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Participatory approaches to strengthening district health managers' capacity: Ugandan and global experiences
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.ORCID iD: 0000-0001-6833-7601
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Introduction:

Residents of low in-come countries have persistently suffered poor health outcomes, modest progress made over time notwithstanding. Weak health systems are one of the key reasons for the less than optimum progress. These health systems are constrained by inadequately equipped managers who play a main role in curbing this progress. Strengthening the capacity of health managers capacity is one of the known ways to improve the performance of health systems. This study examined strategies for strengthening the capacity of health managers at the sub-national level, with a special focus on the Participatory Action Research (PAR) approach.

Methods:

I used an emergent qualitative design which included both primary data collection and a literature review. Primary data collection techniques included individual interviews, Focus Group Discussions (FGDs), participant observations, and a review of project documents and meeting minutes, while searching for peer-reviewed databases was used for the literature review. Several analytical tools were adopted to answer the objectives, including the grounded theory, content and thematic analysis approaches. The Critical Interpretive Synthesis (CIS) method was used to analyze the literature reviewed.

Findings:

Stakeholders’ perceived the approaches to strengthening health managers’ capacity as an overarching process comprised of three interconnected subprocesses namely: the professionalizing of health managers, the use of engaging approaches to learning, and the availability of a supportive work environment. PAR as an engaging approach to learning was experienced by stakeholders as a nuanced awakening approach. On the one hand, stakeholders felt engaged, valued, responsible, awakened and a sense of ownership. On the other hand, they felt conflicted, stressed and uncertain. The PAR approach enhanced health managers’ capacity to collaborate with others, be creative, attain goals, and review progress. Expanded spaces for interaction, the encouragement of flexibility, the empowerment of local managers and the promotion of reflection and accountability enabled this enhancement. Lastly, the literature reviewed revealed five interrelated elements for harnessing PAR to strengthen health managers capacity. These were: a shared purpose, skilled facilitation and social psychological safety, activity integration into organizational procedures, organizational support and supportive external monitoring.

Conclusions:

Health managers have a central role in strengthening health systems; hence the formalization of their role, especially within the public-sector, is needed. In addition, significant investments into developing and strengthening their capacity is required. Strengthening the capacity of health managers is an iterative process that draws synergies from different approaches. The process leans on formal trainings as well as more engaging means of learning, such as PAR. As an engaging approach to learning, PAR expands interaction spaces, provides inclusiveness and flexibility, promotes local ingenuity and shared responsibility, and allows for monitoring and learning. PAR had positive effects on the strengthening of the capacity of health managers while at the same time achieving other project outcomes. Participatory approaches are hence relevant for dealing with the complex challenges bedevilling health systems. The approach nonetheless should be applied with a more nuanced appreciation of the challenges when using it and the elements for harnessing it to strengthen health systems.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2018. , p. 67
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1956
Keywords [en]
Participatory Action Research, Qualitative Research, Management, Health Managers, Systems Strengthening, Health Systems, Districts, Uganda
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Research subject
Public health
Identifiers
URN: urn:nbn:se:umu:diva-146957ISBN: 978-91-7601-866-8 (print)OAI: oai:DiVA.org:umu-146957DiVA, id: diva2:1200482
Public defence
2018-05-18, Lärosal N440, Naturvetarhuset, Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2018-04-27 Created: 2018-04-24 Last updated: 2018-06-09Bibliographically approved
List of papers
1. Building a competent health manager at district level: a grounded theory study from Eastern Uganda
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2016 (English)In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 16, article id 665Article in journal (Refereed) Published
Abstract [en]

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.

Keywords
Health management, Capacity building, Health systems, Low-income settings, District-level, Uganda, Grounded theory method
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-128957 (URN)10.1186/s12913-016-1918-0 (DOI)000388141000001 ()27871333 (PubMedID)
Available from: 2017-01-02 Created: 2016-12-20 Last updated: 2018-06-09Bibliographically approved
2. Experiences of using a participatory action research approach to strengthen district local capacity in Eastern Uganda
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2017 (English)In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, article id 1346038Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: To achieve a sustained improvement in health outcomes, the way health interventions are designed and implemented is critical. A participatory action research approach is applauded for building local capacity such as health management. Thereby increasing the chances of sustaining health interventions.

OBJECTIVE: This study explored stakeholder experiences of using PAR to implement an intervention meant to strengthen the local district capacity.

METHODS: This was a qualitative study featuring 18 informant interviews and a focus group discussion. Respondents included politicians, administrators, health managers and external researchers in three rural districts of eastern Uganda where PAR was used. Qualitative content analysis was used to explore stakeholders' experiences.

RESULTS: 'Being awakened' emerged as an overarching category capturing stakeholder experiences of using PAR. This was described in four interrelated and sequential categories, which included: stakeholder involvement, being invigorated, the risk of wide stakeholder engagement and balancing the risk of wide stakeholder engagement. In terms of involvement, the stakeholders felt engaged, a sense of ownership, felt valued and responsible during the implementation of the project. Being invigorated meant being awakened, inspired and supported. On the other hand, risks such as conflict, stress and uncertainty were reported, and finally these risks were balanced through tolerance, risk-awareness and collaboration.

CONCLUSIONS: The PAR approach was desirable because it created opportunities for building local capacity and enhancing continuity of interventions. Stakeholders were awakened by the approach, as it made them more responsive to systems challenges and possible local solutions. Nonetheless, the use of PAR should be considered in full knowledge of the undesirable and complex experiences, such as uncertainty, conflict and stress. This will enable adequate preparation and management of stakeholder expectations to maximize the benefits of the approach.

Place, publisher, year, edition, pages
Abingdon: Taylor & Francis, 2017
Keywords
Participatory action research, stakeholders experiences, local capacity, districts, implementation science
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-140440 (URN)10.1080/16549716.2017.1346038 (DOI)000423214500011 ()28856974 (PubMedID)
Note

Supplement 4: MANIFEST (Maternal and Neonatal Implementation for Equitable Systems Study)

Available from: 2017-10-11 Created: 2017-10-11 Last updated: 2018-06-09Bibliographically approved
3. A participatory action research approach to strengthening health managers' capacity at district level in Eastern Uganda
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2017 (English)In: Health Research Policy and Systems, ISSN 1478-4505, E-ISSN 1478-4505, Vol. 15, article id 110Article in journal (Refereed) Published
Abstract [en]

Background: Many approaches to improving health managers' capacity in poor countries, particularly those pursued by external agencies, employ non-participatory approaches and often seek to circumvent (rather than strengthen) weak public management structures. This limits opportunities for strengthening local health managers' capacity, improving resource utilisation and enhancing service delivery. This study explored the contribution of a participatory action research approach to strengthening health managers' capacity in Eastern Uganda.

Methods: This was a qualitative study that used open-ended key informant interviews, combined with review of meeting minutes and observations to collect data. Both inductive and deductive thematic analysis was undertaken. The Competing Values Framework of organisational management functions guided the deductive process of analysis and the interpretation of the findings. The framework builds on four earlier models of management and regards them as complementary rather than conflicting, and identifies four managers' capacities (collaborate, create, compete and control) by categorising them along two axes, one contrasting flexibility versus control and the other internal versus external organisational focus.

Results: The findings indicate that the participatory action research approach enhanced health managers' capacity to collaborate with others, be creative, attain goals and review progress. The enablers included expanded interaction spaces, encouragement of flexibility, empowerment of local managers, and the promotion of reflection and accountability. Tension and conflict across different management functions was apparent; for example, while there was a need to collaborate, maintaining control over processes was also needed. These tensions meant that managers needed to learn to simultaneously draw upon and use different capacities as reflected by the Competing Values Framework in order to maximise their effectiveness.

Conclusions: Improved health manager capacity is essential if sustained improvements in health outcomes in low-income countries are to be attained. The expansion of interaction spaces, encouragement of flexibility, empowerment of local managers, and the promotion of reflection and accountability were the key means by which participatory action research strengthened health managers' capacity. The participatory approach to implementation therefore created opportunities to strengthen health managers' capacity.

Place, publisher, year, edition, pages
BioMed Central, 2017
Keywords
competing values framework, district health managers, health systems, participatory action research, Uganda
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-143689 (URN)10.1186/s12961-017-0273-x (DOI)000419507300007 ()29297346 (PubMedID)
Note

Supplement: 2

Available from: 2018-01-05 Created: 2018-01-05 Last updated: 2018-06-09Bibliographically approved
4. Elements for harnessing participatory action research to strengthen health managers’ capacity: a critical interpretative synthesis
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2018 (English)In: Health Research Policy and Systems, ISSN 1478-4505, E-ISSN 1478-4505, Vol. 16, article id 33Article, review/survey (Refereed) Published
Abstract [en]

Background: Health managers play a key role in ensuring that health services are responsive to the needs of the population. Participatory action research (PAR) is one of the approaches that have been used to strengthen managers’ capacity. However, collated knowledge on elements for harnessing PAR to strengthen managers’ capacity is missing. This paper bridges this gap by reviewing existing literature on the subject matter.

Methods: A critical interpretive synthesis method was used to interrogate eight selected articles. These articles reported the use of PAR to strengthen health managers’ capacity. The critical interpretive synthesis method’s approach to analysis guided the synthesis. Here, the authors interpretively made connections and linkages between different elements identified in the literature. Finally, the Atun et al. (Heal Pol Plann, 25:104–111, 2010) framework on integration was used to model the elements synthesised in the literature into five main domains.

Results: Five elements with intricate bi-directional interactions were identified in the literature reviewed. These included a shared purpose, skilled facilitation and psychological safety, activity integration into organisational procedures, organisational support, and external supportive monitoring. A shared purpose of the managers’ capacity strengthening initiative created commitment and motivation to learn. This purpose was built upon a set of facilitation skills that included promoting participation, self-efficacy and reflection, thereby creating a safe psychological space within which the managers interacted and learnt from each other and their actions. Additionally, an integrated intervention strengthened local capacity and harnessed organisational support for learning. Finally, supportive monitoring from external partners, such as researchers, ensured quality, building of local capacity and professional safety networks essential for continued learning.

Conclusions: The five elements identified in this synthesis provide a basis upon which the use of PAR can be harnessed, not only to strengthen health managers’ capacity, but also to foster other health systems strengthening initiatives involving implementation research. In addition, the findings demonstrated the intricate and complex relations between the elements, which further affirms the need for a systems thinking approach to tackling health systems challenges.

Place, publisher, year, edition, pages
BioMed Central, 2018
Keywords
Participatory Action Research, factors, harnessing, health managers' capacity, systems thinking, implementation research
National Category
Health Care Service and Management, Health Policy and Services and Health Economy Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-146830 (URN)10.1186/s12961-018-0306-0 (DOI)29673346 (PubMedID)
Available from: 2018-04-19 Created: 2018-04-19 Last updated: 2018-06-09Bibliographically approved

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