What Governs District Manager Decision Making A Case Study of Complex Leadership in Dangme West District Ghana

In health policy and systems research, management and leadership
are complex but related phenomena. They have various
meanings and requirements.1,2 The World Health
Organization defines good management and leadership as
“providing direction to, and gaining commitment from partners
and staff, facilitating change and achieving better health
services through efficient, creative and responsible deployment
of people and other health resources.”3 In low- and middle-income countries, widespread perceptions of weak
management and leadership at the district level have
prompted calls to increase managerial capacities.4–8 Over the
years, there have been several management and leadership
capacity strengthening initiatives in Ghana directed toward
improving the district health system. Examples include the
Strengthening District Health Systems Initiative,9 the Leadership
Development Program,10–12 and certain health sector
reform activities.13 However, weaknesses in management
and leadership have continued to be predominantly attributed
to individual competencies rather than health system challenges.
As the interface between national-level policy formulation
and sub-district service delivery, district-level health managers
have multiple responsibilities for policy interpretation,
resource management, and leading frontline staff. District
managers serve a boundary function, communicating information
up and down the health system. They provide a
“framework within which health services can be delivered.”
17 By virtue of their mandates of appropriate planning,
budgeting, monitoring, and resource deployment, district
managers are ultimately accountable for realizing district
performance. Thus, the manner in which they make their
decisions is significant. Deleon18 cites decision making as
“the central organizational act,” yet there are few studies in
the health system literature that examine district managerial
decision making and function.19,20
Policy implementation at the district level is influenced by
contextual factors that are both internal and external to the district.
Policy implementation theory has traditionally been held
from two poles: (1) top-down approaches that view rational, linear
processes of implementation as purely technical, following
national-level policy formation,21 and (2) bottom-up
approaches, such as Lipsky’s characterization of frontline public
sector staff as street-level bureaucrats.22 Top-down approaches
are concerned with institutionalized structures of governmental
capacity. Bottom-up approaches privilege beliefs and interorganizational
dynamics of policy implementers. In complex adaptive
systems, such as district health systems, systemic
interactions give rise to patterns that modulate the entire system.
23 Whether district-level policy implementation exhibits
top-down or bottom-up characteristics will be influenced by
interactions between national and regional structures and district-
level organization and will subsequently give rise to capacities
and patterns that we call management and leadership. How
these different factors interact remains unclear.
This article presents an exploratory case study to examine

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how and why district managers in one district in the Ghanaian
health system make decisions with regard to implementation of
maternal and newborn health (MNH) policies. Specifically, our
objectives were to understand the balance of top-down and bottom-
up MNH policy implementation. MNH policies were identified
because the maternal health profile of a country is often
indicative of the performance of its health system.24 As a general
service delivery function, MNH requires many different
health system elements to be functional and working in concert
at various points across the health system. However, the bulk of
MNH interventions to date have focused on infrastructural,
technological, or clinical inputs.25 Less attention has been paid
to the contributions of management and leadership.26–30 This
article seeks to fill part of this knowledge gap.
Ghana, a West African country of 25 million, is a stable
constitutional democracy. A multiparty political system has
existed since 1992. In 2012 (the year of study), Ghana’s
Human Development Index ranking was 135 out of 187
countries.31 The gross domestic product was 48.1 billion
USD, with annual economic growth of 6.0%. Ghana is classified
as lower-middle income. The country is divided into ten
administrative regions and (at the time) 170 districts. More
than half of the country’s population lives in rural settings.
Ghana’s public sector health service delivery is provided by
the Ghana Health Service, an agency of the Ministry of Health.
The Ghana Health Service is regulated by the Ghana Health
Service and Teaching Hospitals Act (525) of 1996 and has a
mandate “to provide and prudently manage comprehensive and
accessible health services with special emphasis on primary
health care at regional, district and sub-district levels in accordance
with approved national policies.”32 The Ghana Health
Service has shifted administrative decision making (i.e., deconcentration)
down national, regional, district, and sub-district
lines. This means that the district health management team
(DHMT), district hospital, and sub-districts report up to the district
director of health services, who reports to the regional
director of health services, who in turn reports directly to the
director general of the Ghana Health Service. The district director
heads the DHMT, the medical superintendent heads the district
hospital, and sub-district heads lead sub-district health
teams. The relationship of the medical superintendent to district
director remains somewhat ambiguous, with a general perception
that it is a peer-to-peer rather than superior–subordinate
relationship. The district health system is also guided by local
government political decision making (i.e., devolution) to district
assemblies in accordance with the Local Government Act
(462) of 1993.33 Apart from reporting to the regional director,
the district director also reports to the district chief executive at
the district assembly. The matrix organization of the district
health system is meant to strengthen reporting between health
and local government sectors. Instead, tensions between Acts


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