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Background: Health systems in low-income countries are often characterized by poor health outcomes. While many reasons have been advanced to explain the persistently poor outcomes, management of the system has been found to play a key role. According to a WHO framework, the management of health systems is central to its ability to deliver needed health services. In this study, we examined how district managers in a rural setting in Uganda perceived existing approaches to strengthening management so as to provide a pragmatic and synergistic model for improving management capacity building. Methods: Twenty-two interviews were conducted with district level administrative and political managers, district level health managers and health facility managers to understand their perceptions and definitions of management and capacity building. Kathy Charmaz’s constructive approach to grounded theory informed the data analysis process. Results: An interative, dynamic and complex model with three sub-process of building a competent health manager was developed. A competent manager was understood as one who knew his/her roles, was well informed and was empowered to execute management functions. Professionalizing health managers which was viewed as the foundation, the use of engaging learning approaches as the inside contents and having a supportive work environment the frame of the model were the sub-processes involved in the model. The sub-processes were interconnected although the respondents agreed that having a supportive work environment was more time and effort intensive relative to the other two sub-processes. Conclusions: The model developed in our study makes four central contributions to enhance the WHO framework and the existing literature. First, it emphasizes management capacity building as an iterative, dynamic and complex process rather than a set of characteristics of competent managers. Second, our model suggests the need for professionalization of health managers at different levels of the health system. Third, our model underscores the benefits that could be accrued from the use of engaging learning approaches through prolonged and sustained processes that act in synergy. Lastly, our model postulates that different resource investments and a varied range of stakeholders could be required at each of the sub-processes.
The study was conducted in three rural eastern Uganda districts – Kamuli, Pallisa and Kibuku. Uganda’s territory is 240,038 km2 of which 82% is covered by land. Whereas the national population is 37 million inhabitants, the district of Kamuli has 486,319, Pallisa has 386,890 and Kibuku has 202,033 inhabitants. All three districts have a fertility rate average of 6 children per woman [29]. These districts are characterized of slow growing townships with opportunities for small scale trading while the main livelihood is subsistence farming. The health services in all three districts are administered in line with the decentralized health system described above. In addition, the three districts receive support from external partners, such as non-governmental organizations, international donor agencies, and academic institutions that focus on strengthening specific aspects of the health system or response to specific health conditions. These partners implement interventions in parts of the districts at different levels, usually through creating separate structures either within or without the formal health system structure. Makerere University School of Public Health (MakSPH), an academic institution to which authors, MT, EEK and SNK belong is one of such partners. At the time of the study, MakSPH was implementing a 4 year project called MANIFEST aimed at increasing access to maternal and neonatal health services in the three districts using a participatory action research approach. The project team worked closely with the district stakeholders to stimulate demand for maternal health services at community level as well as to improve on the quality of health services offered. The uniqueness of the MANIFEST project lay in its approach, which allowed the local district level stakeholders to lead the implementation of the project activities while the external project team played a supportive role. According to the informants in this study, such an approach had previously not been used in the three districts. Kathy Charmaz’s qualitative constructivist approach to grounded theory was used to conduct the study. This method was selected in order to capture local stakeholders’ own perceptions and definitions of management capacity building as well as approaches used to achieve this at the district level. The study began with some sensitizing concepts found in existing literature. While these concepts helped get the research started, the interviewing process remained open to exploring informants own definitions and understandings of the subject [30]. Informants were purposively selected from three different types of district managers: district level administrative and political managers, district level health managers and health facility managers also known as facility in-chargers. District level administrative and political managers selected included the district political heads, the chief administrative officers, and select district council members. District-level health mangers comprised the district health officers and specific program managers such as the district health educators, the district senior nursing officers and the district health information and management systems officers. Then lastly, health facility managers at HCIII and HCIV level were interviewed. All informants were chosen because they held key managerial positions at district level and in the health facilities that provide direct services to the population. For the facility managers, those who had been in service for at least 2 years were selected, as they were assumed to have a richer understanding and experience of the management function at their level. The facility level managers selected for this study came from both the intervention and comparison areas of the MANIFEST study. Table 1 is a summary of the informants’ characteristics. Summary of informants’ characteristics Typical health managers in this study were middle-aged, mostly males and had been in the role for over 6 years at the time of data collection. Managers generally did not have formal management training at the time of being assigned or appointed into the management role Data were collected using intensive interviewing, based on a guide with semi-structured questions [30]. The authors developed a specific guide based on the research question. On average, the interviews took approximately 45 min each. The interviewer [MT] adopted a conversational approach guided by sensitizing concepts (understanding of management, management capacity building, efforts undertaken to improve one’s management capacity, pros and cons of each of the efforts and preference for the efforts) in the interview guide as well as the direction of the responses from the informants. Each interview began by asking the informants to describe what their work usually involved as managers, and from that point on, the interviewer elicited more details while paying attention to new themes as well as ensuring that every informant covered all sensitizing concepts relevant to the subject of inquiry. Initially, two informants across the three districts were selected from each type of managers. These initial interviews informed the direction of the sampling, which is referred to as theoretical sampling in the grounded theory methodology [30]. In order to capture richer perceptions on management capacity building at district level; a decision was taken to interview additional health facility managers rather than the administrative and political managers. As the later were found to posses limited knowledge and experiences of the subject matter although they played key roles in the entire process as shall be seen in the results and decision sections. In total, 22 informants were interviewed: eleven facility managers, six district managers and five district level administrative and political managers. During data collection, memos were written on emerging codes that helped inform the direction of the interviews as well as the selection of the next informants. Saturation was reached by the 19th interview in the MANIFEST intervention areas, which meant that emerging categories were full [30]. Three more interviews were conducted in areas where the MANIFEST intervention was not being implemented in order to see whether these differed theoretically from the previous interviews. They did not and indeed they supported the emerging model. At this point a decision was made to stop collecting any more data. The same principle of saturation was applied during data analysis. The data analysis process was a continuous process of reflection and comparison between empirical findings and emerging codes, beginning from the time of data collection [30]. Interviews were transcribed by research assistants and safely stored in a computer folder and backed up. To check for accuracy, the first author listened to all the audio recordings while reading the transcripts before they were stored. The transcripts were read and re-read entirely to obtain an overall picture of the interviews and to get familiar with the data. The constant comparative method of analysis was continued with the transcribed interviews using MAXQDA a qualitative analysis software version 11.2. The next stage of analysis started by doing open coding (without any pre-determined codes) line by line and paragraph by paragraph in some instances [31]. Open codes were developed from and kept closest to the raw data with a very low level of abstraction. MT performed the coding, working closely with the last author. They shared and discussed the codes with the other authors so as to allow the examining of the codes in relation to the interview transcripts. This also ensured that the emerging analysis was grounded in the empirical data. The open codes were then grouped into clusters that related to each other and labeled. During focused coding, these labeled clusters were then used to re-examine the transcripts while concentrating the analysis on the selected concepts and sharpening them. During theoretical coding, four concepts were established: a competent health manager, professionalizing health managers, engaging learning approaches and a supportive work environment. The linkages between these theoretical codes were examined along with their relation to the theoretical codes families proposed by Glaser [31]. The theoretical code family of “processes” best fitted the findings as it clarified health managers’ perceptions of what mattered regarding health management and building management capacity. A model that captured the iterative process of building a competent health manager was reconstructed. Finally, the findings were compared with the WHO framework [7] and existing literature on management of health systems, as presented in the discussion section. Table 2 attempts to depict the movement from open codes to focused codes and to the theoretical codes. An Illustration of the coding process Table depicts the movement from open codes to focused codes and to the theoretical codes in the analysis process. The theoretical codes where achieved through a back and forth process between the focused codes, the open codes and the original transcripts in order to keep the integrity of the model The trustworthiness of our analysis and the resulting model can be assessed according to four criteria [30]. Our analysis and resulting model have credibility because these were achieved through an iterative process of getting familiar with the setting of the study and the data collected. Specifically, theoretical sampling, a back and forth process of analysis and data collection supported by memo writing was used. The principle of theoretical saturation was adhered to during the data collection to ensure that the theoretical categories in the model were fully explored. MT, EEK and SNK had been working with many of the respondents of the study for over five years as part of MakSPH’s support to districts. This presented an opportunity for MT to build good rapport with the informants and bring a solid understanding of the local context within which the health managers worked. Our analysis and resulting model has resonance because these were achieved through an iterative process that yielded theoretical saturation at both data collection and analysis. The differing and rich experiences of the managers were sufficiently reflected in the model as depicted in the results section of this paper. To further strengthen the resonance of the model, a preliminary model was shared with the study participants for reflection and accreditation. Further research is recommended to allow an actual reflection on the competencies that these different sub-processes that make up the model can actually build among health managers. Our analysis and resulting model have originality because they bring together several approaches that have previously been used and presented in either isolation or in combination. The model therefore advances interventions designed to build health managers’ capacity, which will invariably contribute to the strengthening of weak health systems in low-income countries. The model in addition provides distinctive prospects for different stakeholders to contribute to the process of building a competent health manager. Finally, our analysis and resulting model is modifiable. It may be used in, and modified by studies in other settings and among other cases. This model proposes the combined application of previously disjointed strategies for building health management competencies and enriches the existing literature of strengthening health systems. The authors of the model therefore acknowledge the possibilities of being fine-tuned through its practical application elsewhere. Importantly, the model needs to be tested to get a higher understanding of its applications in the real world.
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