How district health decision-making is shaped within decentralised contexts: A qualitative research in Malawi, Uganda and Ghana

Susan E. Bulthuis*, Maryse C. Kok, Samuel Amon, Samuel Agyei Agyemang, Xavier Nsabagasani, Lifah Sanudi, Joanna Raven, Mairead Finn, Jana Gerold, Olivia Tulloch, Marjolein A. Dieleman

*Corresponding author for this work

Research output: Contribution to JournalArticleAcademicpeer-review


District Health Management Teams (DHMTs) are often entry points for the implementation of health interventions. Insight into decision-making and power relationships at district level could assist DHMTs to make better use of their decision space. This study explored how district-level health system decision-making is shaped by power dynamics in different decentralised contexts in Ghana, Malawi and Uganda. In-depth interviews took place with national- and district-level stakeholders. To unravel how power dynamics influence decision-making, the Arts and Van Tatenhove (2004) framework was applied. In Ghana and Malawi, the national-level Ministry of Health substantially influenced district-level decision-making, because of dispositional power based on financial resources and hierarchy. In Uganda and Malawi, devolution led to decision-making being strongly influenced by relational power, in the form of politics, particularly by district-level political bodies. Structural power based on societal structures was less visible, however, the origin, ethnicity or gender of decision-makers could make them more or less credible, thereby influencing distribution of power. As a result of these different power dynamics, DHMTs experienced a narrow decision space and expressed feelings of disempowerment. DHMTs’ decision-making power can be expanded through using their unique insights into the health realities of their districts and through joint collaborations with political bodies.

Original languageEnglish
Pages (from-to)120-135
Number of pages16
JournalGlobal public health
Issue number1
Early online date13 Jul 2020
Publication statusPublished - 2021


The study presented in this article is performed as part of the PERFORM2Scale project. PERFORM2Scale is a 5-year international research consortium aiming to develop and evaluate a sustainable approach to scaling up a district-level management strengthening intervention in different and changing contexts. This work was supported by the European Union's Horizon 2020 research and innovation programme (grant number 733360). The authors would like to acknowledge all participants who gave their time to be interviewed.

FundersFunder number
Horizon 2020 Framework Programme
Horizon 2020733360


    • decentralisation
    • District level
    • health system decision-making
    • power


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