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

Abstract

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)1-16
Number of pages16
JournalGlobal public health
DOIs
Publication statusPublished - 13 Jul 2020

Keywords

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

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