District health management and its association with health system performance in the Eastern Region of Ghana

Introduction: Effective and efficient management and leadership play an important role in ensuring robust and responsive health systems worldwide. In many African countries, including Ghana, which is of focus in current thesis, district health managers (DHMs) have been mandated by national levels to ensure that the people living within their respective districts have access to high quality health services. The DHMs are responsible for overseeing various health programs, and for ensuring that the appropriate resources (i.e. health workers, medicine, equipment and supplies) are at the right place at the right time. Moreover, they play an important role in ensuring that health workers’ remain motivated in terms of carrying out their jobs. Shortcomings in national health objectives in low-and middle-income countries are partially being attributed to weak management at district level. However, there is limited knowledge on public health system managers, and district health management practices in low- and middle-income countries. Most research on health management has taken place in hospital settings or in the private sector, and primarily in high-income settings.
This thesis was an integral part of the project PERFORM2Scale, which aims at implementing and scaling up a management strengthening intervention at district level in Ghana, Uganda and Malawi. The PERFORM2Scale project is funded by the European Union’s Horizon 2020 Research and Innovation Program.
Aim and objectives: The aim of this thesis is to analyze district health management, and its association with health system performance in Ghana. The specific objectives are: 1) To analyze how district health management emerges, hereunder the contextual, organizational and individual aspects that enable or hinder DHMs in carrying out their functions. 2) To assess managerial capacity at district level in Ghana, Uganda and Malawi. 3) To analyze the association between district health management and health system performance in Ghana, and 4) to analyze managerial practices related to health worker transfers in Ghana. This dissertation seeks to provide insights into district health management that may guide the development of management strengthening strategies in Ghana, and other countries with similarly decentralized health systems.
Methods: The thesis consists of four empirical studies and a commentary on management capacity strengthening. The empirical studies were conducted through a combination of quantitative, qualitative, and mixed-methods research approaches. Objective 1 was addressed through a qualitative study based on semi structured in-depth interviews with DHMs (n=15), their supervisors at regional level (n=4) and NGO partners (n=2). A data triangulation approach was applied to analyze the various study participants’ perspectives on aspects affecting DHMs in carrying out their responsibilities. Objective 2 was addressed through a self-administered cross-sectional survey, in which information was gathered on DHMs’ socio-demographic background; previous management experience and training; the extent of available management support systems; the DHMs self-assessed management competencies and skills; perceived team dynamics; job satisfaction, motivation and organizational commitment. The study includes a comparative descriptive analysis of data collected among DHMs within PERFORM2Scale districts in Ghana (n=32), Uganda (n=17) and Malawi (n=15). Objective 3 was achieved by applying the same cross-sectional survey distributed among DHMs in six districts in the Eastern Region of Ghana (n=59). A descriptive analysis was performed to identify individual and institutional capacity needs, and a non-parametric one-way analysis was applied to test whether there were significant differences in the measured aspects across different performing districts. Health system performance was derived from 17 nationally defined health indicators listed in the Ghana League Table of District Performance. Lastly, Objective 4 was addressed through semi-structured in-depth interviews with DHMs (n=9), regional health administrators (n=2) and national health administrators (n=7) who were involved in the posting and transfer of health workers; a structured face-to-face survey with recently transferred health workers (n=44); and a review of national posting policies and procedures. A data triangulation approach was applied to analyze the different stakeholder perspectives and potential discrepancies between practices and policies. Process maps were developed based on insights from health managers’ and transferred health workers, to picture the complexities of health workforce management practices in Ghana.
Results and discussion:
Objective 1: District health management practices emerge through a complex interplay of contextual, organizational and individual aspects. The contextual aspects include centralized planning and priority setting, priorities among elected officials, inadequate infrastructure, challenging work conditions, delayed disbursement of funds and staff shortages. These affect organizational processes and the way DHMs carry out their role. The hierarchical organizational structures and agendas driven by vertical programs provide DHMs with limited authority to make decisions that are responsive to community needs. The DHMs limited authority combined with restricted opportunities for professional development dampens their motivation and the effort they are willing to expend. Nonetheless, several enabling organizational aspects that provide DHMs with direction and a clear perception of their role were also identified. These include positive dynamics within the district health management teams, good relations with supervisors at the regional level, a well-functioning performance management system, available job descriptions, information systems, policies and guidelines, and highly qualified District Directors. At the individual level, a need for enhancing general management and leadership skills were called for by DHMs as well as by their superiors and peers. The findings demonstrate that district health management is complex, and that strengthening hereof requires systemic approaches.
Objective 2 and 3: Less than half of the studied DHMs in both Uganda (47%) and Ghana (48%) had received formal training in management and leadership, and more than one third had less than 1 year of managerial experience before being posted to their position (information unavailable for Malawi). The DHMs in Ghana rated their competencies, as well as the availability of management support systems more favorable compared with Uganda and particularly Malawi. Moreover, study participants in Ghana appeared to be more positive in terms of team dynamics, job motivation, satisfaction and organizational commitment compared with Uganda (information unavailable for Malawi). Nonetheless, individual and institutional capacity needs were identified within the six districts in Ghana, including managerial staff shortages, restricted funds and logistics to carry out essential supervision and monitoring activities, and limited management and leadership qualifications among DHMs.
It was identified that DHMs in high performing districts rated their overall management and leadership competencies (p=0.02), organizational commitment (p<0.01), teamwork (p=0.02) and communication within teams (p<0.01) better compared with lower performing districts.
Objective 4: One of the core functions of DHMs in Ghana is to appropriately staff health facilities through health worker transfers. Transfers are typically initiated by the DHMs, yet health workers may also initiate a transfer if they wish to leave their current posting. Transfers initiated by health workers were typically based on family and living conditions. Meanwhile, transfers initiated by managers typically were based on service requirements and performance. Managerial practices related to transfers appeared to be insufficiently guided by explicit policies and procedures, and thus depending on the discretion of the DHMs. The posting policies state underlying principles of fairness and transparency, however health worker perceptions of a non-transparent system existed. It was identified that transfer decisions frequently are made with limited involvement of health workers. The limited transparency in managers’ transfer decisions, combined with a lack of incentives for postings in deprived areas, were identified as contributing to dissatisfaction and intentions to leave among health workers.
Conclusion: This study was initiated to contribute to the limited knowledge and evidence surrounding district health management in LMICs. It provides insights into the characteristics of district health managers, and the organization and context in which they are embedded. These insights may be applied to strengthen district health systems in Ghana, as well as in other similarly decentralized settings in LMICs. This thesis provides a number of recommendations that may be considered, including
• Strengthen information channels and policies that ensure involvement of district health managers’ in national decision-making, planning and priority setting: In order to ensure district health systems that are led by motivated management teams, and health services that are more responsive to community needs, decision-makers at the national level may consider granting DHMs higher levels of autonomy in terms of how resources should be spent. Mechanisms, including information channels and policies, may also be developed to ensure involvement of DHMs in decision-making and priority setting.
• Integrate and prioritize “system software” in policies and strategies: At the management level, findings suggest that DHMs’ confidence in their own abilities, commitment and teamwork are associated with health system performance. Moreover, that their ability and willingness to carry out their functions are largely shaped by interpersonal factors (i.e. supportive supervision, relationships within DHMTs). At the health delivery level, findings suggest that managers’ insufficient involvement of health workers in transfer decision-making may result in job dissatisfaction. To ensure an efficient and effective system, the human dimension should be taken into account to a higher extent. This may be encouraged through different mechanisms, for example by creating more ‘people-centered’ policies and by introducing performance metrics such as health worker satisfaction, absenteeism and turnover that may incentivize changed behaviors and practices, such as enhanced participatory decision-making, improved working conditions and supportive supervision.
• Institutionalize management and leadership qualifications at district level: Study participants emphasized management and particularly leadership competencies as being important for all DHMs to navigate within the resource-constrained and complex context. Yet, management and leadership requirements were insufficiently defined for DHMT members, except the District Directors. Strategies to ensure appropriate competencies may be institutionalized by for example providing effective and short-term certified trainings to all DHMs as part of their orientation. The recruitment process of core DHMT members may also be enhanced to ensure that candidates possess the appropriate competencies by undertaking case interviews, requiring management and leadership experience with demonstrated results, or certain educational qualifications.
• Institutionalize district-to-district learning: The observed differences in health system performance between relatively similar districts suggest that inter-district learning may be considered as a viable management strengthening approach.
• Enhance information on the managerial workforce: There is limited information available on the managerial health workforce at the district level in Ghana. The WHO 2030 Workforce Strategy suggests a registry containing essential information on the health workforce. Such registry should include information on managerial staff cadres that can facilitate development, planning and monitoring of management strengthening initiatives.