Managerial capacity among district health managers and its association with district performance: A comparative descriptive study of six districts in the Eastern Region of Ghana

Autoři: Anne Christine Stender Heerdegen aff001;  Moses Aikins aff003;  Samuel Amon aff003;  Samuel Agyei Agyemang aff003;  Kaspar Wyss aff001
Působiště autorů: Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Basel, Switzerland aff001;  University of Basel, Basel, Switzerland aff002;  School of Public Health, College of Health Sciences, University of Ghana, Legon, Accra, Ghana aff003
Vyšlo v časopise: PLoS ONE 15(1)
Kategorie: Research Article
doi: 10.1371/journal.pone.0227974



District health managers play a pivotal role in the delivery of basic health services in many countries, including Ghana, as they are responsible for converting inputs and resources such as, staff, supplies and equipment into effective services that are responsive to population needs. Weak management capacity among local health managers has been suggested as a major obstacle for responsive health service delivery. However, evidence on district health managers’ competencies and its association with health system performance is scarce.


To examine managerial capacity among district health managers and its association with health system performance in six districts in the Eastern Region of Ghana.


Fifty-nine district health managers’ in six different performing districts in the Eastern Region of Ghana completed a self-administered questionnaire measuring their management competencies and skills. In addition, the participants provided information on their socio-demographic background; previous management experience and training; the extent of available management support systems, and the dynamics within their district health management teams. A non-parametric one-way analysis was applied to test the association between management capacity and district performance, which was measured by 17 health indicators.


Shortcomings within different aspects of district management were identified, however there were no significant differences observed in the availability of support systems, characteristics and qualifications of district health managers across the different performing districts. Overall management capacity among district health managers were significantly higher in high performing districts compared with lower performing districts (p = 0.02). Furthermore, district health managers in better performing districts reported a higher extent of teamwork (p = 0.02), communication within their teams (p<0.01) and organizational commitment (p<0.01) compared with lower performing districts.


The findings demonstrate individual and institutional capacity needs, and highlights the importance of developing management competencies and skills as well as positive team dynamics among health managers at district level.

Klíčová slova:

Ghana – Health services administration and management – Health systems strengthening – Malaria – Public and occupational health – Questionnaires – Resource management – Upper respiratory tract infections


1. Bossert TJ, Mitchell AD, Janjua MAJ. Improving health system performance in a decentralized health system: capacity building in Pakistan. Health Systems and Reform. 2015;1(4):276–84. doi: 10.1080/23288604.2015.1056330 31519095

2. Liwanag HJ, Wyss K. What conditions enable decentralization to improve the health system? Qualitative analysis of perspectives on decision space after 25 years of devolution in the Philippines. PLOS ONE. 2018;13(11):e0206809. doi: 10.1371/journal.pone.0206809 30395625

3. Conn CP, Jenkins P, Touray SO. Strengthening health management: experience of district teams in The Gambia. Health Policy Planning. 1996;11(1):64–71. doi: 10.1093/heapol/11.1.64 10155879

4. Fetene N, Canavan ME, Megentta A, Linnander E, Tan AX, Nadew K, et al. District-level health management and health system performance. PLOS ONE. 2019;14(2):e0210624. doi: 10.1371/journal.pone.0210624 30707704

5. Diaz-Monsalve S. The impact of health-management training programs in Latin America on job performance. Cad Saude Publica. 2004;20(4):1110–20. doi: 10.1590/s0102-311x2004000400027 15300305

6. Kwamie A, Agyepong IA, van Dijk H. What Governs District Manager Decision Making? A Case Study of Complex Leadership in Dangme West District, Ghana. Health Systems & Reform. 2015;1(2):167–77.

7. Egger D, Ollier E. Managing the health Millennium Development Goals: the challenge of management strengthening: lessons from three countries. World Health Organization, 2007.

8. Kwamie A, Dijk Hv, Ansah EK, Agyepong IA. The path dependence of district manager decision-space in Ghana. Health Policy and Planning. 2016;31:356–66. doi: 10.1093/heapol/czv069 26318537

9. Kolehmainen-Aitken R-L. Decentralization’s impact on the health workforce: Perspectives of managers, workers and national leaders. Human Resources for Health. 2004;2(1):5. doi: 10.1186/1478-4491-2-5 15144558

10. Rockers PC, Barnighausen T. Interventions for hiring, retaining and training district health systems managers in low- and middle-income countries. The Cochrane database of systematic reviews. 2013;4:CD009035.

11. Tavrow P, KIM Y-M, Malianga L. Measuring the quality of supervisor–provider interactions in health care facilities in Zimbabwe. International Journal for Quality in Health Care. 2002;14(suppl_1):57–066.

12. Dorros GL. Building Management Capacity to Rapidly Scale-up Health Services and Health Outcomes. World Health Organization, 2006.

13. Kotter J. What Leaders Really Do. The Bottom Line. 2000;13(1).

14. Daire J, Gilson L, Cleary S. Developing leadership and management competencies in low and middle-income country health systems: a review of the literature. Resilient and Responsive Health Systems, 2014.

15. Gilson L, Lehmann U, Schneider H. Practicing governance towards equity in health systems: LMIC perspectives and experience. International Journal for Equity in Health. 2017;16(171).

16. Bradley EH, Taylor LA, Cuellar CJ. Management matters: a leverage point for health systems strengthening in global health. International journal of health policy management. 2015;4(7):411. doi: 10.15171/ijhpm.2015.101 26188805

17. Newbrander W, Peercy C, Shepherd-Banigan M, Vergeer P. A tool for assessing management capacity at the decentralized level in a fragile state. The International Journal of Health Planning and Management. 2012;27(4):276–94. doi: 10.1002/hpm.1108 22034286

18. Egger D, Travis P, Dovlo D, Hawken L. Strengthening management in low-income countries. World Health Organization, 2005.

19. Schneider H, Blaauw D, Gilson L, Chabikuli N, Goudge J. Health systems and access to antiretroviral drugs for HIV in Southern Africa: service delivery and human resources challenges. Reproductive health matters. 2006;14(27):12–23. doi: 10.1016/S0968-8080(06)27232-X 16713875

20. Puoane T, Cuming K, Sanders D, Ashworth A. Why do some hospitals achieve better care of severely malnourished children than others? Five-year follow-up of rural hospitals in Eastern Cape, South Africa. Health Policy Planning. 2008;23(6):428–37. doi: 10.1093/heapol/czn036 18796499

21. Hanson K, Mangham LJ. Scaling up in international health: what are the key issues? Health Policy and Planning. 2010;25(2):85–96. doi: 10.1093/heapol/czp066 20071454

22. Filerman G. Closing the management competence gap. Human Resources for Health. 2003;1(1):7. doi: 10.1186/1478-4491-1-7 14613525

23. Tetui M, Hurtig A-K, Ekirpa-Kiracho E, Kiwanuka SN, Coe A-B. Building a competent health manager at district level: a grounded theory study from Eastern Uganda. BMC Health Services Research. 2016;16:655.

24. Seims LRK, Alegre JC, Murei L, Bragar J, Thatte N, Kibunga P, et al. Strengthening management and leadership practices to increase health-service delivery in Kenya: an evidence-based approach. Human Resources for Health. 2012;10(25).

25. Edwards LJ, Moises A, Nzaramba M, Cassimo A, Silva L, Mauricio J, et al. Implementation of a health management mentoring program: year-1 evaluation of its impact on health system strengthening in Zambezia Province, Mozambique. International journal of health policy and management. 2015;4(6):353–61. Epub 2015/06/02. doi: 10.15171/ijhpm.2015.58 26029894

26. Waiswa P, O’Connell T, Bagenda D, Mullachery P, Mpanga F, Henriksson DK, et al. Community and District Empowerment for Scale-up (CODES): a complex district-level management intervention to improve child survival in Uganda: study protocol for a randomized controlled trial. Trials. 2016;17(1):135. Epub 2016/03/13. doi: 10.1186/s13063-016-1241-4 26968957

27. Lega F, Prenestini A, Spurgeon P. Is management essential to improving the performance and sustainability of health care systems and organizations? A systematic review and a roadmap for future studies. Value in health: the journal of the International Society for Pharmacoeconomics and Outcomes Research. 2013;16(1 Suppl):46–51. Epub 2013/01/18.

28. Kwamie A, van Dijk H, Agyepong IA. Advancing the application of systems thinking in health: realist evaluation of the Leadership Development Programme for district manager decision-making in Ghana. Health Research Policy and Systems. 2014;12:29. doi: 10.1186/1478-4505-12-29 24935521

29. Mansour M, Mansour J, El Swesy A. Scaling up proven public health interventions through a locally owned and sustained leadership development programme in rural Upper Egypt. Human Resources for Health 2010;8(1):1.

30. Mutale W, Vardoy-Mutale AT, Kachemba A, Mukendi R, Clarke K, Mulenga D. Leadership and management training as a catalyst to health system strengthening in low-income settings: Evidence from implementation of the Zambia Management and Leadership course for district health managers in Zambia. PLOS ONE. 2017;12(7).

31. Martineau T, Raven J, Aikins M, Alonso-Garbayo A, Baine S, Huss R, et al. Strengthening health district management competencies in Ghana, Tanzania and Uganda: Lessons from using action research to improve health workforce performance. BMJ Global Health. 2018;3(2).

32. Drennan J. Cognitive interviewing: verbal data in the design and pretesting of questionnaires. Journal of advanced nursing. 2003;42(1):57–63. doi: 10.1046/j.1365-2648.2003.02579.x 12641812

33. Sperling CD, Petersen GS, Hølge-Hazelton B, Graugaard C, Winther JF, Gudmundsdottir T, et al. Being young and getting cancer: development of a questionnaire reflecting the needs and experiences of adolescents and young adults with cancer. Journal of adolescent young adult oncology. 2017;6(1):171–7. doi: 10.1089/jayao.2015.0063 27654508

34. Santos JRA. Cronbach’s alpha: A tool for assessing the reliability of scales. Journal of extension. 1999;37(2):1–5.

35. Feldt LS, Woodruff DJ, Salih FA. Statistical Inference for Coefficient Alpha. Applied Psychological Measurement. 1987;11(1):93–103.

36. Rodwell JJ, Kienzle R, Shadur MA. The relationship among work‐related perceptions, employee attitudes, and employee performance: The integral role of communications. Human Resource Management. 1998;37(3‐4):277–93.

37. Vandenabeele W. The mediating effect of job satisfaction and organizational commitment on self-reported performance: more robust evidence of the PSM—performance relationship. International review of administrative sciences. 2009;75(1):11–34.

38. Mbindyo PM, Blaauw D, Gilson L, English M. Developing a tool to measure health worker motivation in district hospitals in Kenya. Human Resources for Health. 2009;7:40. Epub 2009/05/22. doi: 10.1186/1478-4491-7-40 19457237

39. Hoegl M, Gemuenden HG. Teamwork quality and the success of innovative projects: A theoretical concept and empirical evidence. Organization science. 2001;12(4):435–49.

40. Cuzick J. A Wilcoxon‐type test for trend. Statistics in medicine. 1985;4(4):543–7. doi: 10.1002/sim.4780040416 4089356

41. Muchekeza M, Chimusoro A, Gombe NT, Tshimanga M, Shambira G. District health executives in Midlands province, Zimbabwe: are they performing as expected? BMC Health Services Research. 2012;12(1):335.

42. Bonenberger M, Aikins M, Akweongo P, Bosch-Capblanch X, Wyss K. What do district health managers in Ghana use their working time for? A case study of three districts. PLOS ONE. 2015;10(6):e0130633. doi: 10.1371/journal.pone.0130633 26068907

43. Tabrizi JS, Gholipour K, Farahbakhsh M, Hasanzadeh A. Managerial barriers and challenges in iran public health system: East Azerbaijan health managers’ perspective. Journal of the Pakistan Medical Association. 2017;67(3):409–15. 28303991

44. Excellence G-Co. GIMPA Public Sector Management Training Programme [cited 2019 03.05.2019]. Available from:

45. Gholipour K, Tabrizi JS, Farahbakhsh M, Iezadi S, Ghiasi A, Jahanbin H. Evaluation of the district health management fellowship training programme: A case study in Iran. BMJ Open. 2018;8(3).

46. Tabrizi JS, Gholipour K, Farahbakhsh M, Jahanbin H, Karamuz M. Developing management capacity building package to district health manager in northwest of Iran: a sequential mixed method study. Journal of the Pakistan Medical Association. 2016;66:1385–91. 27812053

47. Dieleman M, Gerretsen B, der Wilt GJv. Human resource management interventions to improve health workers’ performance in low and middle income countries: a realist review. Health Research Policy and Systems. 2009;7.

48. Bradley EH, Byam P, Alpern R, Thompson JW, Zerihun A, Abebe Y, et al. A systems approach to improving rural care in Ethiopia. PLOS ONE. 2012;7(4):e35042. Epub 2012/05/05. doi: 10.1371/journal.pone.0035042 22558113

49. Waweru E, Opwora A, Toda M, Fegan G, Edwards T, Goodman C, et al. Are Health Facility Management Committees in Kenya ready to implement financial management tasks: findings from a nationally representative survey. BMC Health Services Research. 2013;13(1):404.

50. Chen L, Evans T, Anand S, Boufford JI, Brown H, Chowdhury M, et al. Human resources for health: overcoming the crisis. Lancet. 2004;(364):1984–90.

51. Bonenberger M, Aikins M, Akweongo P, Wyss K. Factors influencing the work efficiency of district health managers in low-resource settings: A qualitative study in Ghana. BMC Health Services Research. 2016;16(1).

52. Steffensen J, Trollegaard S. Fiscal Decentralisation and Sub-National Government Finance in Relation to Infrastructure and Service Provision: Synthesis Report on 6 Sub-Saharan African Country Studies. World Bank, Washington DC, 2000.

53. Asante A, Roberts G, Hall J. A review of health leadership and management capacity in the Solomon Islands. Human Resources for Health Knowledge Hub: University of New South Wales, Sydney, 2011 Contract No.: 1.

54. Gilson L, Agyepong IA. Strengthening health system leadership for better governance: what does it take? Health Policy and Planning. 2018;33(suppl_2):ii1–ii4. doi: 10.1093/heapol/czy052 30053034

55. Singh PK, Kumar C, Rai RK, Singh L. Factors associated with maternal healthcare services utilization in nine high focus states in India: a multilevel analysis based on 14 385 communities in 292 districts. Health Policy and Planning. 2014;29(5):542–59. Epub 2013/06/21. doi: 10.1093/heapol/czt039 23783832

56. Macarayan EK, Ratcliffe HL, Otupiri E, Hirschhorn LR, Miller K, Lipsitz SR, et al. Facility management associated with improved primary health care outcomes in Ghana. PLOS ONE. 2019;14(7):e0218662. doi: 10.1371/journal.pone.0218662 31265454

57. Avoka JA, Seidu I. Assessing Management and Leadership Quality Styles of Sub-district Leaders in Relation to Staff Performance in the Sub-districts: The Pursuit of Health System Strengthening, Fanteakwa District. Journal of Advances in Medicine and Medical Research. 24(10).

58. Diaz-Monsalve SJ. Measuring the job performance of district health managers in Latin America. Annals of tropical medicine and parasitology. 2003;97(3):299–311. Epub 2003/06/14. doi: 10.1179/000349803235002155 12803861

59. Dargahi H, Shaham G. Self-assessment of administrators’ managerial skills and their relationship with effective management in Hospitals of Tehran University of Medical Sciences. International Journal of Hospital Research. 2012;1(1):65–70.

60. Khadka DK, Gurung M, Chaulagain N. Managerial competencies–A survey of hospital managers’ working in Kathmandu valley, Nepal. Journal of hospital administration. 2013;3(1):62.

61. Pillay R. Managerial competencies of hospital managers in South Africa: a survey of managers in the public and private sectors. Human Resources for Health. 6(4).

62. Burke S, Collins KM. Gender differences in leadership styles and management skills. Women in Management Review. 2001;16(5):244–57.

63. Bolarinwa O. Principles and methods of validity and reliability testing of questionnaires used in social and health science researches. The Nigerian postgraduate medical journal. 2015;22(4):195–201. doi: 10.4103/1117-1936.173959 26776330

64. Howard PF, Liang Z, Leggat S, Karimi LJ. Validation of a management competency assessment tool for health service managers. Journal of health organization management science. 2018;32(1):113–34.

65. Amoakoh-Coleman M, Kayode GA, Brown-Davies C, Agyepong IA, Grobbee DE, Klipstein-Grobusch K, et al. Completeness and accuracy of data transfer of routine maternal health services data in the greater Accra region. BMC research notes. 2015;8(1):114.

66. Kruk ME, Gage AD, Arsenault C, Jordan K, Leslie HH, Roder-DeWan S, et al. High-quality health systems in the Sustainable Development Goals era: time for a revolution. The Lancet Global Health. 2018;6(11):e1196–e252. doi: 10.1016/S2214-109X(18)30386-3 30196093

Článek vyšel v časopise


2020 Číslo 1