Small-world challenges and solutions identified by mid-level managers within a decentralized healthcare system during a tuberculosis-prevention therapy rollout study: “When a big drum like the District Health Officer talks”

Abstract

Decentralisation policies that devolve certain administrative and decision-making powers to local levels can pose challenges for public health and healthcare systems. For a decentralised health system to function optimally, mid-level systems must rely on tightly clustered, so-called “small-world” networks to efficiently scale-up national health campaigns and share best practices. Few studies have qualitatively tackled the mechanisms of small-world creation and their potential effects on public health promotion during centralized national campaigns in a decentralised, mid-level healthcare system tier. We conducted 23 in-depth interviews and six focus group discussions with mid-level healthcare managers during a cluster-randomised trial from 2019 to 2021, whose intervention component aimed to increase isoniazid preventive therapy (IPT) uptake and prevent tuberculosis among people living with HIV in Uganda. The intervention consisted of 8 mini-collaborative meetings where intervention clusters received management and skills-based training and shared results with other district managers. We used a thematic analysis technique to identify key challenges stemming from the decentralised nature of the healthcare system and pinpoint the mechanisms and conceptual tools by which intervention groups overcame these challenges. Training management and leadership skills in mini-collaboratives promoted mid-level manager agency to address several drawbacks associated with the decentralisation of healthcare systems through what we call ‘horizontal accountability’. Improving communication as a group, intervention participants encouraged teamwork in their districts, developed bridging ties with other districts and built a denser cluster of networks. Pairing transparency with a sense of reciprocal accountability moving in multiple directions, upwards to the Ministry of Health (MoH), downwards towards local communities, and horizontally towards peers, fostered the creation of small-world networks and improved information flows within a decentralised healthcare context. Increased collaboration demonstrably strengthened the clustering of small-world network ties at a horizontal level, more quickly disseminating best practices through collegial competition, sustaining the uptake of IPT while ensuring accountability to peers, the MoH, and local communities. Trial registration. NCT03315962. Registered 20 October, 2017.