The district health system usually includes a network of hospitals and primary healthcare facilities catering to a specified population, under the guidance of district health management teams. This structure was developed to facilitate the management and implementation of primary healthcare.12 The management teams’ responsibilities include planning and budgeting, human resource management, monitoring service quality, and ideally allocating resources to most effectively meet local population needs.
Recent evidence suggests that poor performance of district management teams may hinder scaling up of proved health interventions in low and middle income countries.3 Weak performance can result in poor coordination of health service delivery, insufficient funding for affordable and effective health programmes, and inadequate resources for health workers to provide high quality healthcare. Resource related consequences of weak management include running out of medicines, delayed repair of broken equipment, and health worker absenteeism. Poor management can adversely affect health workers’ motivation and may contribute to people moving from the public to the private sector.4 This may reduce the quality of care at health facilities or reduce demand for health services as users of public facilities come to know that certain facilities provide suboptimal services and choose to seek alternative care from traditional medicine providers or refrain from seeking healthcare other than for emergencies.56
Health sector reforms in many low and middle income countries have promoted a shift towards greater decentralisation of responsibilities to districts.7 However, this shift has often not been accompanied by commensurate attention to management capacity, allocation of resources, or autonomy to enable effective priority setting, planning, and implementation.8 As a result many district management teams cannot function as intended, and the perceived benefits of decentralisation—namely, accountability and responsiveness to communities and their specific context and improved access to quality services and health outcomes—have not been realised.9 For example, district managers who identify a need for supervision of trained child health workers at facilities may have insufficient access to funds to provide such supervision.”
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