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

How Does District Health Management Emerge Within a Complex Health System? Insights for Capacity... ORIGINAL RESEARCH published: 08 July 2020 doi: 10.3389/fpubh.2020.00270 How Does District Health Management Emerge Within a Complex Health System? Insights for Capacity Strengthening in Ghana 1,2 1,2 3 Anne Christine Stender Heerdegen , Jana Gerold , Samuel Amon , 3 3 1,2 Samuel Agyei Agyemang , Moses Aikins and Kaspar Wyss 1 2 3 Swiss Tropical and Public Health Institute, Basel, Switzerland, University of Basel, Basel, Switzerland, School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana Introduction: District health managers (DHMs) play a pivotal role in the operation of district health systems in low—and middle income countries, including Ghana. Their capacity is determined by their competencies, but also by the organization and system Edited by: in which they are embedded. The objective of this paper is to explore how district health Sunjoo Kang, Yonsei University, South Korea management emerges from contextual, organizational, and individual factors in order Reviewed by: to demonstrate that capacity strengthening efforts at district level need to transcend Nilesh Chandrakant Gawde, individual competencies to take on more systemic approaches. Tata Institute of Social Sciences, India James F. Phillips, Methods: Semi-structured interviews (n = 21) were conducted to gain insight into Columbia University Irving Medical aspects that affect district health management in the Eastern Region of Ghana. Interviews Center, United States were conducted with DHMs (n = 15) from six different districts, as well as with their *Correspondence: superiors at the regional level (n = 4) and peers from non-governmental organizations Anne Christine Heerdegen [email protected] (n = 2). A thematic analysis was conducted by using an analytical approach based on systems theory. Specialty section: This article was submitted to Results: Contextual aspects, such as priorities among elected officials, poor Public Health Education and infrastructure and working conditions, centralized decision-making, delayed Promotion, a section of the journal disbursement of funds and staff shortages, affect organizational processes and Frontiers in Public Health the way DHMs carry out their role. Enabling organizational aspects that provide DHMs Received: 30 March 2020 with direction and a clear perception of their role, include positive team dynamics, good Accepted: 26 May 2020 relations with supervisors, job descriptions, appraisals, information systems, policies Published: 08 July 2020 and guidelines. Meanwhile, hierarchical organizational structures, agendas driven by Citation: Heerdegen ACS, Gerold J, Amon S, vertical programs and limited opportunities for professional development provide DHMs Agyemang SA, Aikins M and Wyss K with limited authority to make decisions and dampens their motivation. The DHMs ability (2020) How Does District Health Management Emerge Within a to carry out their role effectively depends on their perception of their role and the effort Complex Health System? Insights for they expend, in addition to their competencies. In regards to competencies, a need for Capacity Strengthening in Ghana. more general management and leadership skills were called for by DHMs as well as by Front. Public Health 8:270. doi: 10.3389/fpubh.2020.00270 their superiors and peers. Frontiers in Public Health | www.frontiersin.org 1 July 2020 | Volume 8 | Article 270 Heerdegen et al. Strengthening District Health Management Capacity Conclusion: Systemic approaches are called for in order to strengthen district health management capacity. This study can provide national policy-makers, donors and researchers with a deeper understanding of factors that should be taken into consideration when developing, planning, implementing, and assessing capacity-building strategies targeted at strengthening district health management. Keywords: management and leadership, capacity strengthening, district health systems, systems thinking, complex adaptive systems, low- and middle-income countries, Ghana INTRODUCTION may elicit the need to expand management strengthening beyond the traditional approaches that perceive managers as In many low and middle-income countries (LMICs), including being outside the system with objective abilities to change the Ghana, district health managers’ (DHMs) are the ones who system (13). facilitate the management and implementation of primary Management Structures Within the Ghana healthcare. They have to translate national health policies, as well as human, material and financial inputs, into accessible, high Health System quality health services, and thus play a pivotal role in district In Ghana, the Ministry of Health (MoH) are in charge of health systems (1–4). Shortcomings within district health systems policy making and setting the strategic direction for the health in LMICs, such as an unequally distributed health workforce, sector. Meanwhile, the semi-autonomous agency Ghana Health high levels of absenteeism, medicine stock-outs and poor health Service (GHS) has been mandated by the MoH to implement outcomes, are often attributed to weak management capacity the national health policies through management and operation of nearly all public health facilities. To take on this mandate, (1, 3–9). Capacity has been defined as the “ability of individuals, the GHS is administratively organized at the national, regional organizations or systems to perform appropriate functions and district level (33). The GHS headquarters oversee the GHS effectively, efficiently and sustainably” (10). However, capacity Regional Health Administrations (RHA) that are located within strengthening within the health sector often focuses on each region. At the time this study took place, there were 10 enhancing the skills and technical capacity of individuals (11, 12). regions in Ghana, subdivided into 216 districts. The RHAs, led Individuals do however not operate in a vacuum, and their by the Regional Director of Health Services, oversee the District Health Administrations (DHA) that are established within each capacity is strongly influenced by the system and context in which they are embedded (12, 13). district. The DHAs are run by district health management teams (DHMTs), who are responsible for the operation and Since the 1980s, management strengthening interventions (MSIs) have had a predominant focus on strengthening the management of public health facilities within their district, including health centers and Community Health and Planning DHMs’ individual competencies rather than the system capacity (13–16). Individual competencies among DHMs are indeed Services (CHPS) (33). The DHMTs may consist of up to 12 core members that are led by a District Director of Health Services critical for them to carry out their job in an effective and efficient way (3, 13, 14, 17–25). Nevertheless, it has been posed that (DDHS). To our knowledge, there is no official document leadership and management within complex adaptive systems, outlining core members of DHMTs, however they typically such as the district health system, need to be considered as more include administrative officers (i.e., DDHS, Deputy Director of than the act of individuals, and rather as something that emerges Nursing Services and Health Administrators), technical officers (i.e., Public Health Nurse, Disease Control, Health Information, through an interplay of many interacting forces (26). District health managers’ operate within a context that incentivizes them Nutrition, Health Promotion Officers), and operational officers (i.e., Finance, Human Resource and Supply Officers). The to act in a certain way, and their practices are to a high extent influenced by and interdependent with other entities at the sub- core managers are assisted by various program heads, for example coordinators of community health - and disease district, district, regional and national level (3, 13, 14, 27–31). Inadequate attention has been paid to the influence of the control programs (i.e., CHPS, Tuberculosis, Malaria and HIV coordinators). The DHMTs are vertically accountable to RHAs, context and organizational structures in which DHMs operate in sub-Saharan Africa, including Ghana (13, 32). Thus, the aim of who in turn are accountable to GHS headquarters. Moreover, this paper is to explore how district health management emerges, the DHAs are horizontally accountable to the local governments, hereunder the contextual, organizational and individual aspects namely the district assemblies. The district assemblies are the that enable or hinder DHMs in carrying out their functions. highest political decision-making bodies within the districts, and play an important role in deciding how state resources are The findings may provide national policy-makers, donors and researchers with a deeper understanding of factors that allocated within the districts (34). The funds allocated to health by the district assemblies in each district depends on the priorities should be taken into consideration when developing, planning, implementing and assessing capacity-building strategies targeted of the district assembly and the lobbying power of the district health directorate (15). The private sector, non-governmental at strengthening district health management. Moreover, findings Frontiers in Public Health | www.frontiersin.org 2 July 2020 | Volume 8 | Article 270 Heerdegen et al. Strengthening District Health Management Capacity and faith-based organizations, as well as donor partners, also play their involvement in the PERFORM2Scale project. The sampling an important role in adding resources and addressing challenges strategy was purposive, as described by Ritchie et al. (37), related to service delivery within the Ghana health system. however some of the invited DHMs could not participate due to a National initiatives to strengthen management and leadership national mass distribution of long lasting insecticide-treated bed at district level have taken place in Ghana, including the nets taking place at the same time as this study. Leadership Development Program (LDP) and the Strengthening District Health System Initiative (SDHI) (13). The LDP has been Data Collection implemented in districts across Ghana since 2008. It takes on a Semi-structured in-depth interviews were carried out in team-based approach in which DHMTs apply management and February and March 2018, and were conducted by the first, leadership practices (i.e., root cause analysis, action planning, third and fourth author of this paper. The interviews were monitoring and evaluation etc.) to address service delivery facilitated by semi-structured interview guides, which were problems. Improved practices, team - and work climate were conceptualized based on the World Health Organizations observed during the program and shortly thereafter, however leadership and management strengthening framework (6). were not sustained (3). The unsustainability was partially Separate interview guides were developed for the DHMs, regional attributed to it being introduced in a top-down manner by health administrators and the NGO staff, respectively. However, regional officers, which diminished the DHMs own decision- the three guides included similar questions relating to: (1) making and thus ownership (3). The SDHI was implemented DHMs’ roles and responsibilities; (2) DHMs qualifications; in the late 1980’s. This program also focused on individual and (3) required and perceived management competencies among team competencies, including problem analysis and problem DHMs; (4) DHMs relationship with external partners (NGOs, solving (35). It was sustained for a while due to its focus on donors, academic institutions) and stakeholders at the national, local ownership and a close-knit network between the then regional, and sub-district level; and (5) the organizational and district leaders who shared management strengthening ideas environmental context surrounding DHMs, and how it affects amongst each other after the duration of the program. As a the DHMs in carrying out their responsibilities. Individual result of the program, the DHMTs became better planners interviews were conducted at the study participants’ workplace, and advocates for their needs as their capacity and confidence and lasted ∼40 minutes. All interviewees were informed about increased. Consequently, their decision-space was increased. the interviewers’ affiliation and the procedure of data collection. Nonetheless, the momentum of the SDHI waned after a couple of years partly due to the existing district leaders no Data Analysis longer being in the districts, partly due to lack of financial The interviews were transcribed and subsequently coded support (35). in the qualitative research software Nvivo 12 by using a general inductive approach, as described by Hsieh and Shannon (38). Following a content analysis, global themes METHODS were generated by using a systems theory approach, in Study Setting which data from DHMs, regional administrators and NGOs This study was conducted in six districts in the Eastern were organized into individual, organizational and contextual Region of Ghana. The districts were selected based on their aspects affecting management capacity at district level (39– involvement in the PERFORM2Scale project, which aims to 41) (Figure 1). The framework in Figure 1 demonstrates that scale-up a MSI at district level in Uganda, Malawi, and the broader context refers to situational circumstances and Ghana (www.perform2scale.org). characteristics that influence the behavior among DHMs, such as available resources, relationships with stakeholders, policies, and Study Design and Population regulations. Meanwhile, the organizational context refers to the This study took on an exploratory approach using qualitative characteristics of the organization of GHS in which the DHMTs interviews to gain insight into aspects that enable or hinder are embedded, including organizational processes and culture, DHMs in carrying out their duties in a way that improves health available management support systems and structures, including service delivery and population health outcomes at district level. the DHMs decision-making authority. Lastly, the individual The DHMs were thus the core unit of research, however to verify aspects refer to (1) the DHMs perception of their role, (2) their their observations, a data source triangulation approach was abilities and (3) the efforts they put into carrying out their duties applied (36). In addition to inviting DHMs to participate in the in an efficient and effective way. These three sub-themes have study, regional health administrators and staff from local non- been described by Byars and Rue as affecting the degree to which governmental organizations (NGOs) within the study districts an individual is fulfilling his or her assigned job tasks (42). were invited to participate. The regional health administrators supervise the DHMTs and thus have a good oversight of the Ethics resources and support systems available at district level, as well This study was carried out as an integral part of PERFORM2Scale as the individual capacity among DHMs. Meanwhile, the NGOs under the lead of the Liverpool School of Tropical Medicine collaborate closely with the DHMTs in the field and have insights (LSTM). Ethical clearance was obtained from the Research Ethics into how contextual, organizational or individual aspects affect Committee of LSTM (ID No. 17–046) and the GHS Ethics the DHMs. Access to study participants were obtained through Review Committee (No. GHS-ERC004/01/20). Written informed Frontiers in Public Health | www.frontiersin.org 3 July 2020 | Volume 8 | Article 270 Heerdegen et al. Strengthening District Health Management Capacity FIGURE 1 | Framework on aspects affecting effective and efficient District Health Management. consent was obtained from all study participants and they were interview a health promotion, human resource and supply officer informed about the possibility to withdraw from the interview at due to them being occupied by the ongoing national mass any time. distribution of bed nets. Contextual, organizational and individual aspects, and how they relate and interrelate to shape management at district level, RESULTS are discussed, respectively, in the sections below. A total of 21 key stakeholders participated in the study, including Contextual Aspects fifteen DHMs, four regional health administrators and two Study participants at district, regional and NGO level, repeatedly staff members from two different health-related NGOs located mentioned the infrastructure and physical environment within two of the study districts (Table 1). The mean age of the surrounding the district health facilities as a barrier for the DHMs participating in the study was around 41 years, and the DHMs to carry out their activities, in particular those posted in average time spent in their current management position was rural terrains. Not only did they report on the DHMs difficulties approximately three and half years. Six of the DHMs were female in getting to the facilities for their essential supervision (40%), which was a bit less than the actual proportion (∼50%) and monitoring responsibilities, but they also expressed of females within the DHMTs. One of the regional participants concerns about the distance they had to travel to work at and one of the NGO staff representatives were females. No the DHA. systematic differences were observed between men and women in the interviews, and the results do thus not emphasize gender related perspectives. “We do not have accommodation around, we are all living far The sample represented the majority of core DHMT positions away, so we cannot come easily to the office to do some work. People within the selected districts. However, we were unable to also come late because of that reason“ (DHM). Frontiers in Public Health | www.frontiersin.org 4 July 2020 | Volume 8 | Article 270 Heerdegen et al. Strengthening District Health Management Capacity TABLE 1 | Overview of interview participants. have rendered to health insurance which is not being paid back. So resources are locked.” (RHA). Occupation n The shortage of human resources for health, both at the frontline Regional level 4 and within the DHAs, and the DHMs limited decision-space to Regional Director 1 hire additional staff were emphasized by DHMs, as well as by Research Officer 1 RHAs and NGO staff members. The shortage within the DHA, Administrator 1 forces the DHMs to take on responsibilities that they are not Human Resource Officer 1 equipped or prepared for, and increases their workload. The District level 15 overburden may render them inefficient in their core duties. The District Director of Health Services 3 quote below demonstrates how a DHM took on myriad roles Deputy Director of Nursing Services 1 during his previous posting Health Administrator 1 Health Information Officer 4 “When I was in my old place, I was a transport officer, a CHPS Nutrition Officer 2 coordinator, I was the Procurement Officer and the Nutrition Disease Control Officer 2 Officer at the same time. And any time the Disease Control Officer Public Health Nurse 1 wasn’t there I acted as the Disease Control Officer” (DHM). Staff from health-related non-governmental organizations within the districts 2 Meanwhile, the staff shortage at the frontlines, hinder DHMTs in Total 21 their planning, coordination and execution of activities. “because they [HR at sub-district level] are not there, it means that all these tasks not actually are performed for the sub-district (. . . ) Appropriate accommodation is rarely offered to the DHMs meaning the system can only be weak because the pillars are not working” (DHM). when they are posted to a position in the district. This poses a challenge because the number of effective work hours are reduced significantly as they have to travel long distances to get to and The regional health administrators and the DDHS stated that from work. Moreover, in a setting with poor infrastructure, this annual objectives frequently were unmet due to the lack of poses a substantial safety risk at each commute. One manager financial, material and human resources. Moreover, one of mentioned how his colleague had been involved in an accident the NGO respondents stated that she had experienced that and lost her ability to walk. The limited number of motor DHMs due to a lack of resources and delayed funding were vehicles, as well as money for fuel, were also mentioned by study restrained from carrying out monitoring activities, and for participants as a hurdle for the DHMs in terms of carrying out example following up on frontline health workers that the NGO their essential monitoring and supervision activities. had supported the DHMT in training, causing the trainees to lose The inadequate resources allocated to the districts not only their newly acquired skills. manifests in mobility issues and thus activities that cannot be Study participants from the region, districts and NGOs, carried out due to long commuting distances and time spent emphasized the importance of the DHMs having a good on traveling, it further manifest in work places that diminish relationship with the officials at the district assembly in order effectivity and efficiency, i.e., poor lighting, lack of internet for them to receive additional resources and support to achieve connection, hot office temperatures, overcrowded offices and lack district health objectives. of equipment at health facilities. “(. . . ) we are all competing for the same resources. Education, health, agriculture (. . . ). We are competing, so we need to “. . . look at this office. . . this is where we work. (. . . ) It does not really have a very workable relationship with them [the District depict a well-performing office. When it comes to performance Assembly]” (DHM). the space that you will be allocated with will add on to your performance. Your office should not be as such when you enter the Presence of NGOs within the districts and a good working office and within 5–10 minutes you are tired” (DHM). relationship between the DHMTs and these, as well as with donor partners play a role in DHMTs reaching their goals of improving The regional adminstrators also emphasized these challenges, health indicators. Not only because the NGOs may support the and demonstrated frustration about their inability to address DHMTs with material resources and capacity building at the sub- the issues at district level, due to delayed release of district district level, but also because the NGOs independently work on health funds and health insurance reimbursement from the projects that aim to improve health outcomes within the district. national level. Non-governmental organizations were not present within all the study districts. “. . . if the health insurance is not giving back (. . . ) then how do we get the money to buy the resources and things. That is the “(. . . ) when an NGO comes in and tells me that their objective is issue. So part of the problem is the payment of the services that we to reduce maternal or neonatal deaths at least that burden will be Frontiers in Public Health | www.frontiersin.org 5 July 2020 | Volume 8 | Article 270 Heerdegen et al. Strengthening District Health Management Capacity off my chest. They will be coming to help me to surmount those working. (. . . ). If the funding of a vertical program was flexible problems.” (DHM). to integration, in that case, it can be also integrated in a way that will make both the system and the vertical programs sustainable.” (DHM). Organizational Aspects At the organizational level, structures and processes supporting Continuous community engagement was for example the DHMTs in carrying out their tasks, were identified. The highlighted by a DDHS as being critical for sustaining ones mostly emphasized as enhancing the capacity of the DHMs health improvements within the districts, however the lack include (1) positive team dynamics, frequent information and of flexible resources and guiding policies, restrained them from knowledge sharing within the DHMTs via Whatsapp groups carrying out such activities. Moreover, a DHM stated that the and weekly meetings; and (2) a good and highly dynamic prescriptive directives from higher levels contributed to an relationship between the district and regional level with regular organizational culture that not encourages DHMs to make communication and frequent supervisory check-ins. Moreover, data-driven decisions, as demonstrated by the quote below national directives (i.e., work plans, job descriptions, policies and guidelines) and the availability of health and HR information “We do not make decisions out of data (. . . ) I have been trained systems for surveillance, were mentioned as supporting the to use data. But we could have an interaction, and most of the DHMs in carrying out their duties. However, DHMs raised information I am giving you will not be based on the knowledge that concerns about the information systems relying on poor I have. Why? Because we do not have this culture [to use data]. (. . . ) connection, as well as on substandard data collection and you have to influence by leadership (. . . ) for the culture to change reporting at sub-district levels. Moreover, job descriptions were and become more adaptive to what the data shows” (DHM). not always aligning with actual responsibilities and data reporting forms were frequently outdated. In addition, multiple DHMs The vertical programs frequently target “popular” areas, such expressed a need for additional directives (i.e., on community as disease control, leaving the DHMs with limited funds to engagement, social and resource mobilization). cover other areas. To make the most of the allocated resources, Another emphasized management support structure was the integrated monitoring takes place, in which DHMs go jointly performance management system in which structured appraisals to the sub-districts and monitor a wide range of service take place, both between the DDHS and RHA, as well as between areas. This ensures efficient use of scarce resources by giving the DDHS and the remaining DHMs. The system provides “neglected” areas some attention. However, it reportedly also the DDHS and DHMs with supportive supervision, feedback compromises the overall quality of the essential monitoring and and holds them accountable. Nevertheless, the system was supervision activities. undermined by the fact that identified strengths and needs rarely could be rewarded or addressed due to a lack of institutional “. . . you don’t get time to do a detailed monitoring. (. . . ). When support. The RHA and some DHMTs had established informal you’re doing the monitoring and support visit you are supposed to sit there and watch the person do the work, and if there are loop award systems, for example best DHMT and employee prizes, holes or some problems you take over and let the person observe respectively, however this form of recognition was generally not you, so that you can correct them” (DHM). described by the DHMs as effective in terms of motivating them to do a better job. Nevertheless, the DHMs stated that the integrated monitoring provides them with a common understanding of the different “Formally the district is supposed to sponsor some people to go and DHMT members’ role and responsibilities, which is helpful do some management training. But anytime those opportunities in situations where a DHM is transferred or on leave, and others come, they tell us they do not have the funds to be able to support. So when you have a chance to do, for instance, when I went and did have to take over. my management training I sponsored it myself.” (DHM). Aspects at the Individual Level As depicted at the individual level in the framework (Figure 1), Both DHMs and regional administrators reported that DHMs effective and efficient DHMTs are likely to be determined by: (1) agendas were dominated by vertical programs. These were the DHMs perception of their role; (2) their abilities to carry out perceived positively in terms of adding resources to the district their responsibilities; and ultimately, by (3) the effort they put health system, however were described as contributing to a into carrying out their tasks. culture with little focus on systems strengthening. The vertical The DHMs appeared to have a clear perception of their role programs often have rigid requirements, inflexible funding, due to the dynamics and frequent information sharing within and come along with separate reporting systems that are the DHMTs, and the strong relationship with the regional level not integrated into existing systems. The DHMs have limited who provides supportive supervision. However, the shortage authority to decide on how to utilize the resources, and are of HR, which causes the DHMs to take on additional roles, hindered in integrating them in a way that strengthens the overall imposed a risk of them taking on roles they were not prepared health system. sufficiently for. The DHMs ability to meet objectives depends on their “. . . the vertical programs come with spreadsheets that have direct competencies, as well as on whether they have autonomy to make and very fixed, rigid requirements (. . . ). The assumption of the program funders is that the [existing district health] system is decisions and resources to execute plans. As described in the Frontiers in Public Health | www.frontiersin.org 6 July 2020 | Volume 8 | Article 270 Heerdegen et al. Strengthening District Health Management Capacity sections above, the two latter aspects were limited. In terms of opportunities for professional growth, as well as their restricted competencies, the study participants reported that the DDHS’ autonomy to make decisions. are required to have a Master’s degree in Public Health and some years of public health experience. However, requirements “. . . you have highly trained leaders [referring to the DDHS’], but because of the way they [higher levels] are managing the system, of leadership or managerial experience were not formalized. This they are dampening their spirit (. . . ) So though you can do a lot, was a concern at the regional level. you have the skills to perform. . . but the way things are done we are unable to do anything.” (DHM). “The leaders who are appointed. . . sometimes have no leadership skills. . . in terms of cannot convince. . . cannot The sections above and the quote below demonstrate lead meetings. . . cannot hold any stakeholder meetings with how contextual and organizational aspects influence the communities and with the persons working there. So it’s a gap. So individual practices of DHMs, and that these need to be even if you are given the best of resources, you can’t perform. So the taken into consideration when aiming to strengthen district structures, as getting people who are qualified, and then making sure roles are specified. . . ” (RHA). health management. “You can train the person, but no matter how you train the person Nevertheless, the regional health administrators simultaneously (. . . ) if there is a system failure. . . you can have all the competent stated that the 26 DDHS’ within the Eastern Region at the people in the system because (. . . ) you are not going to work in time of this study were well-qualified. They all possessed isolation. (. . . ). You are looking at management as a system (. . . ) the required qualifications, in addition to having a certificate you need to make sure that all the systems are working properly in Health Administration and Management from the Ghana (. . . )” (RHA). Institute of Management and Public Administration (GIMPA). This certificate is recommended by the national level, yet DISCUSSION the DHMTs have to find place to fund it within the given district health budget. In addition, DDHS candidates with The aim of this study was to explore how district health no managerial experience are recommended to understudy a management emerges, hereunder the contextual, organizational practicing DDHS for some months prior to taking the position. and individual aspects that enable or hinder DHMs in carrying Meanwhile, there appeared to be no formalized requirements for out their functions. Our findings paint a picture of district health the remaining DHMs. management in which it is evident that management capacity not emerges from the competencies of the individual managers “. . . the appointment of these managers at the district and sub- alone, but through a complex interplay of elements within district level should be formalized. Like they appoint DDHS. Some the different levels. The political, social and economic context, laid down criteria will be there, so that the person qualify” (RHA). such as human, material and financial resource availability, mode of decentralization in terms of decision-making, and priorities among elected officials and other health partners, affect The majority of the DHMs reported not having received any organizational structures, processes and values, which in turn formal management and leadership training prior to being affect the DHMs abilities and motivation to carry out their duties. assigned to their role, but having acquired their competencies Supported by previous studies, this study identified contextual at their job. Nevertheless, general management and leadership aspects, such as delayed release of district health funds; poor skills among all DHMs, and not only the DDHS, were called infrastructure and working conditions; staff shortages at district for by the regional administrators, NGOs as well as by the and sub-district level; good working relationships within district DHMs themselves. Leadership skills in particular were described and between districts and regions; lack of opportunities for as being critical for DHMs to motivate frontline staff within professional development; and limited decision-making power, the limited resource settings, and to compete with other sectors as affecting the DHMs ability and willingness to carry out on resource inputs from the district assembly and NGOs, who their tasks effectively and efficiently (13, 25, 43–46). Moreover, frequently serve several sectors within the districts. To enhance management and in particular leadership competencies among the DHMs general management and leadership skills, the district DHMs, including abilities to effectively communicate, inspire has to fund their training from its own funds. This combined with and align employees and potential partners that can provide no one to cover for the person who goes away for training, results support, has in this study, as well as in other studies, been in such trainings rarely being offered to the DHMs. Meanwhile, emphasized as a mean to achieve results within the given trainings provided through vertical programs were described as contextual and organizational arrangements (47–49). primarily targeting the DHMs technical skills rather than their general management and leadership skills. Insights for Strengthening Management at Lastly, the effort the DHMTs put into carrying out their activities were positively affected by the DHMT dynamics District Level and supportive supervision from the regional level and Findings of this study underline that strengthening management respective DDHS’. Nevertheless, various aspects also appeared capacity at district level should be considered at multiple levels to impede their motivation, including the limited resources and rather than only at the individual level. The contextual level Frontiers in Public Health | www.frontiersin.org 7 July 2020 | Volume 8 | Article 270 Heerdegen et al. Strengthening District Health Management Capacity affects the organizational level through its provision of incentives systems are not created (58). Furthermore, in order for DHMs and an enabling environment (50–53). The organizational level to make decisions based on reliable and timely information, affects the individuals’ ability and willingness to perform by our findings indicate that information systems firstly must be providing a framework of structures, processes and procedures optimized by strengthening data reporting mechanisms at sub- (11). In turn, the individual practices at the district level take district level and by ensuring access to information systems in all part in maintaining and shaping the organizational context. The geographic areas, including those with poor tele network. contextual and organizational aspects are less tangible to change Adaptations in organizational structures and processes are compared with individual competencies, however critical for needed to enable DHMs to strengthen district health systems. creating sustainable improvements (16, 29). Nonetheless, these have evolved through decades, and will Certain policies need to be in place in order to ensure take time and political will to change (29). Some studies an enabling and incentivizing environment for the DHMTs. suggest that a critical mass of people with leadership skills at Policies and accountability structures should ensure that resource district level is likely to push changes in the context (48, 59). inputs are distributed in a timely manner. Similar to other In addition, learning from leadership development history in studies in Ghana, we found that untimely release of national Ghana, confident and capacitated DHMTs may push for more health insurance reimbursements, as well as delays in state and decision-space, as well as for changes in current organizational development partner funds, demoralize and prevent DHMs from structures and cultures that diminish bottom-up learning (35). carrying out their activities (25, 33, 54). We did not explore In addition, they may hold higher levels accountable to delayed the bottlenecks in the disbursement of funds, however these disbursements and to enhancing district health funding. must be identified and addressed to ensure that the DHMs Ensuring a sustained critical mass of leaders that are have the necessary resources to carry out their tasks. Advocating able and willing to push for change, firstly require policies for enhancing the commitment and budgetary allocation to that ensure management and leadership competencies among health by the Government of Ghana may also serve as a mean assigned health system managers. This study demonstrated to create a more enabling environment for DHMs. Currently that all DDHS’ within the Eastern Region held a certificate the allocation to health falls short of the 15% pledge in the in Health Administration and Management, largely due to Abuja declaration (55). Moreover, in concordance with another this being an institutionalized recommendation for filling this study from Ghana, we found that resource inputs from local role. Meanwhile, there were no formalized management and governments to some extent rely on personality driven relations leadership requirements for the remaining DHMs, similar to in and preferences among elected officials at the district assemblies other LMICs (47). Consequently, these had little exposure to (13). Currently, the Local Government Act 462 does not clearly management and leadership training, and district health funds define the roles and responsibilities of district assemblies in terms were not prioritized to enhance these competencies. of health, and practices relying on the DHMs ability to lobby are Moreover, sustained management capacity at district level thus encouraged. may be enhanced by building on existing structures and The organizational context is largely affected by political capacities. Confirmed by another study in Ghana, we identified decisions on health system organization, and the scarcity of aspects that enable DHMs to carry out their functions, including resources in the broader context. The hierarchical, top-down good relations within and between the districts and regions; approach to planning and problem-solving may hinder creative as well as the performance management system, in which and adaptive district management that are responsive to local supportive supervision takes place (13). The regions who have health challenges (13, 56, 57). positive relations with the districts are well-positioned to match This study demonstrated that prescriptive directives and fixed learning between well-performing and less performing districts funding diminish bottom-up learning, data-driven decision- based on insights from the performance management system. making, and limits the DHMs from integrating funds into Peer-review of management practices in which DHMTs learn activities, such as community engagement that strengthens the from other DHMTs take place to some extent in the Eastern district health system in ways that are necessary for sustaining Region of Ghana. However, it has to our knowledge not been improvements. In turn, this lessens the DHMs sense of ownership institutionalized and is not widely applied, demonstrated by and internalization of organizational goals and thus the effort neither of the DHMs in current study emphasizing peer-learning they execute (13, 51, 52). from other districts. A study from the Eastern Region of Ghana Other studies have also emphasized that vertical and donor found that better performing districts had transformational programs in Ghana may interrupt and delay coordinated leaders that use a participatory approach that promotes bottom- activities at the district level, as they are poorly planned, up communication to solve problems (60). Inter-district learning communicated, and come along with separate reporting systems may be an advantageous and sustainable approach to strengthen (3, 25, 58). The latter was confirmed in this study. Lack of management and leadership as peers are familiar with the integrated health information systems has been associated with contextual barriers, and how to achieve better performance with poor quality data (58). Thus, parallel reporting systems should be the means available within the given culture and context (61). prevented. Ways to do so may be explored in future research or Moreover, it is inexpensive, and learning from the LDP, using by looking to other countries, such as Rwanda where the MoH peers for mentorship and coaching may enhance commitment has commenced implementation of a nationwide comprehensive among the DHMs, compared with a top-down approach. Future electronic medical record system that ensures that parallel research may look into approaches to strengthen management Frontiers in Public Health | www.frontiersin.org 8 July 2020 | Volume 8 | Article 270 Heerdegen et al. Strengthening District Health Management Capacity and leadership that build on structures and capacities that already provide national policy-makers, donors, and researchers with are in place. a deeper understanding of factors that should be taken into consideration when developing, planning, implementing, and Strengths and Limitations assessing capacity-building strategies targeted at strengthening To understand situations systemically means to put them into district health management. context, and a “system approach” to capacity strengthening at district level, thus first and foremost requires a thorough DATA AVAILABILITY STATEMENT understanding of the context in which the DHMs operate (51). We explored this context through the eyes of DHMs and The datasets presented in this article are not readily available those they work closely with. The DHMs are at the center because it contains information that could compromise the of management strengthening interventions, yet their voices privacy of study participants. Requests to access the datasets are often left unheard despite knowing best what capacity should be directed to [email protected]. is needed and how it best can be developed and sustained within their culture and context (61). Moreover, by including ETHICS STATEMENT individuals who work closely with the DHMs, we gained a richer and more objective view of aspects influencing district Ethical clearance was obtained by the Research Ethics Committee health management. To gain a further understanding of the of Liverpool School of Tropical Medicine (ID No. 17–046) and context in which the DHMs are embedded, future research the Ghana Health Service Ethics Review Committee (No. GHS- may however also include other district health actors, including ERC004/01/20). The study participants provided their written local governments, sub-district health teams and frontline informed consent to participate in this study. health workers. Certain aspects affecting how district health management AUTHOR CONTRIBUTIONS emerges may have been overseen as this study not included all core members of the DHMTs due to the ongoing mass AH: design, data acquisition, analysis, interpretation, and distribution of bed nets. However, we argue that the risk of having drafting. JG: design, interpretation, and critical revision. SA, overseen any major challenges is minor as multiple DDHS’ and SAA, and MA: data acquisition and critical revision. KW: design regional health administrators who have a holistic overview were and critical revision. All authors have contributed to the article included in the study. and approved the submitted version. Data was categorized into contextual, organizational and individual factors that may impact how district health ACKNOWLEDGEMENTS management emerges, however these systemic layers and categorizations of elements within these, are not definitive, This study is an output from the PERFORM2Scale project and may leave out some factors that affect management (2017–2021): Strengthening management at district level to capacity. Other studies have for example emphasized that support the achievement of Universal Health Coverage, funded DHMs also are influenced by their personal family and by the European Commission (reference number: 733360). The socio-economic situation, remuneration, and stability of project involves a consortium of seven partners: Liverpool employment (62). School of Tropical Medicine, United Kingdom; Trinity College and Maynooth University, Ireland; Royal Tropical Institute Amsterdam, Netherlands; School of Public Health, University CONCLUSION of Ghana, Ghana; Swiss Tropical and Public Health Institute, Switzerland; REACH Trust, Malawi; and School of Public This study draws attention to aspects at the individual, Health, Makerere University, Uganda. The authors would like to organizational, and contextual level that influence how district acknowledge and thank all the study participants who took their health management emerges. Aspects that enable and hinder precious time to talk with us and inform the findings of this study. DHMs in carrying out their functions were identified, and may REFERENCES 4. Bradley EH, Taylor LA, Cuellar CJ. Management matters: a leverage point for health systems strengthening in global health. 1. Doherty T, Tran N, Sanders D, Dalglish SL, Hipgrave D, Rasanathan K, et al. Int J Health Policy Manag. 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Swanson RC, Atun R, Best A, Betigeri A, de Campos F, Chunharas S, potential conflict of interest. et al. Strengthening health systems in low-income countries by enhancing organizational capacities and improving institutions. Global Health. (2015) Copyright © 2020 Heerdegen, Gerold, Amon, Agyemang, Aikins and Wyss. This is an 11:5. doi: 10.1186/s12992-015-0090-3 open-access article distributed under the terms of the Creative Commons Attribution 58. Mutale W, Chintu N, Amoroso C, Awoonor-Williams K, Phillips J, License (CC BY). The use, distribution or reproduction in other forums is permitted, Baynes C, et al. Improving health information systems for decision provided the original author(s) and the copyright owner(s) are credited and that the making across five sub-Saharan African countries: implementation original publication in this journal is cited, in accordance with accepted academic strategies from the African health initiative. BMC Health Serv Res. (2013) practice. 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How Does District Health Management Emerge Within a Complex Health System? Insights for Capacity Strengthening in Ghana

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ORIGINAL RESEARCH published: 08 July 2020 doi: 10.3389/fpubh.2020.00270 How Does District Health Management Emerge Within a Complex Health System? Insights for Capacity Strengthening in Ghana 1,2 1,2 3 Anne Christine Stender Heerdegen , Jana Gerold , Samuel Amon , 3 3 1,2 Samuel Agyei Agyemang , Moses Aikins and Kaspar Wyss 1 2 3 Swiss Tropical and Public Health Institute, Basel, Switzerland, University of Basel, Basel, Switzerland, School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana Introduction: District health managers (DHMs) play a pivotal role in the operation of district health systems in low—and middle income countries, including Ghana. Their capacity is determined by their competencies, but also by the organization and system Edited by: in which they are embedded. The objective of this paper is to explore how district health Sunjoo Kang, Yonsei University, South Korea management emerges from contextual, organizational, and individual factors in order Reviewed by: to demonstrate that capacity strengthening efforts at district level need to transcend Nilesh Chandrakant Gawde, individual competencies to take on more systemic approaches. Tata Institute of Social Sciences, India James F. Phillips, Methods: Semi-structured interviews (n = 21) were conducted to gain insight into Columbia University Irving Medical aspects that affect district health management in the Eastern Region of Ghana. Interviews Center, United States were conducted with DHMs (n = 15) from six different districts, as well as with their *Correspondence: superiors at the regional level (n = 4) and peers from non-governmental organizations Anne Christine Heerdegen [email protected] (n = 2). A thematic analysis was conducted by using an analytical approach based on systems theory. Specialty section: This article was submitted to Results: Contextual aspects, such as priorities among elected officials, poor Public Health Education and infrastructure and working conditions, centralized decision-making, delayed Promotion, a section of the journal disbursement of funds and staff shortages, affect organizational processes and Frontiers in Public Health the way DHMs carry out their role. Enabling organizational aspects that provide DHMs Received: 30 March 2020 with direction and a clear perception of their role, include positive team dynamics, good Accepted: 26 May 2020 relations with supervisors, job descriptions, appraisals, information systems, policies Published: 08 July 2020 and guidelines. Meanwhile, hierarchical organizational structures, agendas driven by Citation: Heerdegen ACS, Gerold J, Amon S, vertical programs and limited opportunities for professional development provide DHMs Agyemang SA, Aikins M and Wyss K with limited authority to make decisions and dampens their motivation. The DHMs ability (2020) How Does District Health Management Emerge Within a to carry out their role effectively depends on their perception of their role and the effort Complex Health System? Insights for they expend, in addition to their competencies. In regards to competencies, a need for Capacity Strengthening in Ghana. more general management and leadership skills were called for by DHMs as well as by Front. Public Health 8:270. doi: 10.3389/fpubh.2020.00270 their superiors and peers. Frontiers in Public Health | www.frontiersin.org 1 July 2020 | Volume 8 | Article 270 Heerdegen et al. Strengthening District Health Management Capacity Conclusion: Systemic approaches are called for in order to strengthen district health management capacity. This study can provide national policy-makers, donors and researchers with a deeper understanding of factors that should be taken into consideration when developing, planning, implementing, and assessing capacity-building strategies targeted at strengthening district health management. Keywords: management and leadership, capacity strengthening, district health systems, systems thinking, complex adaptive systems, low- and middle-income countries, Ghana INTRODUCTION may elicit the need to expand management strengthening beyond the traditional approaches that perceive managers as In many low and middle-income countries (LMICs), including being outside the system with objective abilities to change the Ghana, district health managers’ (DHMs) are the ones who system (13). facilitate the management and implementation of primary Management Structures Within the Ghana healthcare. They have to translate national health policies, as well as human, material and financial inputs, into accessible, high Health System quality health services, and thus play a pivotal role in district In Ghana, the Ministry of Health (MoH) are in charge of health systems (1–4). Shortcomings within district health systems policy making and setting the strategic direction for the health in LMICs, such as an unequally distributed health workforce, sector. Meanwhile, the semi-autonomous agency Ghana Health high levels of absenteeism, medicine stock-outs and poor health Service (GHS) has been mandated by the MoH to implement outcomes, are often attributed to weak management capacity the national health policies through management and operation of nearly all public health facilities. To take on this mandate, (1, 3–9). Capacity has been defined as the “ability of individuals, the GHS is administratively organized at the national, regional organizations or systems to perform appropriate functions and district level (33). The GHS headquarters oversee the GHS effectively, efficiently and sustainably” (10). However, capacity Regional Health Administrations (RHA) that are located within strengthening within the health sector often focuses on each region. At the time this study took place, there were 10 enhancing the skills and technical capacity of individuals (11, 12). regions in Ghana, subdivided into 216 districts. The RHAs, led Individuals do however not operate in a vacuum, and their by the Regional Director of Health Services, oversee the District Health Administrations (DHA) that are established within each capacity is strongly influenced by the system and context in which they are embedded (12, 13). district. The DHAs are run by district health management teams (DHMTs), who are responsible for the operation and Since the 1980s, management strengthening interventions (MSIs) have had a predominant focus on strengthening the management of public health facilities within their district, including health centers and Community Health and Planning DHMs’ individual competencies rather than the system capacity (13–16). Individual competencies among DHMs are indeed Services (CHPS) (33). The DHMTs may consist of up to 12 core members that are led by a District Director of Health Services critical for them to carry out their job in an effective and efficient way (3, 13, 14, 17–25). Nevertheless, it has been posed that (DDHS). To our knowledge, there is no official document leadership and management within complex adaptive systems, outlining core members of DHMTs, however they typically such as the district health system, need to be considered as more include administrative officers (i.e., DDHS, Deputy Director of than the act of individuals, and rather as something that emerges Nursing Services and Health Administrators), technical officers (i.e., Public Health Nurse, Disease Control, Health Information, through an interplay of many interacting forces (26). District health managers’ operate within a context that incentivizes them Nutrition, Health Promotion Officers), and operational officers (i.e., Finance, Human Resource and Supply Officers). The to act in a certain way, and their practices are to a high extent influenced by and interdependent with other entities at the sub- core managers are assisted by various program heads, for example coordinators of community health - and disease district, district, regional and national level (3, 13, 14, 27–31). Inadequate attention has been paid to the influence of the control programs (i.e., CHPS, Tuberculosis, Malaria and HIV coordinators). The DHMTs are vertically accountable to RHAs, context and organizational structures in which DHMs operate in sub-Saharan Africa, including Ghana (13, 32). Thus, the aim of who in turn are accountable to GHS headquarters. Moreover, this paper is to explore how district health management emerges, the DHAs are horizontally accountable to the local governments, hereunder the contextual, organizational and individual aspects namely the district assemblies. The district assemblies are the that enable or hinder DHMs in carrying out their functions. highest political decision-making bodies within the districts, and play an important role in deciding how state resources are The findings may provide national policy-makers, donors and researchers with a deeper understanding of factors that allocated within the districts (34). The funds allocated to health by the district assemblies in each district depends on the priorities should be taken into consideration when developing, planning, implementing and assessing capacity-building strategies targeted of the district assembly and the lobbying power of the district health directorate (15). The private sector, non-governmental at strengthening district health management. Moreover, findings Frontiers in Public Health | www.frontiersin.org 2 July 2020 | Volume 8 | Article 270 Heerdegen et al. Strengthening District Health Management Capacity and faith-based organizations, as well as donor partners, also play their involvement in the PERFORM2Scale project. The sampling an important role in adding resources and addressing challenges strategy was purposive, as described by Ritchie et al. (37), related to service delivery within the Ghana health system. however some of the invited DHMs could not participate due to a National initiatives to strengthen management and leadership national mass distribution of long lasting insecticide-treated bed at district level have taken place in Ghana, including the nets taking place at the same time as this study. Leadership Development Program (LDP) and the Strengthening District Health System Initiative (SDHI) (13). The LDP has been Data Collection implemented in districts across Ghana since 2008. It takes on a Semi-structured in-depth interviews were carried out in team-based approach in which DHMTs apply management and February and March 2018, and were conducted by the first, leadership practices (i.e., root cause analysis, action planning, third and fourth author of this paper. The interviews were monitoring and evaluation etc.) to address service delivery facilitated by semi-structured interview guides, which were problems. Improved practices, team - and work climate were conceptualized based on the World Health Organizations observed during the program and shortly thereafter, however leadership and management strengthening framework (6). were not sustained (3). The unsustainability was partially Separate interview guides were developed for the DHMs, regional attributed to it being introduced in a top-down manner by health administrators and the NGO staff, respectively. However, regional officers, which diminished the DHMs own decision- the three guides included similar questions relating to: (1) making and thus ownership (3). The SDHI was implemented DHMs’ roles and responsibilities; (2) DHMs qualifications; in the late 1980’s. This program also focused on individual and (3) required and perceived management competencies among team competencies, including problem analysis and problem DHMs; (4) DHMs relationship with external partners (NGOs, solving (35). It was sustained for a while due to its focus on donors, academic institutions) and stakeholders at the national, local ownership and a close-knit network between the then regional, and sub-district level; and (5) the organizational and district leaders who shared management strengthening ideas environmental context surrounding DHMs, and how it affects amongst each other after the duration of the program. As a the DHMs in carrying out their responsibilities. Individual result of the program, the DHMTs became better planners interviews were conducted at the study participants’ workplace, and advocates for their needs as their capacity and confidence and lasted ∼40 minutes. All interviewees were informed about increased. Consequently, their decision-space was increased. the interviewers’ affiliation and the procedure of data collection. Nonetheless, the momentum of the SDHI waned after a couple of years partly due to the existing district leaders no Data Analysis longer being in the districts, partly due to lack of financial The interviews were transcribed and subsequently coded support (35). in the qualitative research software Nvivo 12 by using a general inductive approach, as described by Hsieh and Shannon (38). Following a content analysis, global themes METHODS were generated by using a systems theory approach, in Study Setting which data from DHMs, regional administrators and NGOs This study was conducted in six districts in the Eastern were organized into individual, organizational and contextual Region of Ghana. The districts were selected based on their aspects affecting management capacity at district level (39– involvement in the PERFORM2Scale project, which aims to 41) (Figure 1). The framework in Figure 1 demonstrates that scale-up a MSI at district level in Uganda, Malawi, and the broader context refers to situational circumstances and Ghana (www.perform2scale.org). characteristics that influence the behavior among DHMs, such as available resources, relationships with stakeholders, policies, and Study Design and Population regulations. Meanwhile, the organizational context refers to the This study took on an exploratory approach using qualitative characteristics of the organization of GHS in which the DHMTs interviews to gain insight into aspects that enable or hinder are embedded, including organizational processes and culture, DHMs in carrying out their duties in a way that improves health available management support systems and structures, including service delivery and population health outcomes at district level. the DHMs decision-making authority. Lastly, the individual The DHMs were thus the core unit of research, however to verify aspects refer to (1) the DHMs perception of their role, (2) their their observations, a data source triangulation approach was abilities and (3) the efforts they put into carrying out their duties applied (36). In addition to inviting DHMs to participate in the in an efficient and effective way. These three sub-themes have study, regional health administrators and staff from local non- been described by Byars and Rue as affecting the degree to which governmental organizations (NGOs) within the study districts an individual is fulfilling his or her assigned job tasks (42). were invited to participate. The regional health administrators supervise the DHMTs and thus have a good oversight of the Ethics resources and support systems available at district level, as well This study was carried out as an integral part of PERFORM2Scale as the individual capacity among DHMs. Meanwhile, the NGOs under the lead of the Liverpool School of Tropical Medicine collaborate closely with the DHMTs in the field and have insights (LSTM). Ethical clearance was obtained from the Research Ethics into how contextual, organizational or individual aspects affect Committee of LSTM (ID No. 17–046) and the GHS Ethics the DHMs. Access to study participants were obtained through Review Committee (No. GHS-ERC004/01/20). Written informed Frontiers in Public Health | www.frontiersin.org 3 July 2020 | Volume 8 | Article 270 Heerdegen et al. Strengthening District Health Management Capacity FIGURE 1 | Framework on aspects affecting effective and efficient District Health Management. consent was obtained from all study participants and they were interview a health promotion, human resource and supply officer informed about the possibility to withdraw from the interview at due to them being occupied by the ongoing national mass any time. distribution of bed nets. Contextual, organizational and individual aspects, and how they relate and interrelate to shape management at district level, RESULTS are discussed, respectively, in the sections below. A total of 21 key stakeholders participated in the study, including Contextual Aspects fifteen DHMs, four regional health administrators and two Study participants at district, regional and NGO level, repeatedly staff members from two different health-related NGOs located mentioned the infrastructure and physical environment within two of the study districts (Table 1). The mean age of the surrounding the district health facilities as a barrier for the DHMs participating in the study was around 41 years, and the DHMs to carry out their activities, in particular those posted in average time spent in their current management position was rural terrains. Not only did they report on the DHMs difficulties approximately three and half years. Six of the DHMs were female in getting to the facilities for their essential supervision (40%), which was a bit less than the actual proportion (∼50%) and monitoring responsibilities, but they also expressed of females within the DHMTs. One of the regional participants concerns about the distance they had to travel to work at and one of the NGO staff representatives were females. No the DHA. systematic differences were observed between men and women in the interviews, and the results do thus not emphasize gender related perspectives. “We do not have accommodation around, we are all living far The sample represented the majority of core DHMT positions away, so we cannot come easily to the office to do some work. People within the selected districts. However, we were unable to also come late because of that reason“ (DHM). Frontiers in Public Health | www.frontiersin.org 4 July 2020 | Volume 8 | Article 270 Heerdegen et al. Strengthening District Health Management Capacity TABLE 1 | Overview of interview participants. have rendered to health insurance which is not being paid back. So resources are locked.” (RHA). Occupation n The shortage of human resources for health, both at the frontline Regional level 4 and within the DHAs, and the DHMs limited decision-space to Regional Director 1 hire additional staff were emphasized by DHMs, as well as by Research Officer 1 RHAs and NGO staff members. The shortage within the DHA, Administrator 1 forces the DHMs to take on responsibilities that they are not Human Resource Officer 1 equipped or prepared for, and increases their workload. The District level 15 overburden may render them inefficient in their core duties. The District Director of Health Services 3 quote below demonstrates how a DHM took on myriad roles Deputy Director of Nursing Services 1 during his previous posting Health Administrator 1 Health Information Officer 4 “When I was in my old place, I was a transport officer, a CHPS Nutrition Officer 2 coordinator, I was the Procurement Officer and the Nutrition Disease Control Officer 2 Officer at the same time. And any time the Disease Control Officer Public Health Nurse 1 wasn’t there I acted as the Disease Control Officer” (DHM). Staff from health-related non-governmental organizations within the districts 2 Meanwhile, the staff shortage at the frontlines, hinder DHMTs in Total 21 their planning, coordination and execution of activities. “because they [HR at sub-district level] are not there, it means that all these tasks not actually are performed for the sub-district (. . . ) Appropriate accommodation is rarely offered to the DHMs meaning the system can only be weak because the pillars are not working” (DHM). when they are posted to a position in the district. This poses a challenge because the number of effective work hours are reduced significantly as they have to travel long distances to get to and The regional health administrators and the DDHS stated that from work. Moreover, in a setting with poor infrastructure, this annual objectives frequently were unmet due to the lack of poses a substantial safety risk at each commute. One manager financial, material and human resources. Moreover, one of mentioned how his colleague had been involved in an accident the NGO respondents stated that she had experienced that and lost her ability to walk. The limited number of motor DHMs due to a lack of resources and delayed funding were vehicles, as well as money for fuel, were also mentioned by study restrained from carrying out monitoring activities, and for participants as a hurdle for the DHMs in terms of carrying out example following up on frontline health workers that the NGO their essential monitoring and supervision activities. had supported the DHMT in training, causing the trainees to lose The inadequate resources allocated to the districts not only their newly acquired skills. manifests in mobility issues and thus activities that cannot be Study participants from the region, districts and NGOs, carried out due to long commuting distances and time spent emphasized the importance of the DHMs having a good on traveling, it further manifest in work places that diminish relationship with the officials at the district assembly in order effectivity and efficiency, i.e., poor lighting, lack of internet for them to receive additional resources and support to achieve connection, hot office temperatures, overcrowded offices and lack district health objectives. of equipment at health facilities. “(. . . ) we are all competing for the same resources. Education, health, agriculture (. . . ). We are competing, so we need to “. . . look at this office. . . this is where we work. (. . . ) It does not really have a very workable relationship with them [the District depict a well-performing office. When it comes to performance Assembly]” (DHM). the space that you will be allocated with will add on to your performance. Your office should not be as such when you enter the Presence of NGOs within the districts and a good working office and within 5–10 minutes you are tired” (DHM). relationship between the DHMTs and these, as well as with donor partners play a role in DHMTs reaching their goals of improving The regional adminstrators also emphasized these challenges, health indicators. Not only because the NGOs may support the and demonstrated frustration about their inability to address DHMTs with material resources and capacity building at the sub- the issues at district level, due to delayed release of district district level, but also because the NGOs independently work on health funds and health insurance reimbursement from the projects that aim to improve health outcomes within the district. national level. Non-governmental organizations were not present within all the study districts. “. . . if the health insurance is not giving back (. . . ) then how do we get the money to buy the resources and things. That is the “(. . . ) when an NGO comes in and tells me that their objective is issue. So part of the problem is the payment of the services that we to reduce maternal or neonatal deaths at least that burden will be Frontiers in Public Health | www.frontiersin.org 5 July 2020 | Volume 8 | Article 270 Heerdegen et al. Strengthening District Health Management Capacity off my chest. They will be coming to help me to surmount those working. (. . . ). If the funding of a vertical program was flexible problems.” (DHM). to integration, in that case, it can be also integrated in a way that will make both the system and the vertical programs sustainable.” (DHM). Organizational Aspects At the organizational level, structures and processes supporting Continuous community engagement was for example the DHMTs in carrying out their tasks, were identified. The highlighted by a DDHS as being critical for sustaining ones mostly emphasized as enhancing the capacity of the DHMs health improvements within the districts, however the lack include (1) positive team dynamics, frequent information and of flexible resources and guiding policies, restrained them from knowledge sharing within the DHMTs via Whatsapp groups carrying out such activities. Moreover, a DHM stated that the and weekly meetings; and (2) a good and highly dynamic prescriptive directives from higher levels contributed to an relationship between the district and regional level with regular organizational culture that not encourages DHMs to make communication and frequent supervisory check-ins. Moreover, data-driven decisions, as demonstrated by the quote below national directives (i.e., work plans, job descriptions, policies and guidelines) and the availability of health and HR information “We do not make decisions out of data (. . . ) I have been trained systems for surveillance, were mentioned as supporting the to use data. But we could have an interaction, and most of the DHMs in carrying out their duties. However, DHMs raised information I am giving you will not be based on the knowledge that concerns about the information systems relying on poor I have. Why? Because we do not have this culture [to use data]. (. . . ) connection, as well as on substandard data collection and you have to influence by leadership (. . . ) for the culture to change reporting at sub-district levels. Moreover, job descriptions were and become more adaptive to what the data shows” (DHM). not always aligning with actual responsibilities and data reporting forms were frequently outdated. In addition, multiple DHMs The vertical programs frequently target “popular” areas, such expressed a need for additional directives (i.e., on community as disease control, leaving the DHMs with limited funds to engagement, social and resource mobilization). cover other areas. To make the most of the allocated resources, Another emphasized management support structure was the integrated monitoring takes place, in which DHMs go jointly performance management system in which structured appraisals to the sub-districts and monitor a wide range of service take place, both between the DDHS and RHA, as well as between areas. This ensures efficient use of scarce resources by giving the DDHS and the remaining DHMs. The system provides “neglected” areas some attention. However, it reportedly also the DDHS and DHMs with supportive supervision, feedback compromises the overall quality of the essential monitoring and and holds them accountable. Nevertheless, the system was supervision activities. undermined by the fact that identified strengths and needs rarely could be rewarded or addressed due to a lack of institutional “. . . you don’t get time to do a detailed monitoring. (. . . ). When support. The RHA and some DHMTs had established informal you’re doing the monitoring and support visit you are supposed to sit there and watch the person do the work, and if there are loop award systems, for example best DHMT and employee prizes, holes or some problems you take over and let the person observe respectively, however this form of recognition was generally not you, so that you can correct them” (DHM). described by the DHMs as effective in terms of motivating them to do a better job. Nevertheless, the DHMs stated that the integrated monitoring provides them with a common understanding of the different “Formally the district is supposed to sponsor some people to go and DHMT members’ role and responsibilities, which is helpful do some management training. But anytime those opportunities in situations where a DHM is transferred or on leave, and others come, they tell us they do not have the funds to be able to support. So when you have a chance to do, for instance, when I went and did have to take over. my management training I sponsored it myself.” (DHM). Aspects at the Individual Level As depicted at the individual level in the framework (Figure 1), Both DHMs and regional administrators reported that DHMs effective and efficient DHMTs are likely to be determined by: (1) agendas were dominated by vertical programs. These were the DHMs perception of their role; (2) their abilities to carry out perceived positively in terms of adding resources to the district their responsibilities; and ultimately, by (3) the effort they put health system, however were described as contributing to a into carrying out their tasks. culture with little focus on systems strengthening. The vertical The DHMs appeared to have a clear perception of their role programs often have rigid requirements, inflexible funding, due to the dynamics and frequent information sharing within and come along with separate reporting systems that are the DHMTs, and the strong relationship with the regional level not integrated into existing systems. The DHMs have limited who provides supportive supervision. However, the shortage authority to decide on how to utilize the resources, and are of HR, which causes the DHMs to take on additional roles, hindered in integrating them in a way that strengthens the overall imposed a risk of them taking on roles they were not prepared health system. sufficiently for. The DHMs ability to meet objectives depends on their “. . . the vertical programs come with spreadsheets that have direct competencies, as well as on whether they have autonomy to make and very fixed, rigid requirements (. . . ). The assumption of the program funders is that the [existing district health] system is decisions and resources to execute plans. As described in the Frontiers in Public Health | www.frontiersin.org 6 July 2020 | Volume 8 | Article 270 Heerdegen et al. Strengthening District Health Management Capacity sections above, the two latter aspects were limited. In terms of opportunities for professional growth, as well as their restricted competencies, the study participants reported that the DDHS’ autonomy to make decisions. are required to have a Master’s degree in Public Health and some years of public health experience. However, requirements “. . . you have highly trained leaders [referring to the DDHS’], but because of the way they [higher levels] are managing the system, of leadership or managerial experience were not formalized. This they are dampening their spirit (. . . ) So though you can do a lot, was a concern at the regional level. you have the skills to perform. . . but the way things are done we are unable to do anything.” (DHM). “The leaders who are appointed. . . sometimes have no leadership skills. . . in terms of cannot convince. . . cannot The sections above and the quote below demonstrate lead meetings. . . cannot hold any stakeholder meetings with how contextual and organizational aspects influence the communities and with the persons working there. So it’s a gap. So individual practices of DHMs, and that these need to be even if you are given the best of resources, you can’t perform. So the taken into consideration when aiming to strengthen district structures, as getting people who are qualified, and then making sure roles are specified. . . ” (RHA). health management. “You can train the person, but no matter how you train the person Nevertheless, the regional health administrators simultaneously (. . . ) if there is a system failure. . . you can have all the competent stated that the 26 DDHS’ within the Eastern Region at the people in the system because (. . . ) you are not going to work in time of this study were well-qualified. They all possessed isolation. (. . . ). You are looking at management as a system (. . . ) the required qualifications, in addition to having a certificate you need to make sure that all the systems are working properly in Health Administration and Management from the Ghana (. . . )” (RHA). Institute of Management and Public Administration (GIMPA). This certificate is recommended by the national level, yet DISCUSSION the DHMTs have to find place to fund it within the given district health budget. In addition, DDHS candidates with The aim of this study was to explore how district health no managerial experience are recommended to understudy a management emerges, hereunder the contextual, organizational practicing DDHS for some months prior to taking the position. and individual aspects that enable or hinder DHMs in carrying Meanwhile, there appeared to be no formalized requirements for out their functions. Our findings paint a picture of district health the remaining DHMs. management in which it is evident that management capacity not emerges from the competencies of the individual managers “. . . the appointment of these managers at the district and sub- alone, but through a complex interplay of elements within district level should be formalized. Like they appoint DDHS. Some the different levels. The political, social and economic context, laid down criteria will be there, so that the person qualify” (RHA). such as human, material and financial resource availability, mode of decentralization in terms of decision-making, and priorities among elected officials and other health partners, affect The majority of the DHMs reported not having received any organizational structures, processes and values, which in turn formal management and leadership training prior to being affect the DHMs abilities and motivation to carry out their duties. assigned to their role, but having acquired their competencies Supported by previous studies, this study identified contextual at their job. Nevertheless, general management and leadership aspects, such as delayed release of district health funds; poor skills among all DHMs, and not only the DDHS, were called infrastructure and working conditions; staff shortages at district for by the regional administrators, NGOs as well as by the and sub-district level; good working relationships within district DHMs themselves. Leadership skills in particular were described and between districts and regions; lack of opportunities for as being critical for DHMs to motivate frontline staff within professional development; and limited decision-making power, the limited resource settings, and to compete with other sectors as affecting the DHMs ability and willingness to carry out on resource inputs from the district assembly and NGOs, who their tasks effectively and efficiently (13, 25, 43–46). Moreover, frequently serve several sectors within the districts. To enhance management and in particular leadership competencies among the DHMs general management and leadership skills, the district DHMs, including abilities to effectively communicate, inspire has to fund their training from its own funds. This combined with and align employees and potential partners that can provide no one to cover for the person who goes away for training, results support, has in this study, as well as in other studies, been in such trainings rarely being offered to the DHMs. Meanwhile, emphasized as a mean to achieve results within the given trainings provided through vertical programs were described as contextual and organizational arrangements (47–49). primarily targeting the DHMs technical skills rather than their general management and leadership skills. Insights for Strengthening Management at Lastly, the effort the DHMTs put into carrying out their activities were positively affected by the DHMT dynamics District Level and supportive supervision from the regional level and Findings of this study underline that strengthening management respective DDHS’. Nevertheless, various aspects also appeared capacity at district level should be considered at multiple levels to impede their motivation, including the limited resources and rather than only at the individual level. The contextual level Frontiers in Public Health | www.frontiersin.org 7 July 2020 | Volume 8 | Article 270 Heerdegen et al. Strengthening District Health Management Capacity affects the organizational level through its provision of incentives systems are not created (58). Furthermore, in order for DHMs and an enabling environment (50–53). The organizational level to make decisions based on reliable and timely information, affects the individuals’ ability and willingness to perform by our findings indicate that information systems firstly must be providing a framework of structures, processes and procedures optimized by strengthening data reporting mechanisms at sub- (11). In turn, the individual practices at the district level take district level and by ensuring access to information systems in all part in maintaining and shaping the organizational context. The geographic areas, including those with poor tele network. contextual and organizational aspects are less tangible to change Adaptations in organizational structures and processes are compared with individual competencies, however critical for needed to enable DHMs to strengthen district health systems. creating sustainable improvements (16, 29). Nonetheless, these have evolved through decades, and will Certain policies need to be in place in order to ensure take time and political will to change (29). Some studies an enabling and incentivizing environment for the DHMTs. suggest that a critical mass of people with leadership skills at Policies and accountability structures should ensure that resource district level is likely to push changes in the context (48, 59). inputs are distributed in a timely manner. Similar to other In addition, learning from leadership development history in studies in Ghana, we found that untimely release of national Ghana, confident and capacitated DHMTs may push for more health insurance reimbursements, as well as delays in state and decision-space, as well as for changes in current organizational development partner funds, demoralize and prevent DHMs from structures and cultures that diminish bottom-up learning (35). carrying out their activities (25, 33, 54). We did not explore In addition, they may hold higher levels accountable to delayed the bottlenecks in the disbursement of funds, however these disbursements and to enhancing district health funding. must be identified and addressed to ensure that the DHMs Ensuring a sustained critical mass of leaders that are have the necessary resources to carry out their tasks. Advocating able and willing to push for change, firstly require policies for enhancing the commitment and budgetary allocation to that ensure management and leadership competencies among health by the Government of Ghana may also serve as a mean assigned health system managers. This study demonstrated to create a more enabling environment for DHMs. Currently that all DDHS’ within the Eastern Region held a certificate the allocation to health falls short of the 15% pledge in the in Health Administration and Management, largely due to Abuja declaration (55). Moreover, in concordance with another this being an institutionalized recommendation for filling this study from Ghana, we found that resource inputs from local role. Meanwhile, there were no formalized management and governments to some extent rely on personality driven relations leadership requirements for the remaining DHMs, similar to in and preferences among elected officials at the district assemblies other LMICs (47). Consequently, these had little exposure to (13). Currently, the Local Government Act 462 does not clearly management and leadership training, and district health funds define the roles and responsibilities of district assemblies in terms were not prioritized to enhance these competencies. of health, and practices relying on the DHMs ability to lobby are Moreover, sustained management capacity at district level thus encouraged. may be enhanced by building on existing structures and The organizational context is largely affected by political capacities. Confirmed by another study in Ghana, we identified decisions on health system organization, and the scarcity of aspects that enable DHMs to carry out their functions, including resources in the broader context. The hierarchical, top-down good relations within and between the districts and regions; approach to planning and problem-solving may hinder creative as well as the performance management system, in which and adaptive district management that are responsive to local supportive supervision takes place (13). The regions who have health challenges (13, 56, 57). positive relations with the districts are well-positioned to match This study demonstrated that prescriptive directives and fixed learning between well-performing and less performing districts funding diminish bottom-up learning, data-driven decision- based on insights from the performance management system. making, and limits the DHMs from integrating funds into Peer-review of management practices in which DHMTs learn activities, such as community engagement that strengthens the from other DHMTs take place to some extent in the Eastern district health system in ways that are necessary for sustaining Region of Ghana. However, it has to our knowledge not been improvements. In turn, this lessens the DHMs sense of ownership institutionalized and is not widely applied, demonstrated by and internalization of organizational goals and thus the effort neither of the DHMs in current study emphasizing peer-learning they execute (13, 51, 52). from other districts. A study from the Eastern Region of Ghana Other studies have also emphasized that vertical and donor found that better performing districts had transformational programs in Ghana may interrupt and delay coordinated leaders that use a participatory approach that promotes bottom- activities at the district level, as they are poorly planned, up communication to solve problems (60). Inter-district learning communicated, and come along with separate reporting systems may be an advantageous and sustainable approach to strengthen (3, 25, 58). The latter was confirmed in this study. Lack of management and leadership as peers are familiar with the integrated health information systems has been associated with contextual barriers, and how to achieve better performance with poor quality data (58). Thus, parallel reporting systems should be the means available within the given culture and context (61). prevented. Ways to do so may be explored in future research or Moreover, it is inexpensive, and learning from the LDP, using by looking to other countries, such as Rwanda where the MoH peers for mentorship and coaching may enhance commitment has commenced implementation of a nationwide comprehensive among the DHMs, compared with a top-down approach. Future electronic medical record system that ensures that parallel research may look into approaches to strengthen management Frontiers in Public Health | www.frontiersin.org 8 July 2020 | Volume 8 | Article 270 Heerdegen et al. Strengthening District Health Management Capacity and leadership that build on structures and capacities that already provide national policy-makers, donors, and researchers with are in place. a deeper understanding of factors that should be taken into consideration when developing, planning, implementing, and Strengths and Limitations assessing capacity-building strategies targeted at strengthening To understand situations systemically means to put them into district health management. context, and a “system approach” to capacity strengthening at district level, thus first and foremost requires a thorough DATA AVAILABILITY STATEMENT understanding of the context in which the DHMs operate (51). We explored this context through the eyes of DHMs and The datasets presented in this article are not readily available those they work closely with. The DHMs are at the center because it contains information that could compromise the of management strengthening interventions, yet their voices privacy of study participants. Requests to access the datasets are often left unheard despite knowing best what capacity should be directed to [email protected]. is needed and how it best can be developed and sustained within their culture and context (61). Moreover, by including ETHICS STATEMENT individuals who work closely with the DHMs, we gained a richer and more objective view of aspects influencing district Ethical clearance was obtained by the Research Ethics Committee health management. To gain a further understanding of the of Liverpool School of Tropical Medicine (ID No. 17–046) and context in which the DHMs are embedded, future research the Ghana Health Service Ethics Review Committee (No. GHS- may however also include other district health actors, including ERC004/01/20). The study participants provided their written local governments, sub-district health teams and frontline informed consent to participate in this study. health workers. Certain aspects affecting how district health management AUTHOR CONTRIBUTIONS emerges may have been overseen as this study not included all core members of the DHMTs due to the ongoing mass AH: design, data acquisition, analysis, interpretation, and distribution of bed nets. However, we argue that the risk of having drafting. JG: design, interpretation, and critical revision. SA, overseen any major challenges is minor as multiple DDHS’ and SAA, and MA: data acquisition and critical revision. KW: design regional health administrators who have a holistic overview were and critical revision. All authors have contributed to the article included in the study. and approved the submitted version. Data was categorized into contextual, organizational and individual factors that may impact how district health ACKNOWLEDGEMENTS management emerges, however these systemic layers and categorizations of elements within these, are not definitive, This study is an output from the PERFORM2Scale project and may leave out some factors that affect management (2017–2021): Strengthening management at district level to capacity. Other studies have for example emphasized that support the achievement of Universal Health Coverage, funded DHMs also are influenced by their personal family and by the European Commission (reference number: 733360). The socio-economic situation, remuneration, and stability of project involves a consortium of seven partners: Liverpool employment (62). School of Tropical Medicine, United Kingdom; Trinity College and Maynooth University, Ireland; Royal Tropical Institute Amsterdam, Netherlands; School of Public Health, University CONCLUSION of Ghana, Ghana; Swiss Tropical and Public Health Institute, Switzerland; REACH Trust, Malawi; and School of Public This study draws attention to aspects at the individual, Health, Makerere University, Uganda. The authors would like to organizational, and contextual level that influence how district acknowledge and thank all the study participants who took their health management emerges. Aspects that enable and hinder precious time to talk with us and inform the findings of this study. DHMs in carrying out their functions were identified, and may REFERENCES 4. Bradley EH, Taylor LA, Cuellar CJ. Management matters: a leverage point for health systems strengthening in global health. 1. Doherty T, Tran N, Sanders D, Dalglish SL, Hipgrave D, Rasanathan K, et al. Int J Health Policy Manag. 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Swanson RC, Atun R, Best A, Betigeri A, de Campos F, Chunharas S, potential conflict of interest. et al. Strengthening health systems in low-income countries by enhancing organizational capacities and improving institutions. Global Health. (2015) Copyright © 2020 Heerdegen, Gerold, Amon, Agyemang, Aikins and Wyss. This is an 11:5. doi: 10.1186/s12992-015-0090-3 open-access article distributed under the terms of the Creative Commons Attribution 58. Mutale W, Chintu N, Amoroso C, Awoonor-Williams K, Phillips J, License (CC BY). The use, distribution or reproduction in other forums is permitted, Baynes C, et al. Improving health information systems for decision provided the original author(s) and the copyright owner(s) are credited and that the making across five sub-Saharan African countries: implementation original publication in this journal is cited, in accordance with accepted academic strategies from the African health initiative. BMC Health Serv Res. (2013) practice. 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