Maye Abu Omar

Abstract views = 965 times | downloads = 380 times


Introduction: Health systems in low-middle income countries are undergoing considerable changes in a context of ongoing health sector reforms. Districts have, therefore, been increasingly recognised as the level where health policies and health sector reforms are interpreted and implemented. At the same time, decentralisation in its different forms has become a popular reform in many countries, and this increases the importance of ensuring that districts have the organisational capacity to offer a good service.

Aim: The article investigates the process, challenges and opportunities of health system development at district level in low-middle income countries.

Discussion: While district strengthening is probably necessary in relation to the success of all other health reforms, it is argued that it has not been accorded the importance probably because it is not seen as glamorous. The district health management team must include both strengthening the capacity of individuals, but crucially also, improvement of systems. Many initiatives have been patchy and fail to provide a consistent national approach. The persistence of top-down approaches to health care works directly against districts being able to take charge of their own affairs.

Conclusions: A shared vision of district strengthening must be achieved in order to progress with the achievement of Universal Health Coverage and Sustainable Development Goals. 

Keywords: district health strengthening, capacity building, low-middle income countries, universal health coverage.

Full Text:



Adeleye, O. A. and Ofili, A. N. (2010) ‘Strengthening Intersectoral Collaboration for Primary Health Care in Developing Countries: Can the Health Sector Play Broader Roles?’, Journal of Environmental and Public Health, pp. 1–6. doi: 10.1155/2010/272896.

Afrizal, S. H. et al. (2019) ‘Barriers and challenges to Primary Health Care Information System (PHCIS) adoption from health management perspective: A qualitative study’, Informatics in Medicine Unlocked, 17, pp. 1–10. doi: 10.1016/j.imu.2019.100198.

Atun, R. et al. (2015) ‘Health-system reform and universal health coverage in Latin America’, The Lancet, 385(9974), pp.1230-1247. doi: 10.1016/S0140-6736(14)61646-9.

Balogh, R. (1996) ‘Exploring the Role of Localities in Health Commissioning: A Review of the Literature’, Social Policy & Administration, 30(2), pp.99-113. doi: 10.1111/j.1467-9515.1996.tb00430.x.

Bamberger, S. G. et al. (2012) ‘Impact of organisational change on mental health: a systematic review’, Occupational and Environmental Medicine, 69(8), pp. 592–598. doi: 10.1136/oemed-2011-100381.

Berwick, D. M. et al. (2006) ‘The 100 000 Lives CampaignSetting a Goal and a Deadline for Improving Health Care Quality’, JAMA, 295(3), pp.324-327. doi: 10.1001/jama.295.3.324.

Bonenberger, M. et al. (2015) ‘What Do District Health Managers in Ghana Use Their Working Time for? A Case Study of Three Districts’, PloS one, 10(6), pp. 1–15. doi: 10.1371/journal.pone.0130633.

Bradley, S. et al. (2013) ‘District health managers’ perceptions of supervision in Malawi and Tanzania’, Human Resources for Health, 11(43), pp. 1–11. doi: 10.1186/1478-4491-11-43.

Brugha, R. and Walt, G. (2001) ‘A global health fund: a leap of faith?’, BMJ (Clinical research ed.), 323(7305), pp.152-154. doi: 10.1136/bmj.323.7305.152.

Checkland, K. et al. (2018) ‘Being Autonomous and Having Space in which to Act: Commissioning in the ‘New NHS’ in England’, Journal of Social Policy, 47(2), pp.377-395. doi: 10.1017/S0047279417000587.

Cobos Muñoz, D. et al. (2017) ‘Decentralization of health systems in low and middle income countries: a systematic review’, International Journal of Public Health, 62(2), pp.219-229. doi: 10.1007/s00038-016-0872-2.

Collins, C. and Green, A. (1994) ‘Decentralization and Primary Health Care: Some Negative Implications in Developing Countries’, International Journal of Health Services, 24(3), pp.459-475. doi: 10.2190/G1XJ-PX06-1LVD-2FXQ.

Collins, C. et al. (2007) ‘Health system decentralisation in Nepal: identifying the issues’, J Health Organ Manag, 21(6), pp.535-45. doi: 10.1108/14777260710834328.

Collins, C. D., Omar, M. and Tarin, E. (2002) ‘Decentralization, health care and policy process in the Punjab, Pakistan in the 1990s’, The International Journal of Health Planning and Management, 17(2), pp. 123–146. doi: 10.1002/hpm.657.

Cometto, G., Buchan, J. and Dussault, G. (2020) ‘Developing the health workforce for universal health coverage’, Bulletin World Health Organization, 98, pp. 109–116.

Cox, E. O. (2001) ‘Community Practice Issues in the 21st Century’, Journal of Community Practice, 9(1), pp.37-55. doi: 10.1300/J125v09n01_03.

Dansereau, E. et al. (2017) ‘Challenges to implementing Gavi’s health system strengthening support in Chad and Cameroon: results from a mixed-methods evaluation’, Globalization and health, 13(83), pp. 1–12. doi: 10.1186/s12992-017-0310-0.

Doherty, T. et al. (2018) ‘Role of district health management teams in child health strategies’, BMJ, 362(k2823), pp. 1–5. doi: 10.1136/bmj.k2823.

Foster, M. et al. (2000) The Status of Sector – Wide Approaches Centre for Aid and Public Expenditure (CAPE). London.

Frenk, J. (1994) ‘Dimensions of health system reform’, Health Policy, 27(1), pp.19-34. doi: 10.1016/0168-8510(94)90155-4

Gidey, M. T. et al. (2019) ‘Willingness to pay for social health insurance and its determinants among public servants in Mekelle City, Northern Ethiopia: a mixed methods study’, BMC Cost Effectiveness and Resource Allocation, 17(2), pp. 1–11. doi: 10.1186/s12962-019-0171-x.

Gishu, T., Weldetsadik, A. Y. and Tekleab, A. M. (2019) ‘Patients’ perception of quality of nursing care; a tertiary center experience from Ethiopia’, BMC Nursing, 18(37), pp. 1–6. doi: 10.1186/s12912-019-0361-z.

Hauck, K. et al. (2019) ‘How can we evaluate the cost-effectiveness of health system strengthening? A typology and illustrations’, Social science & medicine (1982), 220, pp.141-149. doi: 10.1016/j.socscimed.2018.10.030.

Haver, J. et al. (2015) ‘Experiences engaging community health workers to provide maternal and newborn health services: Implementation of four programs’, International Journal of Gynecology & Obstetrics, 130, pp.S32-S39. doi: 10.1016/j.ijgo.2015.03.006.

Heerdegen, A. C. S. et al. (2020) ‘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’, PLoS One, 15(1), pp. 1–18. doi: 10.1371/journal.pone.0227974.

Hill, P. S. (2002) ‘The rhetoric of sector-wide approaches for health development’, Soc Sci Med, 54(11), pp.1725-37. doi: 10.1016/s0277-9536(01)00340-9.

Irimu, G. W. et al. (2014) ‘Factors influencing performance of health workers in the management of seriously sick children at a Kenyan tertiary hospital--participatory action research’, BMC health services research, 14(59), pp. 1–17. doi: 10.1186/1472-6963-14-59.

Jaeger, F. N. et al. (2018) ‘Challenges and opportunities for healthcare workers in a rural district of Chad’, BMC Health Services Research, 18(7), pp. 1–11. doi: 10.1186/s12913-017-2799-6.

Kruk, M. E. et al. (2018) ‘High-quality health systems in the Sustainable Development Goals era: time for a revolution’, Lancet Glob Health, 6(11), pp.e1196-e1252. doi: 10.1016/s2214-109x(18)30386-3.

Liwanag, H. J. and Wyss, K. (2019) ‘Optimising decentralisation for the health sector by exploring the synergy of decision space, capacity and accountability: insights from the Philippines’, Health Research Policy and Systems, 17(4), pp. 1–16. doi: 10.1186/s12961-018-0402-1.

Martineau, T. et al. (2018) ‘Strengthening health district management competencies in Ghana, Tanzania and Uganda: lessons from using action research to improve health workforce performance’, BMJ Global Health, 3(e000619), pp. 1–13. doi: 10.1136/bmjgh-2017-000619.

Mathauer, I. and Imhoff, I. (2006) ‘Health worker motivation in Africa: the role of non-financial incentives and human resource management tools.’, Human resources for health, 4(24), pp. 1–17. doi: 10.1186/1478-4491-4-24.

McNee, A. (2012) Rethinking Health Sector Wide Approaches Through the Lens of Aid Effectiveness. Australia. Available at:

Morgan, L. M. (2001) ‘Community participation in health: perpetual allure, persistent challenge’, Health Policy and Planning, 16(3), pp.221-230. doi: 10.1093/heapol/16.3.221.

Mouhouelo, P., Okessi, A. and Kabore, M.-P. (2006) ‘Where there is no Internet: delivering health information via the blue trunk libraries’, PLoS Medicineedicine, 3(3), pp. 300–302. doi: 10.1371/journal.pmed.0030077.

Olum, Y. (2014) ‘Decentralisation in developing countries: preconditions for successful implementation ’, Commonwealth Journal of Local Governance, 15, pp.23-28. doi: 10.5130/cjlg.v0i0.4061.

Omar, M. (2002) ‘Health Sector Decentralisation in Developing Countries: Unique or Universal!’, World Hospitals and Health Services, 38(2), pp.24-30.

Perrot, J., Carrin, G. and Sergent, F. (1997) The contractual approach : new partnerships for health in developing countries. Geneva: World Health Organization.

Peters, D. H., Paina, L. and Schleimann, F. (2012) ‘Sector-wide approaches (SWAps) in health: what have we learned?’, Health Policy and Planning, 28(8), pp. 884–890. doi: 10.1093/heapol/czs128.

Pickin, C. et al. (2002) ‘Developing a model to enhance the capacity of statutory organisations to engage with lay communities’, J Health Serv Res Policy, 7(1), pp.34-42. doi: 10.1258/1355819021927656.

Prashanth, N. S. et al. (2014) ‘Evaluation of Capacity-Building Program of District Health Managers in India: A Contextualized Theoretical Framework’, Frontiers in Public Health, 2(89), pp. 1–14. doi: 10.3389/fpubh.2014.00089.

Reeve, C., Humphreys, J. and Wakerman, J. (2015) ‘A comprehensive health service evaluation and monitoring framework’, Evaluation and Program Planning, 53, pp. 91–98. doi: 10.1016/j.evalprogplan.2015.08.006.

Roman, T. E., Cleary, S. and McIntyre, D. (2017) ‘Exploring the Functioning of Decision Space: A Review of the Available Health Systems Literature’, International Journal of Health Policy and Management, 6(7), pp. 365–376. doi: 10.15171/ijhpm.2017.26.

Selgelid, M. J. (2007) ‘The importance of "throwing money at" the problem of global health’, Indian J Med Ethics, 4(2), pp.73-5. doi: 10.20529/ijme.2007.027.

Senkubuge, F., Modisenyane, M. and Bishaw, T. (2014) ‘Strengthening health systems by health sector reforms’, Global health action, 7(23568), pp. 1–7. doi: 10.3402/gha.v7.23568.

Shaikh, B. T. and Rabbani, F. (2004) ‘The district health system: a challenge that remains’, Eastern Mediterranean Health Journal, 10(1/2), pp. 206–214.

Sharma, A., Prinja, S. and Aggarwal, A. K. (2017) ‘Measurement of health system performance at district level: A study protocol’, Journal of public health research, 6(917), pp. 175–183. doi: 10.4081/jphr.2017.917.

Starling, M. et al. (2002) New products into old Systems: The Global Alliance for Vaccines and Immunization (GAVI) from a country perspective. London: Save the Children.

Sumah, A. M., Baatiema, L. and Abimbola, S. (2016) ‘The impacts of decentralisation on health-related equity: A systematic review of the evidence’, Health Policy, 120(10), pp. 1183–1192. doi: 10.1016/j.healthpol.2016.09.003.

Tang, S. and Bloom, G. (2000) ‘Decentralizing rural health services: a case study in China’, The International Journal of Health Planning and Management, 15(3), pp.189-200. doi: 10.1002/1099-1751(200007/09)15:3<189::Aid-hpm590>3.0.Co;2-q.

Tareen, E. U. and Omar, A. (1998) ‘Practical Notes Empowerment at village level through a workshop method’, Development in Practice, 8(2), pp.221-225. doi: 10.1080/09614529853846.

Thunhurst, C. (2003) ‘The use of problem structuring methods in strategic health planning’, International Transactions in Operational Research, 10(4), pp.381-392. doi: 10.1111/1475-3995.00414.

Unger, J. P. and Killingsworth, J. R. (1986) ‘Selective primary health care: a critical review of methods and results’, Soc Sci Med, 22(10), pp.1001-13. doi: 10.1016/0277-9536(86)90200-5.

Walker, R. M., Damanpour, F. and Devece, C. A. (2010) ‘Management Innovation and Organizational Performance: The Mediating Effect of Performance Management’, Journal of Public Administration Research and Theory, 21(2), pp. 367–386. doi: 10.1093/jopart/muq043.


  • There are currently no refbacks.


Views JAKI Stats


This journal is indexed by:



And many more...

We follow the ICMJE recommendations and Listed on 


Creative Commons License

This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.