regards them as complementary rather than conflicting, and identifies four managers’ capacities (collaborate, create, compete and control) by categorising them along two axes, one contrasting flexibility versus control and the other internal versus external organisational focus.ResultsThe findings indicate that the participatory action research approach enhanced health managers’ capacity to collaborate with others, be creative, attain goals and review progress. The enablers included expanded interaction spaces, encouragement of flexibility, empowerment of local managers, and the promotion of reflection and accountability. Tension and conflict across different management functions was apparent; for example, while there was a need to collaborate, maintaining control over processes was also needed. These tensions meant that managers needed to learn to simultaneously draw upon and use different capacities as reflected by the Competing Values Framework in order to maximise their effectiveness.ConclusionsImproved health manager capacity is essential if sustained improvements in health outcomes in low-income countries are to be attained. The expansion of interaction spaces, encouragement of flexibility, empowerment of local managers, and the promotion of reflection and accountability were the key means by which participatory action research strengthened health managers’ capacity. The participatory approach to implementation therefore created opportunities to strengthen health managers’ capacity.Electronic supplementary materialThe online version of this article (doi:10.1186/s12961-017-0273-x) contains supplementary material, which is available to authorized users.

Subnational health management and the advancement of health equity: a case study of Ethiopia

“…Further, these mechanisms did not appear to be formally recognized or supported by the health sector in Ethiopia. Research in eastern Uganda reinforces the merits of encouraging subnational health managers to work creatively and flexibly to attain goals and collaborate with others [41], capacities that others suggest should be supported through institutional design and financing [13].…”

Organizational change and everyday health system resilience: Lessons from Cape Town, South Africa

“…Collaboration between managers and researchers, meanwhile, supported a continuing process of action-learning that itself nurtured other resilience capacities. As Sharp et al (2018) argue, appreciative action research enables change in mindsets and relationships, hopefulness in the face of complex demands, a new language that expands opportunities, as well as nurturing ownership of ideas (see also Gilson et al, 2017 ; Kagwanja et al, 2020 ; Tetui et al, 2017 ).…”

Guiding principles for quality, ethical standards and ongoing learning in implementation research: multicountry learnings from participatory action research to strengthen health systems

“…One framework, applied within implementation research is participatory action research (PAR) which is gaining traction as a mechanism for strengthening health systems and improving health programme delivery ( Tetui et al , 2017a ; Di Ruggiero and Edwards, 2018 ; Martineau et al , 2018 ; Tetui et al , 2018 ). PAR is a cyclical research process of problem identification, action and reflection leading to further inquiry and action for change through democratic processes of decision making ( Kindon et al , 2007 ; Chevalier and Buckles, 2013 ; Di Ruggiero and Edwards, 2018 ).…”

“…PAR core principles include; respect for diversity, community strengths, reflection of cultural identities, power-sharing and co-learning ( Minkler, 2000 ). In low- and middle-income countries (LMICs) participatory research is often centred at the community level rather than across the multiple levels in which health systems operate, with fewer examples of PAR at National, State and Regional levels ( Haaland and Vlassoff, 2001 ; Keusch et al , 2010 ; Tetui et al , 2017a ). When the PAR approach has been applied to strengthen health systems and address implementation challenges at the sub-national level, ownership and long-term sustainability of interventions has been demonstrated ( Tetui et al , 2017b ; Martineau et al , 2018 ) illustrating its potential for change.…”