How Does District Health Management Emerge Within a Complex Health System? Insights for Capacity Strengthening in Ghana

Abstract

Introduction: District health managers (DHMs) play a pivotal role in the operation of district health systems in low—and middle income countries, including Ghana. Their capacity is determined by their competencies, but also by the organization and system in which they are embedded. The objective of this paper is to explore how district health management emerges from contextual, organizational, and individual factors in order to demonstrate that capacity strengthening efforts at district level need to transcend individual competencies to take on more systemic approaches. Methods: Semi-structured interviews ( n = 21) were conducted to gain insight into aspects that affect district health management in the Eastern Region of Ghana. Interviews were conducted with DHMs ( n = 15) from six different districts, as well as with their superiors at the regional level ( n = 4) and peers from non-governmental organizations ( n = 2). A thematic analysis was conducted by using an analytical approach based on systems theory. Results: Contextual aspects, such as priorities among elected officials, poor infrastructure and working conditions, centralized decision-making, delayed disbursement of funds and staff shortages, affect organizational processes and the way DHMs carry out their role. Enabling organizational aspects that provide DHMs with direction and a clear perception of their role, include positive team dynamics, good relations with supervisors, job descriptions, appraisals, information systems, policies and guidelines. Meanwhile, hierarchical organizational structures, agendas driven by vertical programs and limited opportunities for professional development provide DHMs with limited authority to make decisions and dampens their motivation. The DHMs ability to carry out their role effectively depends on their perception of their role and the effort they expend, in addition to their competencies. In regards to competencies, a need for more general management and leadership skills were called for by DHMs as well as by their superiors and peers. Conclusion: Systemic approaches are called for in order to strengthen district health management capacity. This study can provide national policy-makers, donors and researchers with a deeper understanding of factors that should be taken into consideration when developing, planning, implementing, and assessing capacity-building strategies targeted at strengthening district health management.

Acceptability and feasibility of inter-related activities to improve agency among African district health managers: A four-country study

“…This coincides with what others have argued: that management skills such as strategic problem-solving, human resource management, financial management and operations management are fundamental to health system strengthening (Fetene et al, 2019). Moreover, improved management arises through a complex interplay of factors at different levels, as complex adaptive systems, rather than from building individual skills and technical capacity alone (Heerdegen et al, 2020;Kwamie et al, 2014). Yet many health professionals take on management positions without any prior management training and may get further training after appointment to improve their credibility (Loh, 2015).…”

“…We argue that the same applies in Africa and that agencythe ability and willingness to act on issues they feel are importantamong DHMs is an important ingredient in managers' ability to effect change, implement innovations and improve quality. Along with other authors, we also stress that contextual factors, political, social and economic, in addition to individual managers' knowledge and skills, are important in understanding the limitations that DHMs experience in LMICs (Heerdegen et al, 2020). Research has shown that decentralisation fails unless DHMs are given the power they need to deal with their challenges (Aberese-Ako et al, 2018).…”

INVESTMENT CASE & EQUITY: A QUASI-EXPERIMENTAL ANALYSIS OF MATERNAL & CHILD HEALTHCARE SERVICES IN PUNJAB

“…The current Pakistan NMN 2007 (Viswanath & Kreuter, 2007) recognizes these inequalities and strives to ensure care for disadvantaged and vulnerable groups (Bhutta et al, 2013). To date, policies and practical measures continue to be "more equal," with a significant focus on enhancing district healthcare organizations through optimized technology and managerial ability and creating a new community skilled workers Structure (Heerdegen et al, 2020). However, efforts were made to increase demand for maternal health care using targeted, socially acceptable communications strategies in government (Fotso et al, 2015).…”

Transforming capacity-strengthening in an era of sustainable development

“…Many district management strengthening interventions focus on strengthening the DHMs' individual competency through formal learning, e.g., classroom training (Martineau et al 2018). Improving the skills, knowledge, and attitudes of DHMs increases their ability to carry out their job, but their performance also depends on the environment in which they operate (Heerdegen et al 2020b). In Ghana, for example, DHMs face resource uncertainty (human, material and financial), have limited decision-making authority, and operate under budgetary restrictions in challenging working conditions (Heerdegen et al 2020b).…”

“…Improving the skills, knowledge, and attitudes of DHMs increases their ability to carry out their job, but their performance also depends on the environment in which they operate (Heerdegen et al 2020b). In Ghana, for example, DHMs face resource uncertainty (human, material and financial), have limited decision-making authority, and operate under budgetary restrictions in challenging working conditions (Heerdegen et al 2020b). No matter how competent the DHMs are, these factors affect their ability to carry out responsibilities and limits their opportunity to be innovative and agile in responding to district health needs (Heerdegen et al 2020b).…”