Background: Leadership skills are essential for middle-level healthcare manager efficacy. Capacity-building efforts may attempt behavioural change by filling 'knowledge gaps' while neglecting a sustainable application of that knowledge. Sustainable application of that knowledge, or implementation know-how, must resonate with local cultural patterns. When it is neglected, root issues like unclear decision-making space and local authority to interpret policy during implementation remain unaddressed. Particularly in decentralized healthcare systems, the impact can appear in implementation challenges, subjective decision-making, poor teamwork, and an absence of disseminating best practices.
Objectives: The SEARCH-IPT trial led a series of mini-collaborative meetings, which provided business leadership and management training for an intervention group of mid-level healthcare system managers in rural Eastern, East-Central, and Southwestern Uganda to see whether this would increase uptake of isoniazid-prevention therapy (IPT) for people living with HIV (PLHIV) in intervention districts. IPT is known to reduce active tuberculosis (TB), a leading cause of death among PLHIV, by 40-60%.
Methods: We performed a thematic analysis of six focus-group discussions from this intervention (held in May 2019, January 2020, September 2021) and 23 key informant interviews with control group participants (between February and August 2019 and September and December 2020).
Results: Analysis revealed five implementation skill sets District Health Officers (DHOs) and District Tuberculosis and Leprosy Supervisors (DTLSs) deployed to achieve sustainable implementation and realize their decision-making space. The five practices were as follows: data-based decision-making, root-cause analysis, quality assurance, evidence-based empowerment, and sharing best practices with colleagues.
Conclusion: These practices reached beyond outcome measures to address root problems around the DHO's range of authority and elicit buy-in from district health workers. For successful capacity building at the mid-manager level, focusing on core practices as part of competency is objectively implementable and measurable at the system level and does not rely on DHO self-assessments.
Keywords: Decision space; HIV; capacity building; decentralization; healthcare; implementation; management; tuberculosis.
Main findings: District Health Officers and District Tuberculosis and Leprosy Supervisors deployed five implementation skill sets to achieve sustainable implementation and clarify ambiguous decision-making space: data-based decision-making, root-cause analysis, quality assurance, evidence-based empowerment, and sharing best practices with colleagues, thereby reaching beyond outcome measures to address root problems around the District Health Officer’s range of authority and obtain buy-in from district health workers.Added knowledge: Horizontal accountability, in which mid-level health system managers share their experiences implementing core practices, has made concrete and demonstrably sustainable implementation changes at the district level, suggesting that capacity building at the mid-manager level must reach further than identifying knowledge gaps and instead additionally show people how to implement knowledge they may already possess.Global health impact for policy and action: Focusing on core practices – rather than competencies – is objectively implementable and measurable at the system level and does not rely on self-assessments of knowledge or pre/post-training skill sets that have been shown to be unreliable in predicting the sustainability of training lessons.