Challenges and constraints at district management level

This chapter explores the constraints and challenges faced by District Health Management Teams (DMTs) as they strive to ensure the delivery of quality public health care in a rapidly changing environment characterised by major national reform initiatives, such as the re-engineering of primary health care (PHC) and the introduction of National Health Insurance (NHI).The main difficulties faced by this group of public health managers were identified through surveys and interviews conducted with a cross-section of managers from urban and rural districts. Data were collected using three methods. Firstly, individual semi-structured interviews were conducted with nine district managers regarding the district planning process. Secondly, quantitative data using a structured questionnaire were collected from 233 operational and district managers within these nine districts regarding their qualifications and their length of service within the health department. Thirdly, this information was supplemented by interviews with representatives of the United States President's Emergency Plan for AIDS Relief who provide technical assistance to DMTs.Most of the problems identified relate to obstacles preventing the effective implementation of various steps in the management model. These originate from within and beyond the DMT, and include issues such inadequate delegation of authority to DMTs, defective budgeting processes, staffing issues, lack of managerial skills and vacancies in key managerial positions, and ineffective use or absence of quality management information systems to support decision-making. Despite these constraints, DMTs take on ambitious national programmes with a positive attitude, and there are promising indications that the hindrances identified are being successfully addressed through policy reforms.