Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Factors influencing the work efficiency of district health managers in low-resource settings: a qualitative study in Ghana

Factors influencing the work efficiency of district health managers in low-resource settings: a... Background: There is increasing evidence that good district management practices can improve health system performance and conversely, that poor and inefficient management practices have detrimental effects. The aim of the present study was to identify factors contributing to inefficient management practices of district health managers and ways to improve their overall efficiency. Methods: Nineteen semi-structured interviews were conducted with district health managers in three districts of the Eastern Region in Ghana. The 19 interviews conducted comprised 90 % of the managerial workforce in these districts in 2013. A thematic analysis was carried out using the WHO’s leadership and management strengthening framework to structure the results. Results: Key factors for inefficient district health management practices were identified to be: human resource shortages, inadequate planning and communication skills, financial constraints, and a narrow decision space that constrains the authority of district health managers and their ability to influence decision-making. Strategies that may improve managerial efficiency at both an individual and organizational level included improvements to planning, communication, and time management skills, and ensuring the timely release of district funds. Conclusions: Filling District Health Management Team vacancies, developing leadership and management skills of district health managers, ensuring a better flow of district funds, and delegating more authority to the districts seems to be a promising intervention package, which may result in better and more efficient management practices and stronger health system performance. Keywords: District health managers, Management, Efficiency, Health system, Decentralisation, Decision space, Ghana, Sub-Saharan Africa Background with lower patient mortality, higher institutional income, There is increasing evidence that good management greater levels of patient satisfaction, and thus higher practices can improve health system performance [1]. overall performance [1, 3, 4]. According to the World Health Organization (WHO) As in other district health systems in low- and middle- [2] managers conduct good management practices when income countries (LMICs), district health managers in they “provide direction to and gain commitment from Ghana form the link between the strategic levels (na- partners and staff, facilitate change and achieve better tional and regional levels) and operational levels (district health services through efficient, creative and respon- and sub-district levels), and are responsible for managing sible deployment of people and other resources”. Studies all areas of health service delivery at the district and indicate that good management practices are associated sub-district levels [5]. They are organised into District Health Management Teams (DHMTs) and members of * Correspondence: [email protected] the teams are composed of administrative, technical and Swiss Centre for International Health, Swiss Tropical and Public Health operational managers. The work places of DHMTs are Institute, Socinstrasse 57, Basel 4002, Switzerland the District Health Administrations (DHAs), which are University of Basel, Basel, Switzerland Full list of author information is available at the end of the article © 2016 Bonenberger et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Bonenberger et al. BMC Health Services Research (2016) 16:12 Page 2 of 10 located in every district in Ghana. DHAs report to, and management of stocks and assets (e.g. drugs, buildings, are supervised by, their respective Regional Health Ad- vehicles, and equipment). Fourth, there must be an enab- ministration (RHA), which is in turn accountable to the ling work environment with regards to roles and responsi- central administration at national level. bilities, supervision and incentives, organisational context In countries which have implemented health sector and rules, as well as the broad cultural, political and eco- decentralisation policies, district health managers often nomic context. The framework suggests that strengthen- have a so-called broadened “decision space” [6], which ing these dimensions can result in more effective health refers to the effective range of choice within the various systems and services through an improved and more effi- functions of the health system such as financing, service cient management (Fig. 1). delivery, human resources (HR), and governance. In This study was carried out within the framework of Ghana, decentralisation was initiated following the PERFORM, a HRM intervention program, which aims at Ghana Health Service (GHS) and Teaching Hospital Act identifying ways of strengthening decentralized district (Act 525) in 1996, which involved de-concentration of management to improve health workforce performance authority to the RHAs and DHAs in the country [6, 7]. in sub-Saharan Africa [17]. The aim of the present study Benefits of decentralisation identified in various countries was to identify factors contributing to inefficient man- include higher regional and local authority, accountability, agement practices of district health managers, coping improved implementation of health care strategies based strategies to alleviate such factors, and ways to improve on need, greater efficiency, and increased responsiveness overall efficiency of district level managers. to community requirements [8–11]. However, health care decentralisation has also been associated with negative ef- Methods fects, such as the delayed transfer of funds from national Study setting government, lack of technical capacity of local govern- The study was conducted in the Eastern Region of ments, and inequity [12–15]. Ghana in the Akwapim North, Upper Manya Krobo and The WHO’s [16] leadership and management strength- Kwahu West districts. These districts were selected by ening framework proposes that for good and efficient the PERFORM country research team in close consult- management at the operational level, there has to be a bal- ation with the regional authorities of the Ghana Health ance between four dimensions. First, there needs to be an Service on the basis of their performance, and interest to adequate number of trained managers. Second, managers take part. Performance of the districts was rated based need to have appropriate competencies, such as know- on information from the national health league table ledge, skills, attitudes and behaviours. Third, critical sup- according to which the 16 districts of the region were port systems must be functional and accessible to classified into good, moderate and poor performers. managers. Such support systems include planning, finan- Eleven districts expressed an interest to participate. The cial management, information system for decision- final selection was for Kwahu West (well performing), making, human resource management (HRM), and Akwapim North (moderately performing), and Upper Fig. 1 Leadership and management strengthening framework. Adapted from WHO [16] Bonenberger et al. BMC Health Services Research (2016) 16:12 Page 3 of 10 Manya Krobo (poorly performing) [18]. While Akwapim usually are not found at sub-district level and hence are North and Kwahu West can be classified as rural and substituted by medical assistants (Table 1). semi-urban respectively, Upper Manya Krobo is predom- CHPS is a primary health care programme in inantly rural and belongs to one of the least developed Ghana, which was pilot-tested in the early 1990s and districts in the region. It is with this context in mind then rolled-out as a national policy from the late that its classification as a poorly performing district 1990s onwards in order to increase health service should be understood [19]. accessibility of people living in rural and remote areas At the time of the study in 2013, there were 21 DHMT [20, 21]. CHPS facilities are managed by CHNs who members working in the districts of which eight were in provide mobile doorstep health services to community Akwapim North, seven in Upper Manya Krobo, and six residents. in Kwahu West. According to baseline data collected for PERFORM, the DHMTs were responsible for 22 health Data collection centres and 37 Community-based Health Planning and All district health managers working in the study dis- Services (CHPS) facilities at sub-district level, with the tricts were asked to take part in the study. A semi- highest number of health facilities located in Kwahu structured guide was developed and used for the inter- West. Although all districts have a hospital, these have views [see Additional file 1]. The guide was divided into their own administrations and are thus not managed by the following thematic areas: usual work activities, DHMTs. The total population living in the catchment causes of inefficient district health management prac- areas of the health facilities in the three study districts tices, strategies to cope with such factors, and possible summed up to 317,989 people. Akwapim North had ways to improve efficiency. Efficiency was thereby de- with 142,275 people the greatest catchment population fined as the ability to produce management outputs by and Upper Manya Krobo with 78,158 people the smal- making an optimal use of resources, including time [22]. lest. All three DHMTs managed a total number of 291 All interviews were conducted by the lead author from health workers of which the DHMT in Akwapim North August to September 2013. Respondents were contacted managed with 140 workers (48.1 %) the highest number. by phone and the study explained. If the respondents Community Health Nurses (CHN) at the district level were willing to take part an appointment was scheduled. form the largest health workforce and the administrative The interviews were carried out in the offices of the re- workforce constitutes the lowest workforce. Due to the spective managers. All interviews were conducted in low numbers of trained doctors, doctors in Ghana English and taped with a digital audio recorder. In total, Table 1 Key characteristics of the three study districts in Ghana District Total Akwapim North Upper Manya Krobo Kwahu West Number of district health managers 21 8 7 6 Health services 59 22 11 26 Health centres 22 (37.3 %) 9 (40.9 %) 5 (45.5 %) 8 (30.8 %) CHPS facilities 37 (62.7 %) 13 (59.1 %) 6 (54.5 %) 18 (69.2 %) Health workers 291 140 72 79 Medical assistants 8 (2.7 %) 5 (3.6 %) 2 (2.8 %) 1 (1.3 %) Midwives 35 (12.2 %) 22 (15.7 %) 4 (5.6 %) 9 (11.4 %) Auxiliary nurses 21 (7.2 %) 11 (7.9 %) 5 (6.9 %) 5 (6.3 %) Community health nurses 152 (52.2 %) 48 (34.3 %) 52 (72.2 %) 52 (65.8 %) Health care assistants 9 (3.1 %) 8 (5.7 %) 1 (1.4 %) 0 (0 %) Technical staff 23 (7.9 %) 12 (8.6 %) 4 (5.6 %) 7 (8.9 %) Administrative staff 1 (0.3 %) 1 (0.7 %) 0 (0 %) 0 (0 %) Orderlies 35 (12.0 %) 27 (19.3 %) 3 (4.2 %) 5 (6.3 %) Support workers 7 (2.4 %) 6 (4.3 %) 1 (1.4 %) 0 (0 %) Population in catchment areas 317,989 142,275 78,158 97,556 In Ghana, other essential professions such as medical doctors and enrolled nurses usually do not work in sub-district facilities and are thus not represented in the statistics CHPS: Community-based health planning and services Bonenberger et al. BMC Health Services Research (2016) 16:12 Page 4 of 10 19 interviews were conducted with district health the study, for which no particular written consent form managers comprising 90 % of the managerial work- was necessary, as they already had provided a general con- forceof thestudydistricts at thetime ofthedata sent for PERFORM. All personal data were anonymised collection in 2013. prior to the analysis. Data analysis Results All interview tapes were transcribed verbatim and a the- Adequate number of managers matic framework method analysis conducted [23]. We As shown in Table 2, all DHAs had vacancies of essential used QSR NVivo version 10 for the analysis. The tran- DHMT personnel. Nine positions were not filled at the scripts were repeatedly read in order to familiarise with time of the study. According to this distribution, a health the data. The four dimensions from the WHO leader- services administrator and a health promotion officer ship and management strengthening framework [16] were available in only one district, and a nutrition officer were used as the main themes of the analytical frame- and a supply officer in two districts. None of the study work, each being subdivided into the categories “con- districts had a HR officer. Respondents emphasised that straints”, “coping strategies”, and “measures to improve the DHAs had repeatedly sent letters to the RHA of the efficiency”. Sub-categories were identified in the tran- Eastern Region requesting for staff to fill their vacancies. scripts through the use of codes as a way of labelling im- By the end of the data collection period, the RHA had portant passages. Interrelated or similar codes were not been in the position to fill any of the DHMT staff grouped together into different sub-categories. The ana- vacancies in the districts. This was likely a result of an lytical framework was applied by indexing all transcripts embargo of new employments for all non-clinical gov- using themes, categories and identified sub-categories. ernmental health workers that was introduced by the Contents of categories and its sub-categories were then Government of Ghana in 2010 in order to reduce the summarised in analytical memos. burden of salary costs within overall governmental ex- penditures [24, 25]. Ethical considerations Due to these HR shortages district health managers As PERFORM is coordinated by the Liverpool School of were required to take over additional tasks on top of Tropical Medicine (LSTM), ethical clearance for the their own duties, which represented a major constraint whole study was obtained from the Research Ethics for most of the respondents, particularly because many Committee of LSTM (ID No.: 12.09). For the present of these tasks such as buying, managing and issuing study additional ethical clearance was obtained from the drugs, where highly time consuming, thereby increasing Ghana Health Service Ethical Review Committee (ID the already high workload. Moreover, many respon- No.: GHS-ERC: 13/05/12). Before the start of the data dents emphasised that staff capacity in each DHA collection we received written clearance from the Eastern department was insufficient, with only one person Regional Health Administration, Koforidua, Ghana. Par- available per job category in most cases. District health ticipants gave verbal informed consent to participate in managers often stated, that the presence of a colleague Table 2 Availability of DHMT staff in the study districts and vacancies Profession Akwapim North Upper Manya Krobo Kwahu West Vacancies (n =8) (n =7) (n =6) (n =9) Administrative managers 2 1 1 2 District directors of health services 1 1 1 0 Administrators 1 0 0 2 Technical managers 4 4 4 3 Public health nurses 1 1 1 0 Disease control officers 1 1 1 0 Health information officers 1 1 1 0 Nutrition officers 0 1 1 1 Health promotion officers 1 0 0 2 Operational managers 2 2 1 4 Finance officers 1 1 1 0 Supply officers 1 1 0 1 Human resource officers 0 0 0 3 Bonenberger et al. BMC Health Services Research (2016) 16:12 Page 5 of 10 and/or assistant would be essential for completing their A similar strategy was to assign non-DHMT staff with work tasks in time. tasks of vacant DHMT positions, such as secretaries tak- ing over HR functions or those of health services adminis- “I am the only one person around [in the department]. trators. One district health manager also reported to have I am the only one doing basically everything. One trained a community health nurse from the sub-districts, person does everything is like one man thousand. I do who was now able to assist in data reporting and other the fieldwork and I do the administrative work. I think activities. I need a helping hand” (DHM #14). In order to alleviate HR constraints, the respondents frequently highlighted the need for the higher levels to “We used to be two, I used to have a boss to work ensure the availability of adequate human resources in with. […] But for now I’m alone, so I have to take care all DHAs so that essential DHMT positions, such as HR of the EPI, and to take care of the surveillance” officers, supply officers and health services administra- (DHM #17). tors do not remain vacant and that also a sufficient As delays were often a result of staff shortages, many number of assistants would be available in each depart- of the described coping strategies also relate to HR. As ment. It was argued that this would likely result in effi- usually not all DHMT members are invited to attend ciency gains through a reduction of workload allowing meetings and workshops at regional level, those who DHMT members to focus on their core duties. stay in the district often take over responsibilities of managers that have to attend. Task sharing was generally “We should have enough staff. That’s what I think a coping strategy for time-bound activities so that these should be, but that’s not the case. You have to double could be completed in time. up, do this, do that, a whole lot. If you are the health information officer your focus should be on health “At the DHA, because we are limited, the staffs are information, if you are the HR officer your focus not adequate. And because we are not enough, jobs should be on HR. If we had fixed personnel handling are shared among us. Like somebody can do some part those things, the work would be a bit smooth for us” of it for you so that you also do other things. So (DHM #16). whatever schedule you are put on you make sure you do it and do it well” (DHM #18). Appropriate competencies Many district health managers criticised that because Executive managers, commonly district directors of they were taking over tasks of vacant professional posi- health services and public health nurses, also reported tions, the quality of work outputs was affected, as they that they delegate some of their work tasks to subordin- were carrying out tasks for which they were not trained ate DHMT members when they were unable to for and for which they lacked the necessary skills and complete them. experience. For instance, in one district the health infor- Those respondents that performed double-functions mation officer was also responsible for HR management, due to HR shortages also stated that they prioritise their including maintaining the HR database, organising in- core duties, thereby neglecting additional duties. and out-transfers and promotions, and counselling of sub-district staff, although the person had not received “Last week, because of the measles immunisation training in these areas whatsoever. The concerned DHMT programme that we had, I couldn’t finish my monthly member stressed that this lack of training in HR manage- report [of routine health data]. So this week I have to ment resulted in mistakes, thereby affecting efficiency. finish with it. Meanwhile, we had an email that we have to update our staff list. By Monday we should “When we have new staff we have to send their details submit it, but I have to forgo that one and make sure I to Accra for input. When they are being promoted you finish with my core duty, which is the monthly report, have to send their details to Accra for it to be inputted and then tackle the other one later” (DHM #16). so that they get their salary. And because it is not my core duty, I do my best, but at times there are some All DHAs made use of national service personnel to corrections so that I have to come back [to the office] fill their vacancies. These are personnel who complete a and print and all those things […]. So I have to travel mandatory one year service to the country after graduat- back and forth until I get it right” (DHM #16). ing from accredited tertiary institutions [26]. It was re- ported that during the time of the interviews national In addition, insufficient planning, communication, and service personnel were carrying out work tasks in HR, time management skills were also frequently reported as supply, disease control, and were also used as accountants. the cause of inefficient management practices. Although Bonenberger et al. BMC Health Services Research (2016) 16:12 Page 6 of 10 DHMTs develop annual action plans at the beginning of substantially to inefficiencies. It was emphasised that regu- each year, district health managers reported difficulties larly the only funds available were those made available in working according to these and to translate plans into for vertical programme funds – such as for the Expanded weekly DHMT activities. Therefore, in order to achieve Programme on Immunisation (EPI) – or other donors. workflow gains at the district level it was stressed that There was however no flexibility in using these resources DHMTs should improve their planning skills, put a as they were earmarked for specific programmes. stronger emphasis on weekly planning, and develop indi- vidual work plans that are consistent with those of the “There are financial constraints here, because the DHA. government is not releasing funds to the DHAs. Formerly we were being given the SBS (Sector Budget “If we are able to work according to action plans it Support) and GoG (Government of Ghana) funds. But will help improve efficiency, because if you are able to for some time now we have not been receiving them. look at action planning, you know that this is what we Only programme funds, but you cannot use them for have for this week. Then you can also plan your own other things. So there are financial constraints, very activities in line with that. It will help” (DHM #12). serious ones. Now it is not only here. The problem is all over” (DHM #19). However, the importance of sharing individual plans during weekly DHMT meetings was also emphasised so that everyone in the DHA, including non-DHMT staffs, were aware of what colleagues had planned for the week. “We have severe funding constraints. We are not able Respondents argued that this would likely lead to im- to do monitoring and other facilitative supportive proved collaboration and to a reduction of duplicated visits that we want to do. For the whole year we have activities resulting from poor communication. done monitoring and supervision only in the first Respondents also stressed that efficiency gains could quarter. In the second quarter we could not do it. And be made by becoming more time conscious, as this this quarter we are also not able to do it, because of a would likely result in the reduction of time spent on un- lack of funds for fuel to travel outside. The vehicle is productive activities, such as having lengthy private con- there, but funds for fuel are not” (DHM #5). versations with colleagues, sitting idly in the office, having extended breaks, and engaging in private activ- As funds were generally limited in the DHAs, district ities during duty hours. health managers reported making use of alternative funding sources to carry out planned activities. For in- Functional support systems stance, in contrast to governmental health funds, re- The efficiency of district health managers is dependent spondents stressed that funds for vertical programmes in part on how well critical support systems function. and from donors were usually released in time. As the District managers in Ghana have access to a broad range frequent inability to buy fuel prevented regular sub- of management systems, most importantly planning, fi- district visits for monitoring and supervision purposes, nance, information, HR, and procurement and distribu- district managers reported to use the opportunity to tion systems for drugs and other commodities. Responses conduct such activities when facilities were visited in the centred mainly on financial constraints, but problems re- frame of vertical programme or donor activities. How- garding other management systems such as HR, monitor- ever, such monitoring and supervision visits can be ing and transport were also mentioned as consequences of regarded as spot checks rather than a systematic visit of these constraints. Although it can be expected that prob- all facilities in the district. lems regarding other management support systems do Under rare circumstances, such as when money was also exist [16], these were not mentioned by any of the urgently needed to attend important national meetings respondents and thus might not be regarded as major or conferences, internally generated funds (IGFs) – reve- constraints. nues generated through the activities of sub-district Financial problems of the district and sub-district health facilities – were also used. In addition, district levels mainly result from the government not releasing health managers reported that they sometimes used their funds in time. These “cash flow” problems led to the in- private money to fund urgent activities, and were paid ability to do regular maintenance of vehicles and tech- back by the DHAs once money became available. nical equipment, buy fuel, and ensure the supply of essential office materials. Such problems, in turn, were “What we have been doing here is that at times we main barriers preventing district health managers to im- pre-finance some programmes. Like if you want to do plement planned activities in time and thus contributed supportive supervision and we see that it is very Bonenberger et al. BMC Health Services Research (2016) 16:12 Page 7 of 10 important for us to do that to correct some things “What happens is that, if nothing comes from the immediately, if there is no fuel in the vehicle we region, if no programmes come from the regional level, normally buy by ourselves and then bring the receipt whatever I have planned I will do it within the week. so that when there is money then they refund it” I’m able to do it” (DHM #17). (DHM #2). It was emphasised that particularly the RHA often sent When funds become available, it was reported that invitations for meetings and workshops at very short no- these were often not sufficient to conduct all activities as tice, although respondents admitted that information planned, such as visiting all sub-district facilities for practices of the RHA had recently improved. In addition, monitoring and supervision. In such instances, a certain district health managers complained that workshops number of health facilities are selected purposefully, for were often held over several days with participation be- example only health centres and CHPS facilities in one ing mandatory. Such workshops frequently interfered or two sub-districts. The remaining facilities in other with time-bound activities at district level. sub-districts are then visited at a later stage when the opportunity arises. “You know, you plan your week. You know this week Most district health managers stressed that the na- you are going to do ABCD. And then a letter will come tional level must ensure an adequate flow of public from theregion, you haveoneweek workshop, you health funds so that health activities could be carried have to stop whatever you are doing and then go” out in time, thereby improving DHMT efficiency. (DHM #11). “I think that basically it is funds. I think if we had the Due to the frequent interruptions through unplanned funds we could do things at the right time, but because activities time-bound activities were regularly at risk of we don’t have funds some of the things are just there. not being completed in time. As a result, almost all dis- We cannot do anything” (DHM #9). trict health managers stated that they were usually work- “If the [financial] resources would come on time for ing overtime, and sometimes also on weekends in order you to work with, it would help us. But the funds are to meet their deadlines. Some respondents also reported not coming on time and then when it comes we have that they were regularly working in the evening hours limited time to finish with it” (DHM #18). after workshops so as to complete activities in time. Many district health managers stressed that the higher Enabling environment levels should improve their planning and communica- Factors critical for good and efficient management in- tion concerning the district level, which particularly re- clude policies, legislation, norms and standards, which ferred to meetings and workshops, but generally to all support the appropriate delegation of authority; ad- activities that directly affected the districts. Although na- equate support for managers, especially regarding access tional annual plans exist and were widely distributed to information, communication, and supervision; finan- within the GHS, it was emphasised that these plans only cial and non-financial incentives for good management; included national celebrations, health weeks and some and accountability [27]. Despite this broad range of pos- management meetings. District health managers, there- sible topics concerning the work environment, district fore, frequently stressed that both the national and the health managers primarily regarded inadequate planning regional levels should inform regularly and more timely and communication of the higher health system levels as on all upcoming activities so that DHMTs could incorp- a constraint for efficient district management. orate these in their work plans. Because decisions of the higher levels generally super- sede those of the district level, demands from these “So they should give us a work plan: these are the levels have higher priorities than all activities routinely meetings and workshops we are going to hold and this conducted by district health managers. A high share of is the time we will be holding them, these are the the activities conducted by district health managers is personnel that will be involved […]. But they let us do usually required by the national and regional administra- our plans and they also do their own and they are tions leaving little room for them to focus on district interfering left and right. They are our biggest specific activities. problem” (DHM #15). Most respondents complained that the higher levels regularly informed them about upcoming activities at very In order to ensure that meetings and workshops did short notice so that these activities are difficult to incorp- not interfere so frequently with activities at district level orate in their work schedules. As such, they interrupted it was recommended that the higher levels should better their plans and resulted in implementation delays. coordinate such events, for instance by involving the Bonenberger et al. BMC Health Services Research (2016) 16:12 Page 8 of 10 DHAs in the planning process or at least by considering This, however, indicates that DHMT members may not district work plans. use their work time efficiently and that gains can be achieved without additional resources through proper Discussion time management and training. Our findings indicate that there are limitations in all Several factors affecting efficiency as proposed by the four dimensions of the WHO’s leadership and manage- WHO’s leadership and management strengthening ment strengthening framework. All study DHAs had HR framework [16] were not identified by respondents. Such shortages, as essential DHMT positions such as HR offi- factors include inadequate access to supportive supervi- cers and health services administrators were vacant and sion and appraisals, HR management systems, collabor- thus the number of district health managers was inad- ation with other stakeholders at district level, and equate. Our findings also suggest that planning as well incentives for good performance. Although district as communication of district managers are both inad- health managers in the study districts may not perceive equate and, therefore, managers lack appropriate compe- these factors as primarily constraining their efficiency, tencies in these areas. That several of the critical support research conducted in other LMICs suggests that such systems, especially the finance management system, are factors may indeed affect managerial efficiency [27, 31]. inadequate is a further, major finding of this study. Also Common strategies of district health managers to cope the narrow decision-space of district health managers in with the untimely release of funds are to carry out rou- Ghana does not seem to provide an enabling working en- tine activities while on duty for vertical programs or do- vironment to solve district specific problems. nors, to borrow IGFs from sub-district health facilities, DHMT members foremost identified difficulties in fi- or to use private cash to advance funds for DHMT activ- nancial management processes as a determinant elem- ities. Such strategies confirm those reported in a study ent. Financial constraints are indeed well-known to conducted by Asante et al. [13] in Ghana. Regarding the many health systems in LMICs [28] and were identified other strategies described in this study, some are them- as main barriers to efficient district health management selves a source of inefficient district management. For also in this study. Abekah-Nkrumah et al. [29] have instance, while prioritising core duties increases effi- shown in a review of the budgetary process in the Ghan- ciency of such activities, additional duties are neglected aian health sector that although channels for disbursing at the same time, thereby affecting efficiency. Also mak- administrative funds are smooth, disbursements are er- ing use of unqualified staff to carry out DHMT work ratic due to challenges with cash flow. In addition, cum- tasks may improve efficiency in some work areas due to bersome central procedures for approval of local budgets the greater number of workers, but may simultaneously and a lack of administrative capacity at the national level decrease efficiency in other areas through mistakes regularly result in delayed approvals of district funds [29, resulting from a lack of appropriate training and skills. 30]. That this untimely release of administrative funds dis- Moreover, using unqualified staff to carry out qualified rupts the implementation of DHMT activities is also a work is also likely to have negative effects on the quality major finding in another study from Ghana [13]. Besides of work outputs. financial constraints, HR shortages in the DHAs, inad- It is generally assumed that managers are more effi- equate planning skills of district health managers, and cient in decentralised health systems, given that they poor planning and communication of upcoming activities have better control over resources and activities and are from the higher levels are also identified as key factors for in a better position to plan and prioritise as compared to inefficient district management practices. These findings managers in centrally managed health systems [22, 32]. are supported by quantitative data we reported in a previ- Very limited financial resources are generated at district ous article on DHMT time use practices, which showed level and these can be administered by district managers. that great shares of managers’ capacities are used for only However, most of these resources are made available to few district activities by at the same time neglecting other local managers by the national and the regional adminis- important activities, which we attributed mainly to HR tration [6, 19] and here the district managers have only shortages in the DHAs as well as insufficient planning and little control. In addition, studies also emphasised the coordination by the higher health system levels [18]. low decision-making authority of Ghana’s district health District health managers reported that DHMTs spend managers [5, 6, 33], which was attributed to the colonial time on unproductive activities such as having lengthy organisation structure inherent in the modern health private conversations with colleagues and extended system encouraging a centralised hierarchical adminis- breaks. Although managers attributed these activities to tration culture with little involvement of the district level fellow DHMT members and never to themselves, such in planning and implementation of health services [34]. statements are at odds with the frequent requirement to In our study, we identify both issues – low control over work overtime and on weekends due to high workloads. resources coupled with little authority over district Bonenberger et al. BMC Health Services Research (2016) 16:12 Page 9 of 10 activities – as major factors for inefficient district man- Additional file agement. Our findings thus confirm the rather narrow Additional file 1: Interview guide. (DOCX 35 kb) decision space attributed to district health managers by studies carried out in Ghana in recent years [5, 6]. Abbreviations This study has limitations. As the focus is only on CHN: Community health nurse; CHPS: Community-based Health Planning district health managers in three districts, perceptions and Services; DDHS: District director of health services; DHA: District Health concerning these districts may not be generalizable for Administration; DHM: District health manager; DHMT: District health management team; EPI: Expanded Programme on Immunisation; GHS: Ghana all areas in the country. However, given their broader Health Service; HR: Human resources; HRM: Human resource management; administrative responsibilities, findings regarding the HS: Health system; IGF: Internally generated funds; LMICs: Low- and middle- higher health system levels are likely to also prevail in income countries; RHA: Regional Health Administration; WHO: World Health Organisation. other areas. Moreover, the issues emerging from the data reveal relationships significant for management Competing interests strengthening in LMICs and are thus relevant for re- The authors declare that they have no competing interests. searchers, donors and policy makers. Although the Authors’ contributions three DHAs included in this study differ in terms of MB designed and implemented the study, conducted and transcribed the factors such as DHMT composition, distance to the interviews, performed the analysis, and drafted the manuscript. MA and PA regional and national administrations, and socio- participated in the design of the study, contributed to its implementation, and commented on draft versions of the manuscript. KW participated in the economic status of the districts, we pooled all data and, design of the study and contributed to the writing and revising of the by doing so, may have masked discrepancies between manuscript. All authors read and approved the final manuscript. the districts that could have been revealed through a Acknowledgements stratified analysis. We also recognise the limitation of We thank all district health managers who have made available their not having explored the perceptions from regional and precious time and responded to our questions and gratefully acknowledge national health managers, health workers as well as the support from the Eastern Regional Health Administration, Koforidua, Ghana. We also thank Martina Bonenberger (University of Lucerne, Lucerne, from patients and health service users concerning Switzerland) for her participation in the data collection. We are grateful to DHMT efficiency. Such triangulation might have added Helen Prytherch (Swiss TPH, Basel, Switzerland) for her valuable comments different perspectives. and suggestions on draft versions of the manuscript. This study was funded by the European Commission’s Seventh Framework programme (FP7 Theme Health: 2010.3.4-1, grant agreement number 266334). MB received additional funds for fieldwork from the Freiwillige Akademische Gesellschaft (FAG) Conclusions Basel, Switzerland. This financial support is highly acknowledged. This study has shown that inefficient district health Author details management is mainly a result of HR shortages at the Swiss Centre for International Health, Swiss Tropical and Public Health DHAs, inadequate planning and communication skills of Institute, Socinstrasse 57, Basel 4002, Switzerland. University of Basel, Basel, Switzerland. School of Public Health, University of Ghana, Legon, Ghana. district health managers, financial constraints, and a nar- row decision space giving district managers little author- Received: 10 June 2015 Accepted: 12 January 2016 ity over activities. The findings thus suggest limitations in all four dimensions of the WHO’s leadership and References management strengthening framework. As these are 1. Lega F, Prenestini A, Spurgeon P. Is management essential to improving the closely interrelated, efforts to strengthen management at performance and sustainability of health care systems and organizations? district level are unlikely to succeed when these are not A systematic review and a roadmap for future studies. Value Health. 2013;16:S46–51. tackled at the same time. It is, therefore, not sufficient to 2. World Health Organization. Strengthening management in low-income just carry out interventions at the district level by im- countries, Making health systems work: working paper no 1. Geneva: World proving management skills of district health managers Health Organization; 2005. 3. West MA, Borrill C, Dawson J, Scully J, Carter M, Anelay S, et al. The link or increasing their number. Although developing man- between the management of employees and patient mortality in acute agement skills of district health managers is undoubtedly hospitals. Int J Hum Resour Manag. 2002;13:1299–310. important, our findings strongly suggest that the wider 4. Dorgan S, Layton D, Bloom N, Homkes R, Sadun R, Van Reenen J. Management in healthcare: why good practice really matters. London: health system must also be considered in order to McKinsey & Company and London School of Economics and Political achieve better management efficiency. Filling vacancies Science; 2010. of DHMT members in all districts, developing leader- 5. Kwamie A, van Dijk H, Agyepong IA. Advancing the application of systems thinking in health: realist evaluation of the Leadership Development ship and management skills of district health managers, Programme for district manager decision-making in Ghana. Health Res ensuring a better flow of district funds, and delegating Policy Syst. 2014;12:29. more authority to the districts seems to be a promising 6. Bossert TJ, Beauvais JC. Decentralization of health systems in Ghana, Zambia, Uganda and the Philippines: a comparative analysis of decision intervention package, which may result in improved and space. Health Policy Plan. 2002;17:14–31. more efficient management practices and stronger health 7. Ayee J, Dickovick JT. Comparative Assessment of Decentralization in Africa: system performance. Ghana Desk Study. Washington, DC: USAID; 2010. Bonenberger et al. BMC Health Services Research (2016) 16:12 Page 10 of 10 8. Bergman SE. Swedish models of health care reform: A review and 31. World Health Organization. Strengthening Management in Low-Income assessment. Int J Health Plann Manag. 1998;13:91–106. Countries: Lessons from Uganda, Making health systems work: working 9. Jervis P, Plowden W. The impact of political devolution on the UK’s health paper no 11. Geneva: World Health Organization; 2007. services: final report of a project to monitor the impact of devolution on 32. Conn CP, Jenkins P, Touray SO. Strengthening health management: experience the United Kingdom’s health services 1999–2002. London: The Nuffield of district teams in The Gambia. Health Policy Plan. 1996;11:64–71. Trust; 2003. 33. Kwamie A, Agyepong IA, van Dijk H. What Governs District Manager Decision Making? A Case Study of Complex Leadership in Dangme West 10. Jommi C, Fattore G. Regionalization and drugs cost-sharing in the Italian District, Ghana. Health Systems & Reform. 2015;1:167–77. NHS. Euro Observer. 2003;5:1–4. 34. Sakyi EK. A retrospective content analysis of studies on factors constraining 11. Frumence G, Nyamhanga T, Mwangu M, Hurtig AK. Participation in health the implementation of health sector reform in Ghana. Int J Health Plann planning in a decentralised health system: Experiences from facility Manage. 2008;23:259–85. governing committees in the Kongwa district of Tanzania. Glob Public Health. 2014;9:1125–38. 12. Kolehmainen-Aitken RL. Decentralization's impact on the health workforce: Perspectives of managers, workers and national leaders. Hum Resour Health. 2004;2:5. 13. Asante AD, Zwi AB, Ho MT. Getting by on credit: how district health managers in Ghana cope with the untimely release of funds. BMC Health Serv Res. 2006;6:105. 14. Saltman RB, Bankauskaite V, Vrangbæk K. Decentralization in Health Care. Strategies and Outcomes. London: Open University Press; 2007. 15. Abimbola S, Olanipekun T, Igbokwe U, Negin J, Jan S, Martiniuk A, et al. How decentralisation influences the retention of primary health care workers in rural Nigeria. Glob Health Action. 2015;8:26616. 16. World Health Organization. Towards better leadership and management in health: Report on an international consultation on strengthening leadership and management in low-income countries, Making health systems work: working paper no 10. Geneva: World Health Organization; 2007. 17. Mshelia C, Huss R, Mirzoev T, Elsey H, Baine SO, Aikins M, et al. Can action research strengthen district health management and improve health workforce performance? A research protocol. BMJ Open. 2013;3:e003625. 18. Bonenberger M, Aikins M, Akweongo P, Bosch-Capblanch X, Wyss K. What Do District Health Managers in Ghana Use Their Working Time for? A Case Study of Three Districts. PLoS One. 2015;10:e0130633. 19. Bonenberger M, Aikins M, Akweongo P, Wyss K. The effects of health worker motivation and job satisfaction on turnover intention in Ghana: a cross- sectional study. Hum Resour Health. 2014;12:43. 20. Nyonator FK, Awoonor-Williams JK, Phillips JF, Jones TC, Miller RA. The Ghana community-based health planning and services initiative for scaling up service delivery innovation. Health Policy Plan. 2005;20:25–34. 21. Binka FN, Bawah AA, Phillips JF, Hodgson A, Adjuik M, MacLeod B. Rapid achievement of the child survival millennium development goal: evidence from the Navrongo experiment in Northern Ghana. Trop Med Int Health. 2007;12:578–83. 22. Hurley J, Birch S, Eyles J. Geographically-decentralized planning and management in health care: some informational issues and their implications for efficiency. Soc Sci Med. 1995;41:3–11. 23. Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13:117. 24. Abbey EE. Government Places Embargo On Employment, Modern Ghana. Accra: Modern Ghana Media Communication Ltd; 2010. 25. Siewobr CL. Is There A Ban On Employment In Both The Ghana Education Service And The Ghana Health Service? Modern Ghana. Accra: Modern Ghana Media Communication Ltd.; 2015. 26. Frontani HG, Taylor LC. Development through civic service: the Peace Corps and national service programmes in Ghana. Prog Dev Stud. 2009;9:87–99. 27. World Health Organization. Managing the Health Millennium Development Submit your next manuscript to BioMed Central Goals - The Challenge of Health Management Strengthening: Lessons from Three Countries, Making health systems work: working paper no 8. Geneva: and we will help you at every step: World Health Organization; 2007. • We accept pre-submission inquiries 28. Travis P, Bennett S, Haines A, Pang T, Bhutta Z, Hyder AA, et al. Overcoming health-systems constraints to achieve the Millennium Development Goals. � Our selector tool helps you to find the most relevant journal Lancet. 2004;364:900–6. � We provide round the clock customer support 29. Abekah-Nkrumah G, Dinklo T, Abor J: Financing the Health Sector in Ghana: � Convenient online submission A Review of the Budgetary Process. European Journal of Economics, Finance and Administrative Sciences 2009;17:45–59 � Thorough peer review 30. Steffensen J, Trollegaard S. Fiscal Decentralisation and Sub-National � Inclusion in PubMed and all major indexing services Government Finance in Relation to Infrastructure and Service Provision: � Maximum visibility for your research Synthesis Report on 6 Sub-Saharan African Country Studies. Washington, DC: World Bank; 2000. Submit your manuscript at www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Health Services Research Springer Journals

Factors influencing the work efficiency of district health managers in low-resource settings: a qualitative study in Ghana

Loading next page...
 
/lp/springer-journals/factors-influencing-the-work-efficiency-of-district-health-managers-in-49LCd1cKEn

References (42)

Publisher
Springer Journals
Copyright
2016 Bonenberger et al.
eISSN
1472-6963
DOI
10.1186/s12913-016-1271-3
Publisher site
See Article on Publisher Site

Abstract

Background: There is increasing evidence that good district management practices can improve health system performance and conversely, that poor and inefficient management practices have detrimental effects. The aim of the present study was to identify factors contributing to inefficient management practices of district health managers and ways to improve their overall efficiency. Methods: Nineteen semi-structured interviews were conducted with district health managers in three districts of the Eastern Region in Ghana. The 19 interviews conducted comprised 90 % of the managerial workforce in these districts in 2013. A thematic analysis was carried out using the WHO’s leadership and management strengthening framework to structure the results. Results: Key factors for inefficient district health management practices were identified to be: human resource shortages, inadequate planning and communication skills, financial constraints, and a narrow decision space that constrains the authority of district health managers and their ability to influence decision-making. Strategies that may improve managerial efficiency at both an individual and organizational level included improvements to planning, communication, and time management skills, and ensuring the timely release of district funds. Conclusions: Filling District Health Management Team vacancies, developing leadership and management skills of district health managers, ensuring a better flow of district funds, and delegating more authority to the districts seems to be a promising intervention package, which may result in better and more efficient management practices and stronger health system performance. Keywords: District health managers, Management, Efficiency, Health system, Decentralisation, Decision space, Ghana, Sub-Saharan Africa Background with lower patient mortality, higher institutional income, There is increasing evidence that good management greater levels of patient satisfaction, and thus higher practices can improve health system performance [1]. overall performance [1, 3, 4]. According to the World Health Organization (WHO) As in other district health systems in low- and middle- [2] managers conduct good management practices when income countries (LMICs), district health managers in they “provide direction to and gain commitment from Ghana form the link between the strategic levels (na- partners and staff, facilitate change and achieve better tional and regional levels) and operational levels (district health services through efficient, creative and respon- and sub-district levels), and are responsible for managing sible deployment of people and other resources”. Studies all areas of health service delivery at the district and indicate that good management practices are associated sub-district levels [5]. They are organised into District Health Management Teams (DHMTs) and members of * Correspondence: [email protected] the teams are composed of administrative, technical and Swiss Centre for International Health, Swiss Tropical and Public Health operational managers. The work places of DHMTs are Institute, Socinstrasse 57, Basel 4002, Switzerland the District Health Administrations (DHAs), which are University of Basel, Basel, Switzerland Full list of author information is available at the end of the article © 2016 Bonenberger et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Bonenberger et al. BMC Health Services Research (2016) 16:12 Page 2 of 10 located in every district in Ghana. DHAs report to, and management of stocks and assets (e.g. drugs, buildings, are supervised by, their respective Regional Health Ad- vehicles, and equipment). Fourth, there must be an enab- ministration (RHA), which is in turn accountable to the ling work environment with regards to roles and responsi- central administration at national level. bilities, supervision and incentives, organisational context In countries which have implemented health sector and rules, as well as the broad cultural, political and eco- decentralisation policies, district health managers often nomic context. The framework suggests that strengthen- have a so-called broadened “decision space” [6], which ing these dimensions can result in more effective health refers to the effective range of choice within the various systems and services through an improved and more effi- functions of the health system such as financing, service cient management (Fig. 1). delivery, human resources (HR), and governance. In This study was carried out within the framework of Ghana, decentralisation was initiated following the PERFORM, a HRM intervention program, which aims at Ghana Health Service (GHS) and Teaching Hospital Act identifying ways of strengthening decentralized district (Act 525) in 1996, which involved de-concentration of management to improve health workforce performance authority to the RHAs and DHAs in the country [6, 7]. in sub-Saharan Africa [17]. The aim of the present study Benefits of decentralisation identified in various countries was to identify factors contributing to inefficient man- include higher regional and local authority, accountability, agement practices of district health managers, coping improved implementation of health care strategies based strategies to alleviate such factors, and ways to improve on need, greater efficiency, and increased responsiveness overall efficiency of district level managers. to community requirements [8–11]. However, health care decentralisation has also been associated with negative ef- Methods fects, such as the delayed transfer of funds from national Study setting government, lack of technical capacity of local govern- The study was conducted in the Eastern Region of ments, and inequity [12–15]. Ghana in the Akwapim North, Upper Manya Krobo and The WHO’s [16] leadership and management strength- Kwahu West districts. These districts were selected by ening framework proposes that for good and efficient the PERFORM country research team in close consult- management at the operational level, there has to be a bal- ation with the regional authorities of the Ghana Health ance between four dimensions. First, there needs to be an Service on the basis of their performance, and interest to adequate number of trained managers. Second, managers take part. Performance of the districts was rated based need to have appropriate competencies, such as know- on information from the national health league table ledge, skills, attitudes and behaviours. Third, critical sup- according to which the 16 districts of the region were port systems must be functional and accessible to classified into good, moderate and poor performers. managers. Such support systems include planning, finan- Eleven districts expressed an interest to participate. The cial management, information system for decision- final selection was for Kwahu West (well performing), making, human resource management (HRM), and Akwapim North (moderately performing), and Upper Fig. 1 Leadership and management strengthening framework. Adapted from WHO [16] Bonenberger et al. BMC Health Services Research (2016) 16:12 Page 3 of 10 Manya Krobo (poorly performing) [18]. While Akwapim usually are not found at sub-district level and hence are North and Kwahu West can be classified as rural and substituted by medical assistants (Table 1). semi-urban respectively, Upper Manya Krobo is predom- CHPS is a primary health care programme in inantly rural and belongs to one of the least developed Ghana, which was pilot-tested in the early 1990s and districts in the region. It is with this context in mind then rolled-out as a national policy from the late that its classification as a poorly performing district 1990s onwards in order to increase health service should be understood [19]. accessibility of people living in rural and remote areas At the time of the study in 2013, there were 21 DHMT [20, 21]. CHPS facilities are managed by CHNs who members working in the districts of which eight were in provide mobile doorstep health services to community Akwapim North, seven in Upper Manya Krobo, and six residents. in Kwahu West. According to baseline data collected for PERFORM, the DHMTs were responsible for 22 health Data collection centres and 37 Community-based Health Planning and All district health managers working in the study dis- Services (CHPS) facilities at sub-district level, with the tricts were asked to take part in the study. A semi- highest number of health facilities located in Kwahu structured guide was developed and used for the inter- West. Although all districts have a hospital, these have views [see Additional file 1]. The guide was divided into their own administrations and are thus not managed by the following thematic areas: usual work activities, DHMTs. The total population living in the catchment causes of inefficient district health management prac- areas of the health facilities in the three study districts tices, strategies to cope with such factors, and possible summed up to 317,989 people. Akwapim North had ways to improve efficiency. Efficiency was thereby de- with 142,275 people the greatest catchment population fined as the ability to produce management outputs by and Upper Manya Krobo with 78,158 people the smal- making an optimal use of resources, including time [22]. lest. All three DHMTs managed a total number of 291 All interviews were conducted by the lead author from health workers of which the DHMT in Akwapim North August to September 2013. Respondents were contacted managed with 140 workers (48.1 %) the highest number. by phone and the study explained. If the respondents Community Health Nurses (CHN) at the district level were willing to take part an appointment was scheduled. form the largest health workforce and the administrative The interviews were carried out in the offices of the re- workforce constitutes the lowest workforce. Due to the spective managers. All interviews were conducted in low numbers of trained doctors, doctors in Ghana English and taped with a digital audio recorder. In total, Table 1 Key characteristics of the three study districts in Ghana District Total Akwapim North Upper Manya Krobo Kwahu West Number of district health managers 21 8 7 6 Health services 59 22 11 26 Health centres 22 (37.3 %) 9 (40.9 %) 5 (45.5 %) 8 (30.8 %) CHPS facilities 37 (62.7 %) 13 (59.1 %) 6 (54.5 %) 18 (69.2 %) Health workers 291 140 72 79 Medical assistants 8 (2.7 %) 5 (3.6 %) 2 (2.8 %) 1 (1.3 %) Midwives 35 (12.2 %) 22 (15.7 %) 4 (5.6 %) 9 (11.4 %) Auxiliary nurses 21 (7.2 %) 11 (7.9 %) 5 (6.9 %) 5 (6.3 %) Community health nurses 152 (52.2 %) 48 (34.3 %) 52 (72.2 %) 52 (65.8 %) Health care assistants 9 (3.1 %) 8 (5.7 %) 1 (1.4 %) 0 (0 %) Technical staff 23 (7.9 %) 12 (8.6 %) 4 (5.6 %) 7 (8.9 %) Administrative staff 1 (0.3 %) 1 (0.7 %) 0 (0 %) 0 (0 %) Orderlies 35 (12.0 %) 27 (19.3 %) 3 (4.2 %) 5 (6.3 %) Support workers 7 (2.4 %) 6 (4.3 %) 1 (1.4 %) 0 (0 %) Population in catchment areas 317,989 142,275 78,158 97,556 In Ghana, other essential professions such as medical doctors and enrolled nurses usually do not work in sub-district facilities and are thus not represented in the statistics CHPS: Community-based health planning and services Bonenberger et al. BMC Health Services Research (2016) 16:12 Page 4 of 10 19 interviews were conducted with district health the study, for which no particular written consent form managers comprising 90 % of the managerial work- was necessary, as they already had provided a general con- forceof thestudydistricts at thetime ofthedata sent for PERFORM. All personal data were anonymised collection in 2013. prior to the analysis. Data analysis Results All interview tapes were transcribed verbatim and a the- Adequate number of managers matic framework method analysis conducted [23]. We As shown in Table 2, all DHAs had vacancies of essential used QSR NVivo version 10 for the analysis. The tran- DHMT personnel. Nine positions were not filled at the scripts were repeatedly read in order to familiarise with time of the study. According to this distribution, a health the data. The four dimensions from the WHO leader- services administrator and a health promotion officer ship and management strengthening framework [16] were available in only one district, and a nutrition officer were used as the main themes of the analytical frame- and a supply officer in two districts. None of the study work, each being subdivided into the categories “con- districts had a HR officer. Respondents emphasised that straints”, “coping strategies”, and “measures to improve the DHAs had repeatedly sent letters to the RHA of the efficiency”. Sub-categories were identified in the tran- Eastern Region requesting for staff to fill their vacancies. scripts through the use of codes as a way of labelling im- By the end of the data collection period, the RHA had portant passages. Interrelated or similar codes were not been in the position to fill any of the DHMT staff grouped together into different sub-categories. The ana- vacancies in the districts. This was likely a result of an lytical framework was applied by indexing all transcripts embargo of new employments for all non-clinical gov- using themes, categories and identified sub-categories. ernmental health workers that was introduced by the Contents of categories and its sub-categories were then Government of Ghana in 2010 in order to reduce the summarised in analytical memos. burden of salary costs within overall governmental ex- penditures [24, 25]. Ethical considerations Due to these HR shortages district health managers As PERFORM is coordinated by the Liverpool School of were required to take over additional tasks on top of Tropical Medicine (LSTM), ethical clearance for the their own duties, which represented a major constraint whole study was obtained from the Research Ethics for most of the respondents, particularly because many Committee of LSTM (ID No.: 12.09). For the present of these tasks such as buying, managing and issuing study additional ethical clearance was obtained from the drugs, where highly time consuming, thereby increasing Ghana Health Service Ethical Review Committee (ID the already high workload. Moreover, many respon- No.: GHS-ERC: 13/05/12). Before the start of the data dents emphasised that staff capacity in each DHA collection we received written clearance from the Eastern department was insufficient, with only one person Regional Health Administration, Koforidua, Ghana. Par- available per job category in most cases. District health ticipants gave verbal informed consent to participate in managers often stated, that the presence of a colleague Table 2 Availability of DHMT staff in the study districts and vacancies Profession Akwapim North Upper Manya Krobo Kwahu West Vacancies (n =8) (n =7) (n =6) (n =9) Administrative managers 2 1 1 2 District directors of health services 1 1 1 0 Administrators 1 0 0 2 Technical managers 4 4 4 3 Public health nurses 1 1 1 0 Disease control officers 1 1 1 0 Health information officers 1 1 1 0 Nutrition officers 0 1 1 1 Health promotion officers 1 0 0 2 Operational managers 2 2 1 4 Finance officers 1 1 1 0 Supply officers 1 1 0 1 Human resource officers 0 0 0 3 Bonenberger et al. BMC Health Services Research (2016) 16:12 Page 5 of 10 and/or assistant would be essential for completing their A similar strategy was to assign non-DHMT staff with work tasks in time. tasks of vacant DHMT positions, such as secretaries tak- ing over HR functions or those of health services adminis- “I am the only one person around [in the department]. trators. One district health manager also reported to have I am the only one doing basically everything. One trained a community health nurse from the sub-districts, person does everything is like one man thousand. I do who was now able to assist in data reporting and other the fieldwork and I do the administrative work. I think activities. I need a helping hand” (DHM #14). In order to alleviate HR constraints, the respondents frequently highlighted the need for the higher levels to “We used to be two, I used to have a boss to work ensure the availability of adequate human resources in with. […] But for now I’m alone, so I have to take care all DHAs so that essential DHMT positions, such as HR of the EPI, and to take care of the surveillance” officers, supply officers and health services administra- (DHM #17). tors do not remain vacant and that also a sufficient As delays were often a result of staff shortages, many number of assistants would be available in each depart- of the described coping strategies also relate to HR. As ment. It was argued that this would likely result in effi- usually not all DHMT members are invited to attend ciency gains through a reduction of workload allowing meetings and workshops at regional level, those who DHMT members to focus on their core duties. stay in the district often take over responsibilities of managers that have to attend. Task sharing was generally “We should have enough staff. That’s what I think a coping strategy for time-bound activities so that these should be, but that’s not the case. You have to double could be completed in time. up, do this, do that, a whole lot. If you are the health information officer your focus should be on health “At the DHA, because we are limited, the staffs are information, if you are the HR officer your focus not adequate. And because we are not enough, jobs should be on HR. If we had fixed personnel handling are shared among us. Like somebody can do some part those things, the work would be a bit smooth for us” of it for you so that you also do other things. So (DHM #16). whatever schedule you are put on you make sure you do it and do it well” (DHM #18). Appropriate competencies Many district health managers criticised that because Executive managers, commonly district directors of they were taking over tasks of vacant professional posi- health services and public health nurses, also reported tions, the quality of work outputs was affected, as they that they delegate some of their work tasks to subordin- were carrying out tasks for which they were not trained ate DHMT members when they were unable to for and for which they lacked the necessary skills and complete them. experience. For instance, in one district the health infor- Those respondents that performed double-functions mation officer was also responsible for HR management, due to HR shortages also stated that they prioritise their including maintaining the HR database, organising in- core duties, thereby neglecting additional duties. and out-transfers and promotions, and counselling of sub-district staff, although the person had not received “Last week, because of the measles immunisation training in these areas whatsoever. The concerned DHMT programme that we had, I couldn’t finish my monthly member stressed that this lack of training in HR manage- report [of routine health data]. So this week I have to ment resulted in mistakes, thereby affecting efficiency. finish with it. Meanwhile, we had an email that we have to update our staff list. By Monday we should “When we have new staff we have to send their details submit it, but I have to forgo that one and make sure I to Accra for input. When they are being promoted you finish with my core duty, which is the monthly report, have to send their details to Accra for it to be inputted and then tackle the other one later” (DHM #16). so that they get their salary. And because it is not my core duty, I do my best, but at times there are some All DHAs made use of national service personnel to corrections so that I have to come back [to the office] fill their vacancies. These are personnel who complete a and print and all those things […]. So I have to travel mandatory one year service to the country after graduat- back and forth until I get it right” (DHM #16). ing from accredited tertiary institutions [26]. It was re- ported that during the time of the interviews national In addition, insufficient planning, communication, and service personnel were carrying out work tasks in HR, time management skills were also frequently reported as supply, disease control, and were also used as accountants. the cause of inefficient management practices. Although Bonenberger et al. BMC Health Services Research (2016) 16:12 Page 6 of 10 DHMTs develop annual action plans at the beginning of substantially to inefficiencies. It was emphasised that regu- each year, district health managers reported difficulties larly the only funds available were those made available in working according to these and to translate plans into for vertical programme funds – such as for the Expanded weekly DHMT activities. Therefore, in order to achieve Programme on Immunisation (EPI) – or other donors. workflow gains at the district level it was stressed that There was however no flexibility in using these resources DHMTs should improve their planning skills, put a as they were earmarked for specific programmes. stronger emphasis on weekly planning, and develop indi- vidual work plans that are consistent with those of the “There are financial constraints here, because the DHA. government is not releasing funds to the DHAs. Formerly we were being given the SBS (Sector Budget “If we are able to work according to action plans it Support) and GoG (Government of Ghana) funds. But will help improve efficiency, because if you are able to for some time now we have not been receiving them. look at action planning, you know that this is what we Only programme funds, but you cannot use them for have for this week. Then you can also plan your own other things. So there are financial constraints, very activities in line with that. It will help” (DHM #12). serious ones. Now it is not only here. The problem is all over” (DHM #19). However, the importance of sharing individual plans during weekly DHMT meetings was also emphasised so that everyone in the DHA, including non-DHMT staffs, were aware of what colleagues had planned for the week. “We have severe funding constraints. We are not able Respondents argued that this would likely lead to im- to do monitoring and other facilitative supportive proved collaboration and to a reduction of duplicated visits that we want to do. For the whole year we have activities resulting from poor communication. done monitoring and supervision only in the first Respondents also stressed that efficiency gains could quarter. In the second quarter we could not do it. And be made by becoming more time conscious, as this this quarter we are also not able to do it, because of a would likely result in the reduction of time spent on un- lack of funds for fuel to travel outside. The vehicle is productive activities, such as having lengthy private con- there, but funds for fuel are not” (DHM #5). versations with colleagues, sitting idly in the office, having extended breaks, and engaging in private activ- As funds were generally limited in the DHAs, district ities during duty hours. health managers reported making use of alternative funding sources to carry out planned activities. For in- Functional support systems stance, in contrast to governmental health funds, re- The efficiency of district health managers is dependent spondents stressed that funds for vertical programmes in part on how well critical support systems function. and from donors were usually released in time. As the District managers in Ghana have access to a broad range frequent inability to buy fuel prevented regular sub- of management systems, most importantly planning, fi- district visits for monitoring and supervision purposes, nance, information, HR, and procurement and distribu- district managers reported to use the opportunity to tion systems for drugs and other commodities. Responses conduct such activities when facilities were visited in the centred mainly on financial constraints, but problems re- frame of vertical programme or donor activities. How- garding other management systems such as HR, monitor- ever, such monitoring and supervision visits can be ing and transport were also mentioned as consequences of regarded as spot checks rather than a systematic visit of these constraints. Although it can be expected that prob- all facilities in the district. lems regarding other management support systems do Under rare circumstances, such as when money was also exist [16], these were not mentioned by any of the urgently needed to attend important national meetings respondents and thus might not be regarded as major or conferences, internally generated funds (IGFs) – reve- constraints. nues generated through the activities of sub-district Financial problems of the district and sub-district health facilities – were also used. In addition, district levels mainly result from the government not releasing health managers reported that they sometimes used their funds in time. These “cash flow” problems led to the in- private money to fund urgent activities, and were paid ability to do regular maintenance of vehicles and tech- back by the DHAs once money became available. nical equipment, buy fuel, and ensure the supply of essential office materials. Such problems, in turn, were “What we have been doing here is that at times we main barriers preventing district health managers to im- pre-finance some programmes. Like if you want to do plement planned activities in time and thus contributed supportive supervision and we see that it is very Bonenberger et al. BMC Health Services Research (2016) 16:12 Page 7 of 10 important for us to do that to correct some things “What happens is that, if nothing comes from the immediately, if there is no fuel in the vehicle we region, if no programmes come from the regional level, normally buy by ourselves and then bring the receipt whatever I have planned I will do it within the week. so that when there is money then they refund it” I’m able to do it” (DHM #17). (DHM #2). It was emphasised that particularly the RHA often sent When funds become available, it was reported that invitations for meetings and workshops at very short no- these were often not sufficient to conduct all activities as tice, although respondents admitted that information planned, such as visiting all sub-district facilities for practices of the RHA had recently improved. In addition, monitoring and supervision. In such instances, a certain district health managers complained that workshops number of health facilities are selected purposefully, for were often held over several days with participation be- example only health centres and CHPS facilities in one ing mandatory. Such workshops frequently interfered or two sub-districts. The remaining facilities in other with time-bound activities at district level. sub-districts are then visited at a later stage when the opportunity arises. “You know, you plan your week. You know this week Most district health managers stressed that the na- you are going to do ABCD. And then a letter will come tional level must ensure an adequate flow of public from theregion, you haveoneweek workshop, you health funds so that health activities could be carried have to stop whatever you are doing and then go” out in time, thereby improving DHMT efficiency. (DHM #11). “I think that basically it is funds. I think if we had the Due to the frequent interruptions through unplanned funds we could do things at the right time, but because activities time-bound activities were regularly at risk of we don’t have funds some of the things are just there. not being completed in time. As a result, almost all dis- We cannot do anything” (DHM #9). trict health managers stated that they were usually work- “If the [financial] resources would come on time for ing overtime, and sometimes also on weekends in order you to work with, it would help us. But the funds are to meet their deadlines. Some respondents also reported not coming on time and then when it comes we have that they were regularly working in the evening hours limited time to finish with it” (DHM #18). after workshops so as to complete activities in time. Many district health managers stressed that the higher Enabling environment levels should improve their planning and communica- Factors critical for good and efficient management in- tion concerning the district level, which particularly re- clude policies, legislation, norms and standards, which ferred to meetings and workshops, but generally to all support the appropriate delegation of authority; ad- activities that directly affected the districts. Although na- equate support for managers, especially regarding access tional annual plans exist and were widely distributed to information, communication, and supervision; finan- within the GHS, it was emphasised that these plans only cial and non-financial incentives for good management; included national celebrations, health weeks and some and accountability [27]. Despite this broad range of pos- management meetings. District health managers, there- sible topics concerning the work environment, district fore, frequently stressed that both the national and the health managers primarily regarded inadequate planning regional levels should inform regularly and more timely and communication of the higher health system levels as on all upcoming activities so that DHMTs could incorp- a constraint for efficient district management. orate these in their work plans. Because decisions of the higher levels generally super- sede those of the district level, demands from these “So they should give us a work plan: these are the levels have higher priorities than all activities routinely meetings and workshops we are going to hold and this conducted by district health managers. A high share of is the time we will be holding them, these are the the activities conducted by district health managers is personnel that will be involved […]. But they let us do usually required by the national and regional administra- our plans and they also do their own and they are tions leaving little room for them to focus on district interfering left and right. They are our biggest specific activities. problem” (DHM #15). Most respondents complained that the higher levels regularly informed them about upcoming activities at very In order to ensure that meetings and workshops did short notice so that these activities are difficult to incorp- not interfere so frequently with activities at district level orate in their work schedules. As such, they interrupted it was recommended that the higher levels should better their plans and resulted in implementation delays. coordinate such events, for instance by involving the Bonenberger et al. BMC Health Services Research (2016) 16:12 Page 8 of 10 DHAs in the planning process or at least by considering This, however, indicates that DHMT members may not district work plans. use their work time efficiently and that gains can be achieved without additional resources through proper Discussion time management and training. Our findings indicate that there are limitations in all Several factors affecting efficiency as proposed by the four dimensions of the WHO’s leadership and manage- WHO’s leadership and management strengthening ment strengthening framework. All study DHAs had HR framework [16] were not identified by respondents. Such shortages, as essential DHMT positions such as HR offi- factors include inadequate access to supportive supervi- cers and health services administrators were vacant and sion and appraisals, HR management systems, collabor- thus the number of district health managers was inad- ation with other stakeholders at district level, and equate. Our findings also suggest that planning as well incentives for good performance. Although district as communication of district managers are both inad- health managers in the study districts may not perceive equate and, therefore, managers lack appropriate compe- these factors as primarily constraining their efficiency, tencies in these areas. That several of the critical support research conducted in other LMICs suggests that such systems, especially the finance management system, are factors may indeed affect managerial efficiency [27, 31]. inadequate is a further, major finding of this study. Also Common strategies of district health managers to cope the narrow decision-space of district health managers in with the untimely release of funds are to carry out rou- Ghana does not seem to provide an enabling working en- tine activities while on duty for vertical programs or do- vironment to solve district specific problems. nors, to borrow IGFs from sub-district health facilities, DHMT members foremost identified difficulties in fi- or to use private cash to advance funds for DHMT activ- nancial management processes as a determinant elem- ities. Such strategies confirm those reported in a study ent. Financial constraints are indeed well-known to conducted by Asante et al. [13] in Ghana. Regarding the many health systems in LMICs [28] and were identified other strategies described in this study, some are them- as main barriers to efficient district health management selves a source of inefficient district management. For also in this study. Abekah-Nkrumah et al. [29] have instance, while prioritising core duties increases effi- shown in a review of the budgetary process in the Ghan- ciency of such activities, additional duties are neglected aian health sector that although channels for disbursing at the same time, thereby affecting efficiency. Also mak- administrative funds are smooth, disbursements are er- ing use of unqualified staff to carry out DHMT work ratic due to challenges with cash flow. In addition, cum- tasks may improve efficiency in some work areas due to bersome central procedures for approval of local budgets the greater number of workers, but may simultaneously and a lack of administrative capacity at the national level decrease efficiency in other areas through mistakes regularly result in delayed approvals of district funds [29, resulting from a lack of appropriate training and skills. 30]. That this untimely release of administrative funds dis- Moreover, using unqualified staff to carry out qualified rupts the implementation of DHMT activities is also a work is also likely to have negative effects on the quality major finding in another study from Ghana [13]. Besides of work outputs. financial constraints, HR shortages in the DHAs, inad- It is generally assumed that managers are more effi- equate planning skills of district health managers, and cient in decentralised health systems, given that they poor planning and communication of upcoming activities have better control over resources and activities and are from the higher levels are also identified as key factors for in a better position to plan and prioritise as compared to inefficient district management practices. These findings managers in centrally managed health systems [22, 32]. are supported by quantitative data we reported in a previ- Very limited financial resources are generated at district ous article on DHMT time use practices, which showed level and these can be administered by district managers. that great shares of managers’ capacities are used for only However, most of these resources are made available to few district activities by at the same time neglecting other local managers by the national and the regional adminis- important activities, which we attributed mainly to HR tration [6, 19] and here the district managers have only shortages in the DHAs as well as insufficient planning and little control. In addition, studies also emphasised the coordination by the higher health system levels [18]. low decision-making authority of Ghana’s district health District health managers reported that DHMTs spend managers [5, 6, 33], which was attributed to the colonial time on unproductive activities such as having lengthy organisation structure inherent in the modern health private conversations with colleagues and extended system encouraging a centralised hierarchical adminis- breaks. Although managers attributed these activities to tration culture with little involvement of the district level fellow DHMT members and never to themselves, such in planning and implementation of health services [34]. statements are at odds with the frequent requirement to In our study, we identify both issues – low control over work overtime and on weekends due to high workloads. resources coupled with little authority over district Bonenberger et al. BMC Health Services Research (2016) 16:12 Page 9 of 10 activities – as major factors for inefficient district man- Additional file agement. Our findings thus confirm the rather narrow Additional file 1: Interview guide. (DOCX 35 kb) decision space attributed to district health managers by studies carried out in Ghana in recent years [5, 6]. Abbreviations This study has limitations. As the focus is only on CHN: Community health nurse; CHPS: Community-based Health Planning district health managers in three districts, perceptions and Services; DDHS: District director of health services; DHA: District Health concerning these districts may not be generalizable for Administration; DHM: District health manager; DHMT: District health management team; EPI: Expanded Programme on Immunisation; GHS: Ghana all areas in the country. However, given their broader Health Service; HR: Human resources; HRM: Human resource management; administrative responsibilities, findings regarding the HS: Health system; IGF: Internally generated funds; LMICs: Low- and middle- higher health system levels are likely to also prevail in income countries; RHA: Regional Health Administration; WHO: World Health Organisation. other areas. Moreover, the issues emerging from the data reveal relationships significant for management Competing interests strengthening in LMICs and are thus relevant for re- The authors declare that they have no competing interests. searchers, donors and policy makers. Although the Authors’ contributions three DHAs included in this study differ in terms of MB designed and implemented the study, conducted and transcribed the factors such as DHMT composition, distance to the interviews, performed the analysis, and drafted the manuscript. MA and PA regional and national administrations, and socio- participated in the design of the study, contributed to its implementation, and commented on draft versions of the manuscript. KW participated in the economic status of the districts, we pooled all data and, design of the study and contributed to the writing and revising of the by doing so, may have masked discrepancies between manuscript. All authors read and approved the final manuscript. the districts that could have been revealed through a Acknowledgements stratified analysis. We also recognise the limitation of We thank all district health managers who have made available their not having explored the perceptions from regional and precious time and responded to our questions and gratefully acknowledge national health managers, health workers as well as the support from the Eastern Regional Health Administration, Koforidua, Ghana. We also thank Martina Bonenberger (University of Lucerne, Lucerne, from patients and health service users concerning Switzerland) for her participation in the data collection. We are grateful to DHMT efficiency. Such triangulation might have added Helen Prytherch (Swiss TPH, Basel, Switzerland) for her valuable comments different perspectives. and suggestions on draft versions of the manuscript. This study was funded by the European Commission’s Seventh Framework programme (FP7 Theme Health: 2010.3.4-1, grant agreement number 266334). MB received additional funds for fieldwork from the Freiwillige Akademische Gesellschaft (FAG) Conclusions Basel, Switzerland. This financial support is highly acknowledged. This study has shown that inefficient district health Author details management is mainly a result of HR shortages at the Swiss Centre for International Health, Swiss Tropical and Public Health DHAs, inadequate planning and communication skills of Institute, Socinstrasse 57, Basel 4002, Switzerland. University of Basel, Basel, Switzerland. School of Public Health, University of Ghana, Legon, Ghana. district health managers, financial constraints, and a nar- row decision space giving district managers little author- Received: 10 June 2015 Accepted: 12 January 2016 ity over activities. The findings thus suggest limitations in all four dimensions of the WHO’s leadership and References management strengthening framework. As these are 1. Lega F, Prenestini A, Spurgeon P. Is management essential to improving the closely interrelated, efforts to strengthen management at performance and sustainability of health care systems and organizations? district level are unlikely to succeed when these are not A systematic review and a roadmap for future studies. Value Health. 2013;16:S46–51. tackled at the same time. It is, therefore, not sufficient to 2. World Health Organization. Strengthening management in low-income just carry out interventions at the district level by im- countries, Making health systems work: working paper no 1. Geneva: World proving management skills of district health managers Health Organization; 2005. 3. West MA, Borrill C, Dawson J, Scully J, Carter M, Anelay S, et al. The link or increasing their number. Although developing man- between the management of employees and patient mortality in acute agement skills of district health managers is undoubtedly hospitals. Int J Hum Resour Manag. 2002;13:1299–310. important, our findings strongly suggest that the wider 4. Dorgan S, Layton D, Bloom N, Homkes R, Sadun R, Van Reenen J. Management in healthcare: why good practice really matters. London: health system must also be considered in order to McKinsey & Company and London School of Economics and Political achieve better management efficiency. Filling vacancies Science; 2010. of DHMT members in all districts, developing leader- 5. Kwamie A, van Dijk H, Agyepong IA. Advancing the application of systems thinking in health: realist evaluation of the Leadership Development ship and management skills of district health managers, Programme for district manager decision-making in Ghana. Health Res ensuring a better flow of district funds, and delegating Policy Syst. 2014;12:29. more authority to the districts seems to be a promising 6. Bossert TJ, Beauvais JC. Decentralization of health systems in Ghana, Zambia, Uganda and the Philippines: a comparative analysis of decision intervention package, which may result in improved and space. Health Policy Plan. 2002;17:14–31. more efficient management practices and stronger health 7. Ayee J, Dickovick JT. Comparative Assessment of Decentralization in Africa: system performance. Ghana Desk Study. Washington, DC: USAID; 2010. Bonenberger et al. BMC Health Services Research (2016) 16:12 Page 10 of 10 8. Bergman SE. Swedish models of health care reform: A review and 31. World Health Organization. Strengthening Management in Low-Income assessment. Int J Health Plann Manag. 1998;13:91–106. Countries: Lessons from Uganda, Making health systems work: working 9. Jervis P, Plowden W. The impact of political devolution on the UK’s health paper no 11. Geneva: World Health Organization; 2007. services: final report of a project to monitor the impact of devolution on 32. Conn CP, Jenkins P, Touray SO. Strengthening health management: experience the United Kingdom’s health services 1999–2002. London: The Nuffield of district teams in The Gambia. Health Policy Plan. 1996;11:64–71. Trust; 2003. 33. Kwamie A, Agyepong IA, van Dijk H. What Governs District Manager Decision Making? A Case Study of Complex Leadership in Dangme West 10. Jommi C, Fattore G. Regionalization and drugs cost-sharing in the Italian District, Ghana. Health Systems & Reform. 2015;1:167–77. NHS. Euro Observer. 2003;5:1–4. 34. Sakyi EK. A retrospective content analysis of studies on factors constraining 11. Frumence G, Nyamhanga T, Mwangu M, Hurtig AK. Participation in health the implementation of health sector reform in Ghana. Int J Health Plann planning in a decentralised health system: Experiences from facility Manage. 2008;23:259–85. governing committees in the Kongwa district of Tanzania. Glob Public Health. 2014;9:1125–38. 12. Kolehmainen-Aitken RL. Decentralization's impact on the health workforce: Perspectives of managers, workers and national leaders. Hum Resour Health. 2004;2:5. 13. Asante AD, Zwi AB, Ho MT. Getting by on credit: how district health managers in Ghana cope with the untimely release of funds. BMC Health Serv Res. 2006;6:105. 14. Saltman RB, Bankauskaite V, Vrangbæk K. Decentralization in Health Care. Strategies and Outcomes. London: Open University Press; 2007. 15. Abimbola S, Olanipekun T, Igbokwe U, Negin J, Jan S, Martiniuk A, et al. How decentralisation influences the retention of primary health care workers in rural Nigeria. Glob Health Action. 2015;8:26616. 16. World Health Organization. Towards better leadership and management in health: Report on an international consultation on strengthening leadership and management in low-income countries, Making health systems work: working paper no 10. Geneva: World Health Organization; 2007. 17. Mshelia C, Huss R, Mirzoev T, Elsey H, Baine SO, Aikins M, et al. Can action research strengthen district health management and improve health workforce performance? A research protocol. BMJ Open. 2013;3:e003625. 18. Bonenberger M, Aikins M, Akweongo P, Bosch-Capblanch X, Wyss K. What Do District Health Managers in Ghana Use Their Working Time for? A Case Study of Three Districts. PLoS One. 2015;10:e0130633. 19. Bonenberger M, Aikins M, Akweongo P, Wyss K. The effects of health worker motivation and job satisfaction on turnover intention in Ghana: a cross- sectional study. Hum Resour Health. 2014;12:43. 20. Nyonator FK, Awoonor-Williams JK, Phillips JF, Jones TC, Miller RA. The Ghana community-based health planning and services initiative for scaling up service delivery innovation. Health Policy Plan. 2005;20:25–34. 21. Binka FN, Bawah AA, Phillips JF, Hodgson A, Adjuik M, MacLeod B. Rapid achievement of the child survival millennium development goal: evidence from the Navrongo experiment in Northern Ghana. Trop Med Int Health. 2007;12:578–83. 22. Hurley J, Birch S, Eyles J. Geographically-decentralized planning and management in health care: some informational issues and their implications for efficiency. Soc Sci Med. 1995;41:3–11. 23. Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13:117. 24. Abbey EE. Government Places Embargo On Employment, Modern Ghana. Accra: Modern Ghana Media Communication Ltd; 2010. 25. Siewobr CL. Is There A Ban On Employment In Both The Ghana Education Service And The Ghana Health Service? Modern Ghana. Accra: Modern Ghana Media Communication Ltd.; 2015. 26. Frontani HG, Taylor LC. Development through civic service: the Peace Corps and national service programmes in Ghana. Prog Dev Stud. 2009;9:87–99. 27. World Health Organization. Managing the Health Millennium Development Submit your next manuscript to BioMed Central Goals - The Challenge of Health Management Strengthening: Lessons from Three Countries, Making health systems work: working paper no 8. Geneva: and we will help you at every step: World Health Organization; 2007. • We accept pre-submission inquiries 28. Travis P, Bennett S, Haines A, Pang T, Bhutta Z, Hyder AA, et al. Overcoming health-systems constraints to achieve the Millennium Development Goals. � Our selector tool helps you to find the most relevant journal Lancet. 2004;364:900–6. � We provide round the clock customer support 29. Abekah-Nkrumah G, Dinklo T, Abor J: Financing the Health Sector in Ghana: � Convenient online submission A Review of the Budgetary Process. European Journal of Economics, Finance and Administrative Sciences 2009;17:45–59 � Thorough peer review 30. Steffensen J, Trollegaard S. Fiscal Decentralisation and Sub-National � Inclusion in PubMed and all major indexing services Government Finance in Relation to Infrastructure and Service Provision: � Maximum visibility for your research Synthesis Report on 6 Sub-Saharan African Country Studies. Washington, DC: World Bank; 2000. Submit your manuscript at www.biomedcentral.com/submit

Journal

BMC Health Services ResearchSpringer Journals

Published: Dec 1, 2015

Keywords: public health; health administration; health informatics; nursing research

There are no references for this article.