Participatory approaches to strengthening district health managers' capacity : Ugandan and global experiences
Introduction: Residents of low in-come countries have persistently suffered poor health outcomes, modest progress made over time notwithstanding. Weak health systems are one of the key reasons for the less than optimum progress. These health systems are constrained by inadequately equipped managers who play a main role in curbing this progress. Strengthening the capacity of health managers capacity is one of the known ways to improve the performance of health systems. This study examined strategies for strengthening the capacity of health managers at the sub-national level, with a special focus on the Participatory Action Research (PAR) approach. Methods: I used an emergent qualitative design which included both primary data collection and a literature review. Primary data collection techniques included individual interviews, Focus Group Discussions (FGDs), participant observations, and a review of project documents and meeting minutes, while searching for peer-reviewed databases was used for the literature review. Several analytical tools were adopted to answer the objectives, including the grounded theory, content and thematic analysis approaches. The Critical Interpretive Synthesis (CIS) method was used to analyze the literature reviewed. Findings: Stakeholders' perceived the approaches to strengthening health managers' capacity as an overarching process comprised of three interconnected subprocesses namely: the professionalizing of health managers, the use of engaging approaches to learning, and the availability of a supportive work environment. PAR as an engaging approach to learning was experienced by stakeholders as a nuanced awakening approach. On the one hand, stakeholders felt engaged, valued, responsible, awakened and a sense of ownership. On the other hand, they felt conflicted, stressed and uncertain. The PAR approach enhanced health managers' capacity to collaborate with others, be creative, attain goals, and review progress. Expanded spaces for interaction, the encouragement of flexibility, the empowerment of local managers and the promotion of reflection and accountability enabled this enhancement. Lastly, the literature reviewed revealed five interrelated elements for harnessing PAR to strengthen health managers capacity. These were: a shared purpose, skilled facilitation and social psychological safety, activity integration into organizational procedures, organizational support and supportive external monitoring. Conclusions: Health managers have a central role in strengthening health systems; hence the formalization of their role, especially within the public-sector, is needed. In addition, significant investments into developing and strengthening their capacity is required. Strengthening the capacity of health managers is an iterative process that draws synergies from different approaches. The process leans on formal trainings as well as more engaging means of learning, such as PAR. As an engaging approach to learning, PAR expands interaction spaces, provides inclusiveness and flexibility, promotes local ingenuity and shared responsibility, and allows for monitoring and learning. PAR had positive effects on the strengthening of the capacity of health managers while at the same time achieving other project outcomes. Participatory approaches are hence relevant for dealing with the complex challenges bedevilling health systems. The approach nonetheless should be applied with a more nuanced appreciation of the challenges when using it and the elements for harnessing it to strengthen health systems.