Building a competent health manager at district level: a grounded theory study from Eastern Uganda

Power and positionality in the practice of health system responsiveness at sub-national level: insights from the Kenyan coast

BACKGROUND

Health system responsiveness to public priorities and needs is a broad, multi-faceted and complex health system goal thought to be important in promoting inclusivity and reducing system inequity in participation. Power dynamics underlie the complexity of responsiveness but are rarely considered. This paper presents an analysis of various manifestations of power within the responsiveness practices of Health Facility Committees (HFCs) and Sub-county Health Management Teams (SCHMTs) operating at the subnational level in Kenya. Kenyan policy documents identify responsiveness as an important policy goal.

METHODS

Our analysis draws on qualitative data (35 interviews with health managers and local politicians, four focus group discussions with HFC members, observations of SCHMT meetings, and document review) from a study conducted at the Kenyan Coast. We applied a combination of two power frameworks to interpret our findings: Gaventa's power cube and Long's actor interface analysis.

RESULTS

We observed a weakly responsive health system in which system-wide and equity in responsiveness were frequently undermined by varied forms and practices of power. The public were commonly dominated in their interactions with other health system actors: invisible and hidden power interacted to limit their sharing of feedback; while the visible power of organisational hierarchy constrained HFCs' and SCHMTs' capacity both to support public feedback mechanisms and to respond to concerns raised. These power practices were underpinned by positional power relationships, personal characteristics, and world views. Nonetheless, HFCs, SCHMTs and the public creatively exercised some power to influence responsiveness, for example through collaborations with political actors. However, most resulting responses were unsustainable, and sometimes undermined equity as politicians sought unfair advantage for their constituents.

CONCLUSION

Our findings illuminate the structures and mechanisms that contribute to weak health system responsiveness even in contexts where it is prioritised in policy documents. Supporting inclusion and participation of the public in feedback mechanisms can strengthen receipt of public feedback; however, measures to enhance public agency to participate are also needed. In addition, an organisational environment and culture that empowers health managers to respond to public inputs is required.

Tools, frameworks and resources to guide global action on strengthening rural health systems: a mapping review

BACKGROUND

Inequities of health outcomes persist in rural populations globally. This is strongly associated with there being less health coverage in rural and underserviced areas. Increasing health care coverage in rural area requires rural health system strengthening, which subsequently necessitates having tools to guide action.

OBJECTIVE

This mapping review aimed to describe the range of tools, frameworks and resources (hereafter called tools) available globally for rural health system capacity building.

METHODS

This study collected peer-reviewed materials published in 15-year period (2005-2020). A systematic mapping review process identified 149 articles for inclusion, related to 144 tools that had been developed, implemented, and/or evaluated (some tools reported over multiple articles) which were mapped against the World Health Organization's (WHO's) six health system building blocks (agreed as the elements that need to be addressed to strengthen health systems).

RESULTS

The majority of tools were from high- and middle-income countries (n = 85, 59% and n = 43, 29%, respectively), and only 17 tools (12%) from low-income countries. Most tools related to the health service building block (n = 57, 39%), or workforce (n = 33, 23%). There were a few tools related to information and leadership and governance (n = 8, 5% each). Very few tools related to infrastructure (n = 3, 2%) and financing (n = 4, 3%). This mapping review also provided broad quality appraisal, showing that the majority of the tools had been evaluated or validated, or both (n = 106, 74%).

CONCLUSION

This mapping review provides evidence that there is a breadth of tools available for health system strengthening globally along with some gaps where no tools were identified for specific health system building blocks. Furthermore, most tools were developed and applied in HIC/MIC and it is important to consider factors that influence their utility in LMIC settings. It may be important to develop new tools related to infrastructure and financing. Tools that have been positively evaluated should be made available to all rural communities, to ensure comprehensive global action on rural health system strengthening.

Dimensions of Health Care Management Professionalization: A Scoping Review

Background

Within the public sector, health managers occupy positions that are typically filled by individuals with a medical, clinical, or nursing experience who are entrusted with assuming an additional role. The primary objective of this study was to employ a scoping review methodology to ascertain a cluster of prevalent subjects encompassing the development of a proficient health care manager.

Methods

The purpose of this scoping review study was to identify critical components in the field of management professionalization, as described by Arksey and O'Malley. A total of 13 studies, characterized by predefined keywords, were meticulously culled from Scopus, Web of Science, PubMed, and Embase, Magiran, and SID databases. The inclusion and exclusion criteria considered factors such as language, temporal relevance, redundancy, thematic alignment with the professionalization domain, and congruence with the overarching objectives and methodologies of the present investigation. Subsequently, the contents of the selected studies were subjected to rigorous thematic analysis and judicious categorization using a framework analysis approach.

Results

From a total of 10,117 articles, a rigorous selection process yielded 13 articles to be included in this study. The identified dimensions are classified and elucidated across 6 overarching domains; namely, the science of management, educational trajectory, and curriculum, cultural infrastructure and ideologies, standards, professional institutions and associations, and licenses and certifications.

Conclusion

To enhance the efficacy of health management, policymakers and planners ought to adeptly incorporate these dimensions within the framework of the country's health system.

Sustainability capacity and health worker normalisation of a successful non-communicable disease (NCD) health systems intervention within primary care settings in Uganda: a quantitative approach to a qualitative question

BACKGROUND

Interventions for non-communicable diseases are increasingly implemented and evaluated in sub-Saharan Africa, but little is known about their medium- to long-term sustainability beyond the end of research funding. A cluster randomised trial conducted between 2013 and 2016 in Uganda and Tanzania showed that an intervention package to improve hypertension (HT) and type-2 diabetes mellitus (DM) care was highly effective in increasing service readiness and quality of care. The present study assesses the sustainability of the intervention 4 years after the trial in Uganda.

METHODS

The study was conducted in 2020 in 22 primary care health facilities (HFs) (3 referrals and 19 lower-level units) that had received the intervention package until trial end (2016), to assess their current capacity and practice to sustain ongoing intervention activities for HT and DM care. Through a cross-sectional survey, 4 pre-defined domains (i.e., cognitive participation, coherence, collective action, and reflexive monitoring) were examined with regard to health worker (HW) normalization and 8 pre-defined domains for intervention sustainability (i.e., organisational capacity, local environment, funding stability, partnerships, communication, evaluation, adaptation, and strategic planning), using the normalisation tool and the program sustainability tool (PSAT). Summary scores were assessed by domains and facility level.

RESULTS

Overall normalization strength was adequate at 4.0 (IQR: 3.8, 4.2) of a possible 5 with no evidence of association with HF level (p = 0.40); cognitive participation (buy-in) and reflexive monitoring (appraisal) were strongest at > 4 across all HF levels. All HF levels were weak (< 4) on collective action (teamwork) and coherence (sense-making). Only collective action differed by level (p < 0.002). Overall intervention sustainability was suboptimal at 3.1 [IQR: 1.9, 4.1] of a possible 7 with weak scores on funding stability (2.0), supportive partnerships (2.2), and strategic planning (2.6). Domain differences by HF level were significant for environmental support (p = 0.02) and capacity in organisation (p = 0.01). Adequate strength at a cut-off mean of ≥5 did not differ by HF level for any domain.

CONCLUSIONS

Four years after their introduction, practice-dependent intervention elements e.g., local organisational context, HW knowledge or dedication were sustained, but external elements e.g., new funding support or attracting new partners to sustain intervention efforts were not. Whenever new interventions are introduced into an existing health service, their long-term sustainability including the required financial support should be ensured. The quality of services should be upheld by providing routine in-service training with dedicated support supervision.

How capacity building of district health managers has been designed, delivered and evaluated in sub-Saharan Africa: a scoping review and best fit framework analysis

OBJECTIVES

We aimed to understand how capacity building programmes (CBPs) of district health managers (DHMs) have been designed, delivered and evaluated in sub-Saharan Africa. We focused on identifying the underlying assumptions behind leadership and management CBPs at the district level.

DESIGN

Scoping review.

DATA SOURCES

We searched five electronic databases (MEDLINE, Health Systems Evidence, Wiley Online Library, Cochrane Library and Google Scholar) on 6 April 2021 and 13 October 2022. We also searched for grey literature and used citation tracking.

ELIGIBILITY CRITERIA

We included all primary studies (1) reporting leadership or management capacity building of DHMs, (2) in sub-Saharan Africa, (3) written in English or French and (4) published between 1 January 1987 and 13 October 2022.

DATA EXTRACTION AND SYNTHESIS

Three independent reviewers extracted data from included articles. We used the best fit framework synthesis approach to identify an a priori framework that guided data coding, analysis and synthesis. We also conducted an inductive analysis of data that could not be coded against the a priori framework.

RESULTS

We identified 2523 papers and ultimately included 44 papers after screening and assessment for eligibility. Key findings included (1) a scarcity of explicit theories underlying CBPs, (2) a diversity of learning approaches with increasing use of the action learning approach, (3) a diversity of content with a focus on management rather than leadership functions and (4) a diversity of evaluation methods with limited use of theory-driven designs to evaluate leadership and management capacity building interventions.

CONCLUSION

This review highlights the need for explicit and well-articulated programme theories for leadership and management development interventions and the need for strengthening their evaluation using theory-driven designs that fit the complexity of health systems.

Capacity building of district health management teams in the era of provincial health administration reform in the Democratic Republic of Congo: a realist evaluation protocol

INTRODUCTION

In 2006, the Congolese Ministry of Health developed a health system strengthening strategy focusing on health district development. This strategy called for reforming the provincial health administration in order to better support the health district development through leadership and management capacity building of district health management teams. The implementation is currently underway, yet, more evidence on how, for whom and under what conditions this capacity building works is needed. The proposed research aims to address this gap using a realist evaluation approach.

METHODS AND ANALYSIS

We will follow the cycle of the realist evaluation. First, we will elicit the initial programme theory through a scoping review (completed in December 2022, using MEDLINE, Health Systems Evidence, Wiley Online Library, Cochrane Library, Google Scholar and grey literature), a review of health policy documents (completed in March 2023), and interviews with key stakeholders (by June 2023). Second, we will empirically test the initial programme theory using a multiple-embedded case study design in two provincial health administrations and four health districts (by March 2024). Data will be collected through document reviews, in-depth interviews, non-participant observations, a questionnaire, routine data from the health information management system and a context mapping tool. We will analyse data using the Intervention-Context-Actor-Mechanism-Outcome configuration heuristic. Last, we will refine the initial programme theory based on the results of the empirical studies and develop recommendations for policymakers (by June 2024).

ETHICS AND DISSEMINATION

The Institutional Review Board of the Institute of Tropical Medicine and the Medical Ethics Committee of the University of Lubumbashi approved this study. We will also seek approvals from provincial-level and district-level health authorities before data collection in their jurisdictions. We will disseminate the study findings through the publication of articles in peer-reviewed academic journals, policy briefs for national policymakers and presentations at national and international conferences.

Acceptability and feasibility of inter-related activities to improve agency among African district health managers: A four-country study

District health managers (DHMs) lead and manage Ministry of Health programmes and system performance. We report on the acceptability and feasibility of inter-related activities to increase the agency of DHMs in Kenya, Nigeria, South Africa and Uganda using a cross-sectional rapid appraisal with 372 DHMs employing structured questionnaires. We found differences and similarities between the countries, in particular, who becomes a DHM. The opportunity to provide leadership and effect change and being part of a team were reported as rewarding aspects of DHMs' work. Demotivating factors included limited resources, bureaucracy, staff shortages, lack of support from leadership and inadequate delegation of authority. District managers ranked the acceptability of the inter-related activities similarly despite differences between contexts. Activities highly ranked by DHMs were to employ someone to support primary care staff to compile and analyse district-level data; to undertake study tours to well-functioning districts; and joining an African Regional DHM Association. DHMs rated these activities as feasible to implement. This study confirms that DHMs are in support of a process to promote bottom-up, data-driven, context-specific actions that can promote self-actualisation, recognises the roles DHMs play, provides opportunities for peer learning and can potentially improve quality of care.

An assessment of a 'training-of-trainers programme for clinic committees' in a South African district: a qualitative exploratory study

Background

In South Africa (SA), clinics and community health centres are the predominant primary level health care facilities in the public health sector. As part of legislated health governance requirements, clinic committees (referring to those for clinics and community health centres) were established to provide management oversight and bring to bear the perspectives and participation of communities at Primary Health Care (PHC) facilities. Clinic committees need training in order to better understand their roles. Facilitators in a district of SA were trained through a designated programme, called the ‘PHC Facility Governance Structures Trainer-of-Facilitator (ToF) Learning Programme‘, in preparation for the training of clinic committees. This paper explores how the programme had evolved and was experienced by the trained facilitators, in a district in SA.

Methods

We employed a retrospective qualitative case study design, guided by the Illuminative Evaluation Framework, with the training programme in the selected district as the case. The study assessed whether the intended aims of the training programme were clearly conveyed by the trainers, and how participants understood and subsequently conveyed the training programme intentions to the clinic committees. Key informant interviews and focus group discussions were conducted with trainers and managers, complemented by a review of relevant policy and legislative documents, and published literature.

Study participants were purposively selected based on their involvement in the development, facilitation or training of the programme. Thirteen individuals participated in the study, and 23 (national, provincial and partner) documents were reviewed.

Results

Despite the different perceptions and understandings of the ToF Learning Programme, its overall aims were achieved. Trainers’ capacity was strengthened and clinic committees were trained accordingly. The training programme holds promise for possible national scale-up. The high quality of the interactive posters can be considered equally valuable as a training tool as the training manuals.

Conclusions

Trainers’ capacity was strengthened and clinic committees were trained accordingly, despite deviations in implementation of the original training approach and plan.

Exploring Issues and Challenges of Leadership among Early Career Doctors in Nigeria Using a Mixed-Method Approach: CHARTING Study

(1) Background: leadership behaviour is a poorly explored phenomenon among early-career doctors (ECDs). Good leadership is vital in maximising the effective management of patients in a clinical setting. While a good number of studies, though with small sample surveys, have researched the role of leadership in clinical setting quantitatively, qualitative investigations are yet to be done in Nigeria. This study aims to explore the attitudes, skills, and experience of ECDs in Nigeria on issues pertaining to leadership in a medical setting, using a mixed-method approach. (2) Methods: we conducted two sessions of key informant focus group discussion (FGD) that involved 14 ECD leaders in Nigeria, exploring their leadership experience in a clinical setting. Furthermore, we used a self-administered questionnaire to quantitatively survey 474 ECDs from seven Nigerian teaching hospitals to explore their attitudes, skills, and experience on issues pertaining to medical leadership. (3) Results: taking on leadership roles is a common phenomenon (52.7%) among the surveyed ECDs; however, the medical leadership position can be very challenging for ECDs in Nigeria. Despite the fact that many (91.1%) of the surveyed ECDs perceived leadership skills as essential skills needed by a doctr, many (44.1%) of them were yet to be formally trained on medical leadership. About three out of every 10 (23.6%) of surveyed ECDs that have ever held leadership positions in a medical setting experienced major leadership challenges while in such office due to their lack of training on leadership skills. Leadership skill acquisition programmes are highly recommended to become an integral part of medical training programmes in Nigeria. (4) Conclusion: there is a need for a structured leadership skill acquisition programme for ECDs in Nigeria. This programme will help in the robust delivery of highly effective healthcare services in Nigeria, as effective leadership is crucial to patient care services.

Managerial capacity among district health managers and its association with district performance: A comparative descriptive study of six districts in the Eastern Region of Ghana

INTRODUCTION

District health managers play a pivotal role in the delivery of basic health services in many countries, including Ghana, as they are responsible for converting inputs and resources such as, staff, supplies and equipment into effective services that are responsive to population needs. Weak management capacity among local health managers has been suggested as a major obstacle for responsive health service delivery. However, evidence on district health managers' competencies and its association with health system performance is scarce.

AIM

To examine managerial capacity among district health managers and its association with health system performance in six districts in the Eastern Region of Ghana.

METHODS

Fifty-nine district health managers' in six different performing districts in the Eastern Region of Ghana completed a self-administered questionnaire measuring their management competencies and skills. In addition, the participants provided information on their socio-demographic background; previous management experience and training; the extent of available management support systems, and the dynamics within their district health management teams. A non-parametric one-way analysis was applied to test the association between management capacity and district performance, which was measured by 17 health indicators.

RESULTS

Shortcomings within different aspects of district management were identified, however there were no significant differences observed in the availability of support systems, characteristics and qualifications of district health managers across the different performing districts. Overall management capacity among district health managers were significantly higher in high performing districts compared with lower performing districts (p = 0.02). Furthermore, district health managers in better performing districts reported a higher extent of teamwork (p = 0.02), communication within their teams (p<0.01) and organizational commitment (p<0.01) compared with lower performing districts.

CONCLUSION

The findings demonstrate individual and institutional capacity needs, and highlights the importance of developing management competencies and skills as well as positive team dynamics among health managers at district level.

Hybrid clinical-managers in Kenyan hospitals

Purpose

The purpose of this paper is to explore the way “hybrid” clinical managers in Kenyan public hospitals interpret and enact hybrid clinical managerial roles in complex healthcare settings affected by professional, managerial and practical norms.

Design/methodology/approach

The authors conducted a case study of two Kenyan district hospitals, involving repeated interviews with eight mid-level clinical managers complemented by interviews with 51 frontline workers and 6 senior managers, and 480 h of ethnographic field observations. The authors analysed and theorised data by combining inductive and deductive approaches in an iterative cycle.

Findings

Kenyan hybrid clinical managers were unprepared for managerial roles and mostly reluctant to do them. Therefore, hybrids’ understandings and enactment of their roles was determined by strong professional norms, official hospital management norms (perceived to be dysfunctional and unsupportive) and local practical norms developed in response to this context. To navigate the tensions between managerial and clinical roles in the absence of management skills and effective structures, hybrids drew meaning from clinical roles, navigating tensions using prevailing routines and unofficial practical norms.

Practical implications

Understanding hybrids’ interpretation and enactment of their roles is shaped by context and social norms and this is vital in determining the future development of health system’s leadership and governance. Thus, healthcare reforms or efforts aimed towards increasing compliance of public servants have little influence on behaviour of key actors because they fail to address or acknowledge the norms affecting behaviours in practice. The authors suggest that a key skill for clinical managers in managers in low- and middle-income country (LMIC) is learning how to read, navigate and when opportune use local practical norms to improve service delivery when possible and to help them operate in these new roles.

Originality/value

The authors believe that this paper is the first to empirically examine and discuss hybrid clinical healthcare in the LMICs context. The authors make a novel theoretical contribution by describing the important role of practical norms in LMIC healthcare contexts, alongside managerial and professional norms, and ways in which these provide hybrids with considerable agency which has not been previously discussed in the relevant literature.

Effect of a participatory multisectoral maternal and newborn intervention on birth preparedness and knowledge of maternal and newborn danger signs among women in Eastern Uganda: a quasi-experiment study

Background: Knowledge of obstetric danger signs and adequate birth preparedness (BP) are critical for improving maternal services utilization.

Objectives: This study assessed the effect of a participatory multi-sectoral maternal and newborn intervention on BP and knowledge of obstetric danger signs among women in Eastern Uganda.

Methods: The Maternal and Neonatal Implementation for Equitable Systems (MANIFEST) study was implemented in three districts from 2013 to 2015 using a quasi-experimental pre–post comparison design. Data were collected from women who delivered in the last 12 months. Difference-in-differences (DiD) and generalized linear modelling analysis were used to assess the effect of the intervention on BP practices and knowledge of obstetric danger signs.

Results: The overall BP practices increased after the intervention (DiD = 5, p < 0.05). The increase was significant in both intervention and comparison areas (7–39% vs. 7–36%, respectively), with a slightly higher increase in the intervention area. Individual savings, group savings, and identification of a transporter increased in both intervention and comparison area (7–69% vs. 10–64%, 0–11% vs. 0–5%, and 9–14% vs. 9–13%, respectively). The intervention significantly increased the knowledge of at least three obstetric danger signs (DiD = 31%) and knowledge of at least two newborn danger signs (DiD = 21%). Having knowledge of at least three BP components and attending community dialogue meetings increased the odds of BP practices and obstetric danger signs’ knowledge, respectively. Village health teams’ home visits, intervention area residence, and being in the 25+ age group increased the odds of both BP practices and obstetric danger signs’ knowledge.

Conclusions: The intervention resulted in a modest increase in BP practices and knowledge of obstetric danger signs. Multiple strategies targeting women, in particular the adolescent group, are needed to promote behavior change for improved BP and knowledge of obstetric danger signs.

Elements for harnessing participatory action research to strengthen health managers' capacity: a critical interpretative synthesis

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.

The financial transaction between counseling and nursing care service centers (CNCSCs) and their clients: a qualitative study

Background

Community-oriented nursing care is an important model of nursing care. Counseling and Nursing Care Service Centers (CNCSCs) have been providing these private services to the Iranian community for nearly two decades. Resource management, cost-benefit analysis and affordability are important steps in providing these services. The present study was conducted to explore the challenges of financial transactions between CNCSCs and their clients.

Methods

This study has a qualitative design and was conducted on a total of 30 participants, consisting of CNCSC managers, staff, physicians and clients who were selected through purposive theoretical sampling. Data were collected through in-depth interviews and direct observations and were analyzed using conventional qualitative content analysis.

Results

The analysis of the data led to the extraction of three main categories, including the flaunted atmosphere due to direct financial transaction, instability in determining tariffs for nursing services and the use of strategies for cost-effective services and client satisfaction.

Conclusion

To increase affordability and satisfaction and expand private community-based nursing.

Services, appropriate financial policies should be designed and applied that can lead to transparent and simple financial transactions with the clients by way of indirect monetary exchanges. These policies should be designed in a systematic manner with integrity, facilitate inter-sectorial cooperation in the health sector and be cost-effective for the clients, insurance companies and the health system.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-2934-z) contains supplementary material, which is available to authorized users.

A participatory action research approach to strengthening health managers' capacity at district level in Eastern Uganda

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.

Electronic supplementary material

The online version of this article (doi:10.1186/s12961-017-0273-x) contains supplementary material, which is available to authorized users.