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A participatory action research approach to strengthening health managers' capacity at district level in Eastern Uganda
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Makerere University School of Public Health (MakSPH), Makerere University, New Mulago Complex, Kampala, Uganda.
Umeå University, Faculty of Social Sciences, Department of Sociology.
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.ORCID iD: 0000-0001-7087-1467
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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. Vol. 15, article id 110
Keywords [en]
competing values framework, district health managers, health systems, participatory action research, Uganda
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:umu:diva-143689DOI: 10.1186/s12961-017-0273-xISI: 000419507300007PubMedID: 29297346OAI: oai:DiVA.org:umu-143689DiVA, id: diva2:1171052
Note

Supplement: 2

Available from: 2018-01-05 Created: 2018-01-05 Last updated: 2018-06-09Bibliographically approved
In thesis
1. Participatory approaches to strengthening district health managers' capacity: Ugandan and global experiences
Open this publication in new window or tab >>Participatory approaches to strengthening district health managers' capacity: Ugandan and global experiences
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
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:nbn:se:umu:diva-146957 (URN)978-91-7601-866-8 (ISBN)
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

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