Assessing the scalability of a health management-strengthening intervention at the district level: a qualitative study in Ghana, Malawi and Uganda

Abstract

Background The scale-up of successfully tested public health interventions is critical to achieving universal health coverage. To ensure optimal use of resources, assessment of the scalability of an intervention is recognized as a crucial step in the scale-up process. This study assessed the scalability of a tested health management-strengthening intervention (MSI) at the district level in Ghana, Malawi and Uganda. Methods Qualitative interviews were conducted with intervention users (district health management teams, DHMTs) and implementers of the scale-up of the intervention (national-level actors) in Ghana, Malawi and Uganda, before and 1 year after the scale-up had started. To assess the scalability of the intervention, the CORRECT criteria from WHO/ExpandNet were used during analysis. Results The MSI was seen as credible, as regional- and national-level Ministry of Health officials were championing the intervention. While documented evidence on intervention effectiveness was limited, district- and national-level stakeholders seemed to be convinced of the value of the intervention. This was based on its observed positive results regarding management competencies, teamwork and specific aspects of health workforce performance and service delivery. The perceived need for strengthening of management capacity and service delivery showed the relevance of the intervention, and relative advantages of the intervention were its participatory and sustainable nature. Turnover within the DHMTs and limited (initial) management capacity were factors complicating implementation. The intervention was not contested and was seen as compatible with (policy) priorities at the national level. Conclusion We conclude that the MSI is scalable. However, to enhance its scalability, certain aspects should be adapted to better fit the context in which the intervention is being scaled up. Greater involvement of regional and national actors alongside improved documentation of results of the intervention can facilitate scale-up. Continuous assessment of the scalability of the intervention with all stakeholders involved is necessary, as context, stakeholders and priorities may change. Therefore, adaptations of the intervention might be required. The assessment of scalability, preferably as part of the monitoring of a scale-up strategy, enables critical reflections on next steps to make the intervention more scalable and the scale-up more successful.

How capacity building of district health managers has been designed, delivered and evaluated in sub-Saharan Africa: a scoping review and best fit framework analysis

“…The emergent approach entails a dynamic, flexible or adaptable process that emerges from stakeholders’ interactions. We found that most CBP approaches were prescribed and collective,4 9 19 47 67 70 72 75–79 81 84 85 87 89–93 95–100 103 105 and prescribed and individual 17 68 69 71 73 80 82 83 86 94 101 102. The emergent and collective approach was marginal9 49 (figure 4).…”

“…Weak leadership and/or management were considered the major causes of poor health outcomes in low-income and middle-income countries 4 6 19 49 67–88. Frequently mentioned causes of weak leadership and/or management capacity were (1) inadequate professional profiles of health managers (often being clinicians without formal training on leadership and management)17 73 75 81 89 90 and (2) inadequate efficacy of leadership and management courses (usually classroom-based and knowledge-focused instead of practice-based and providing know-how to deal with real-life situations) 47 68 69 73 74…”

“…The CBPs were supposed to trigger health team members’ self-confidence to undertake good leadership and/or management practices which would, in turn, activate their job satisfaction, motivation and sense of ownership 68 91 93. The good management practices reported included: effective and efficient use of resources,70 83 86 92 priority setting and better planning,17 70 78 86 87 92 use of data for decision making,17 87 92 supervision of health workers,17 70 86 91 93 ensuring monitoring and evaluation,81 86 94 teamwork and regular meetings 17 49 70 89. The good leadership practices reported included creating a positive work climate,4 17 83 84 and relationship building among stakeholders 9 82…”

“…Thirty-seven articles outlined the objectives or expected outcomes of the programme. Analysis shows that they all refer to the improvement of either the management knowledge, skills and practices of DHMs4 17 49 68–73 75–77 81 82 84–87 89 95–97 or the leadership and management knowledge, skills and practices4 17 47 77 82–84 as the main outputs. The outcomes expected from these main outputs were the increase of health service access and coverage,77 78 93 97 the improvement of the (quality and equity of) health service delivery,47 67 75 80 83 84 89 93 96 98 99 the improvement of maternal and child health outcomes 72 75 76 78 87 97…”

How to scale-up: a comparative case study of scaling up a district health management strengthening intervention in Ghana, Malawi and Uganda

“…In this last element, the different elements of the framework come together, as the scale-up strategy should contain strategic choices concerning dissemination and advocacy, organizational processes, cost and resource mobilization, and monitoring and evaluation. In the context of PERFORM2Scale, the innovation is the management strengthening intervention, which proved to be a scalable intervention based on an assessment of the scalability of the intervention [ 10 ]. The user organization in Uganda is the Ministry of Health (MoH), in Malawi it is the MoH and the Ministry of Local Government, and in Ghana it is the MoH and the Ghana Health Service.…”