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Power sources among district health managers in Ghana: a qualitative study

Power sources among district health managers in Ghana: a qualitative study Background: In Ghana district directors of health services and district hospital medical superintendents provide leadership and management within district health systems. A healthy relationship among these managers is depend‑ ent on the clarity of formal and informal rules governing their routine duties. These rules translate into the power structures within which district health managers operate. However, detailed nuanced studies of power sources among district health managers are scarce. This paper explores how, why and from where district health directors and medical superintendents derive power in their routine functions. Methods: A multiple case study was conducted in three districts; Bongo, Kintampo North and Juaboso. In each case study site, a cross‑sectional design was used to explore the research question. Purposive sampling technique was used to select study sites and 61 participants for interview and focus group discussion. A total of 11 interviews (3 in each district and 2 with deputy regional directors), and 9 focus group discussions (3 in each district) were conducted. Transcriptions of the voice‑recordings were done verbatim, cleaned and imported into the Nvivo version 11 software for analysis using the inductive content analysis approach. Results: The findings revealed that legitimacy provides formal power source for district health managers since they are formally appointed by the Director General of the Ghana Health Service after going through the appointment processes. These appointments serve as the primary power source for district health managers based on the existing legal and policy framework of the Ghana Health Service. Additionally, resource control especially finances and medical dominance are major informal sources of power that district health managers often employ for the management and administration of their functional areas in the health districts. Conclusions: The study concludes that district health managers derive powers primarily from their positions within the hierarchical structure (legitimacy) of the district health system. Secondary sources of power stems from resource control (medical dominance and financial dominance), and these power sources inform the way district health managers relate to each other. This paper recommends that district health managers are oriented to understand the power dynamics in the district health system. Keywords: Power, District health system, District health managers Background Health systems functions with diverse health profes- sionals responding to a range of healthcare needs across populations. Healthcare is routinely delivered by a com- *Correspondence: desmondkuupie198@hotmail.com bined efforts of clinicians and non-clinicians who func - Department of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu‑Natal, 4001 Durban, South Africa tion with their own set of cultures, norms, educational Full list of author information is available at the end of the article © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Bawontuo et al. BMC Primary Care (2022) 23:68 Page 2 of 9 backgrounds and identities [1]. Everyday interface In Ghana, studies have highlighted how micro health between and across different health professionals is managers variously drive power [9, 10]. An important characterised by power relations that define managerial source of such power is linked to the existing leadership functions and healthcare delivery. Power play and power hierarchies embedded in decentralised systems. In every sources have thus become fundamental to understanding district health system, the district director and the medi- how health systems function to achieve equity, respon- cal superintendent play complementary roles in the day- sive, effective and efficient care [2]. Power has been vari - to-day administration of the district health system. The ously defined but can simply be described as the ability or district director who can be a clinician or non-clinician capacity to direct or influence a person’s behaviour or act has oversight responsibilities over resource allocation in a way to bring about changes in an event or outcome (human, financial, materials), supervision, and project [2]. and programme coordination [11]. Generally, the district Literature has acknowledged that managerial and lead- director presides over all managerial aspects of the dis- ership practices in health systems are characterised by trict health system and reports to the regional director structural, economic and social power dynamics which of health services in the line of duties [12]. The medical shapes how people behaviour, act or make choices [3]. superintendent, who is a medical doctor, heads the dis- But how do individuals gain power over others within trict hospital which is the referral point for lower level the social structures of health systems and organisations? facilities. The medical superintendent coordinates, con - Answers to this question are embedded in how health trols, directs and plans health service delivery in the systems are organised and managed, as well as the diver- district hospital. Both the district director and medical gent sources of power discussed in the literature [3]. This superintendent are members of the district health man- study employed and analysed power from the perspective agement team (DHMT) – which is the highest decision of French and Raven’s [4] typology of power (cohesion, body on health issues in the district. The complexity of legitimate, rewards, reference and expert), Finkelstein’s the functional and professional differences between sources of power (structure, ownership, expert and pres- the director and medical superintendent often invoke tige) [5] and Lucio’s theory of resource control [6]. implicit and explicit power dynamics in determining who Health systems are generally structured and man- gets what power and how [8, 10]. These power dynamics aged in a top-down approach and this provides incen- span from routine reporting channels, negotiations, and tives for power play. Such power dynamics manifest interaction to decision space on resource allocation and greatly in decentralised systems where power, authority distribution [8]. and resources are often devolved to peripheral units by In principle, for example, the medical superintendent the central administration [7]. In sub-Saharan Africa, reports to the district director, but in practice, it is not decentralisation is a common reform implemented to strictly followed especially when the latter is not a doc- enable district health systems to function effectively tor [13]. This is partly attributed to the medicalisation of in improving equity, efficiency and meeting the health healthcare, giving doctors strong control and dominance needs of peripheral populations [8]. Given the complex- over other health professionals [14]. The district director ity of health systems, decentralisation is widely seen as a in turn can constrain the functions of the medical super- vehicle of promoting decisional control of district health intendent by failing to provide requisite medical and managers to navigate routine challenges confronting the human resources to support care delivery at the district provision of health services [9]. With bottom-up deci- hospital. Given the complex adaptive nature of health sion making approach, decentralisation is argued to lead systems in general and micro health systems in particular, to better coordination, planning, greater participation in power play and competition over power can considerably health and increased power for sub-national managers stifle progress in achieving target health incomes. Identi - [3]. However, questions abound as to whether decentrali- fying and dealing with the mechanisms in which district sation actually results in achieving intended outcomes health managers draw on and exercise power is crucial such as better population health and managerial effi - to promote a healthy relation for efficient public health ciency. Too often, the discretionary exercise of power and management. In addition, an understanding of how and authority by decentralised health managers tend to stifle why social and political factors interact to shape maldis- quality healthcare delivery or negatively shape the way in tribution of resources in district health systems requires which policies and programmes are executed leading to exploring and analysing the sources that give rise to poor outcomes. Yet, an understanding of how and from power imbalances and privileges among district health where decentralised health managers draw on power and managers. Accordingly, this study sought to explore how exercise same for their own gains is poorly understood and why district directors and medical superintendents empirically. This knowledge gap occasioned this study. derive power in the discharge of their duties. Ba wontuo et al. BMC Primary Care (2022) 23:68 Page 3 of 9 Table 1 Summary of study participants showing their categories Methods and districts/regions Study design and participants The study used multiple case study design involving 3 Study Site Health Frontline managers Healthcare districts selected from the northern (Bongo district), Providers middle (Kintampo North district) and southern (Jua- boso district) belts of Ghana. A ‘case’ is defined as a com - Male Female Male Female Total plex functioning unit, investigated in its natural context Bongo District/Upper East Region 6 4 10 5 25 [15]. Cross-sectional data collection was implemented Kintampo North / Brong Ahafo 7 3 9 5 24 Region in each study site. Within each district, the target par- Juaboso district/Western Region 7 2 8 6 23 ticipants were health managers (Deputy Regional Health Directors - Clinical Care, district health management Total 20 9 27 16 72 team members, hospital management team members and sub-district health leaders) and frontline providers: sectional heads and hospital ward in-charges (nurses, meeting venues were pre-arranged with the participants midwives, lab. technicians, health information officers, in order to ensure commitment. All interviews were tape physician assistants), and midwives, nurses, lab tech- recorded alongside note taking. nicians, records officers and dispensing technicians in health centres. All the 3 district health directors sampled Data analysis were nurses with public health background. Interviews notes and tape recordings were transcribed verbatim by the authors. The transcripts of the voice- recordings and field notes were cleaned and imported Sampling into the Nvivo (version 11) software. The analysis was The 3 regions sampled purposively based on the 3 eco - done using the inductive content analysis approach by logical belts of the country and health sector perfor- coding to identify common patterns [18]. Common pat- mance indicators. The health sector performance reports terns in the dataset were categorised into two major described the selected regions in each belt as best per- themes: formal sources of power (sub-themes were; legit- forming [16]. We used district health systems that have imate source of power for district directors, and legiti- a district health directorate, a district hospital and a mate source of power for medical superintendents), and functioning health centre. Bongo district was used as a informal sources of power (sub-themes were; financial nucleus district, while Kintampo North and Juaboso dis- dominance and medical dominance). tricts served as triangulation districts [17]. Bongo-Soe health centre was selected in the Bongo District, New Longoro health centre in the Kintampo North Munici- Results pality and Bonsu-Nkwanta health centre in the Juaboso The results are structured around the themes that District. The health managers and frontline providers emerged from the data analysis. These themes are related were sampled purposively because of the critical roles to the formal (legitimate) as well as informal power that they play in providing health services. A summary of sources that define how district directors and medical the study sampled participants in the 3 districts is pre- superintendents exercise power, with whom and over sented in Table 1. who, and why. Legitimate source of power ‑ district directors Data collection Even though there are relational gaps in the district Interviews and Focus Group Discussion (FGDs) were health system, the findings revealed that district direc - used to collect data. Eleven (11) in-depth interviews tors are still recognized as formal heads of the district involving 3 district directors, 3 medical superintendents, health systems and derive powers from their legitimate 3 sub-district leaders and 2 deputy regional directors - positions. Legitimate power is derived from the position clinical care; were conducted. Also, nine (9) FGDs in each a person holds in an organization’s hierarchy. Thus, the case study site, were conducted. The FGDs were con - study found that district directors gain power because ducted among selected district health managers, frontline district health directorates are the apex of all health insti- providers in the hospitals and health centres. An inter- tutions at the district health system. As to why district view guide with probes and prompts on power sources directors have legitimate power, the findings revealed and power relations was used to collect data across the that they serve as figureheads and represent the district selected districts. Interview and FGD dates, times and in various meetings. For instance, they represent the Bawontuo et al. BMC Primary Care (2022) 23:68 Page 4 of 9 health sector during district assembly meetings – a meet- though the organisational structure of district health sys- ing of assembly members and heads of various institu- tems shows that district directors head all health insti- tions in the district - to discuss developmental issues of tutions, participants reported that district hospitals and concern. However, the medical superintendent or hos- district health directorates have separate heads: pital administrator represents the health sector in such […] The district director is the head of the district assembly meetings in the absence of the district director: health directorate, and the medical superintendent […] If I (district director) am not able to attend any is the head of the district hospital, which is part of district assembly meeting, the medical superinten- the district health directorate […] (Interview, Dep- dent or the hospital administrator attends on my uty Regional Director, Clinical Care). behalf and brief me afterwards. […] (Interview, Another reason for which medical superintendents District Director). acquire legitimate power was that district hospitals are In such meetings, the district directors have power to autonomous and deal directly with the Regional Direc- negotiate and dialogue with the assembly, thus pushing tors of Health Services in spite of the fact that district the entire district health agenda for consideration by the hospitals are integral part of the district health systems. assembly. This was confirmed in this statement: The findings also revealed that district directors repre - […] Theoretically, the district hospital is part of the sent the district during regional health management team district health directorate, but practically or in real- meetings. Regional health directorates provide manage- ity it is not […] In terms of management, the hospital rial support to the district health services, and periodi- does not report to the district health directorate, but cally hold management meetings involving all districts in directly to the regional director […] (FGD, Nurse). the region to discuss healthcare delivery issues. Addition- ally, regional health directorates organise periodic perfor- Consequently, the annual performance appraisals of mance review meetings to monitor the performance of medical superintendents are not done by the district the districts. In such meetings, district directors present directors, but by their respective regional directors of a composite report of all health activities carried out at health services. As pointed out by this participant: the district hospital, health centres and the CHPS zones/ […] Though the hospital is an integral part of the compounds during these regional performance review district, I (district director) do not appraise him meetings: (medical superintendent); we are both appraised by […] The district is preparing for the annual regional the regional director every year […] (Interview, Dis- performance review meeting, and the district direc- trict Director). tor will lead the team to present the district annual While the established policies prescribed the formal activities in one composite report […] (Interview, power relationships between the district director and the Medical Superintendent). medical superintendent, there were perceived conflicts This clearly shows that the district director derive due to the kind of informal sources of power that exist in power as a legitimate head of the district; present and practice. Such informal power sources also inform how defend healthcare activities for the year under review and these district health managers relate to each other within set targets for the next year. the district health system. Informal power sources of district health managers Legitimate source of power ‑ medical superintendent The findings further revealed that the availability and It was found that medical superintendents derive power control of resources (finances) as well as knowledge and from their positions as heads of the district hospitals. A expertise were additional layers of legitimate power of review of the Ghana Health Service and Teaching Hospi- the district health managers. These are further explored tals Board Act 525 (1996) showed that district hospitals below. have financial and administrative authority to operate as independent budget management centres (BMCs) within the district health systems. With this policy, district hos- Financial dominance as an informal power source pitals are devolved from the district health directorates The study participants attributed this form of power to and have the power to make decisions for the smooth government’s inability to directly finance district health functioning of the hospitals. This demonstrates how med - activities through subventions. Instead, government ical superintendents gain legitimate power to oversee and is funding district health activities through funds gen- supervise district hospital activities. Consequently, even erated internally at the point of care. This means that Ba wontuo et al. BMC Primary Care (2022) 23:68 Page 5 of 9 district health institutions must maximise the use of their accessed in different forms contingent on the needs of resources in order to generate enough funds to ensure the directorates: sustainability. For this reason, district health institutions […] There was a letter asking hospitals to be sup - that generate funds, and are able to generate more, have porting the district health directorate […] What we access to finances to support and sustain their healthcare normally do here is that, anytime we are in need of activities: something and we are tight; we call on them (hospi- […] Budgetary allocations to the BMCs have dwin- tal management) for support […] (Interview, Dis- dled or stopped completely […] Government is now trict Director). funding our budgets through the services we provide Even though the support system is mandatory, study […] So we just have to generate more money to sur- participants reported that some medical superintendents vive […] (FGD, Nurse). are reluctant to comply with directive. This implies that Medical superintendents derive financial power by vir - implementation of the directive depends on the rela- tue of their internally generated funds (IGF) and make tionship between medical superintendents and district independent decisions on the use of financial resources directors, and how much district directors can negotiate without consulting the district directors. The study par - for their packages. This confirms why medical superin - ticipants disclosed that district hospitals provide ser- tendents have so much resource power over the district vices that are paid for either at the point-of-care (cash directors. and carry) by the service recipients, or retrospectively by the National Health Insurance Scheme (NHIS). In this Medical dominance as an informal power source instance, medical superintendents have strong control The findings revealed how and why medical dominance over financial resources generated through the services serves as another source of power for district health delivered at the hospital: managers. For instance, it was reported that medical doctors use their knowledge and expertise to gain power […] District hospitals generate funds from their over other health professionals in the health sector. This services, and as medical superintendents, we have suggests that medical doctors derive power from their authority to make independent decisions on the training and profession. Consequently, it was suggested funds we generate […] Yes, we have that power […] that medical doctors should be positioned higher in the (Interview, Medical Superintendent). hierarchical ladder of any health system. This suggests On the contrary, the district health directorates do not that no other health professional can exercise power over generate any revenue and solely depend on government the medical doctor: subvention. This is because district health directorates, […] The districts should be manned by medically per the policy guidelines of the Ghana Health Service trained persons, meaning persons who have gone provide preventive health services which are not income through medicine and passed out […] The post/posi - generating. This poses financial challenge in the day-to- tion should be a preserve for doctors, so that all the day administration of the district health directorates. At other categories of health professionals can fall in the same time, financial support from government has place without any qualms […] (Interview, Deputy dwindled leaving directorates with budgetary deficits: Regional Director, Clinical Care). […] We do not generate any income from the direc- A review of the GHS job description and specification torate here, we normally depend on central govern- for medical superintendents and district directors con- ment subventions to carry out our planned activi- firmed that medical superintendents are medical doc - ties, but these days we hardly get money from the tors (preferably specialists), and district directors are central government […] (Interview, District Direc- either medical doctors (with public health background) tor). or any other health professionals who have public health Furthermore, the district directors rely on the hos- background. One of two scenarios, therefore, exist in a pitals for financial support to implement health and district. Firstly, a district director who is not a medical administrative activities at the district health directo- doctor works with a medical doctor as the medical super- rate levels. Study participants confirmed that district intendent. Secondly, a district director who is a medi- directors receive various forms of support (including cal doctor works with a colleague medical doctor as the traveling expenses, financing health programmes and medical superintendent in the district hospital. administrative support) from the medical superinten- The findings revealed that in the first scenario where dents. This financial support is mandatory, and can be the medical superintendent is a medical doctor and the Bawontuo et al. BMC Primary Care (2022) 23:68 Page 6 of 9 district director is not, the former derives power and superintendents have diverse sources of power including exercise same over the district director. Participants legitimacy, medical dominance and financial dominance, reported that in districts where a district director (who and these power sources inform how district directors is not a medical doctor) attempts to show superior- and medical superintendents relate to each other in the ity over the medical superintendent, he/she often faces discharge of their duties. challenges: The findings revealed how legitimacy serves as power source for both district directors and medical superinten- […] If the district director thinks that he/she is a boss dents since they are formally appointed by the Director to somebody like the doctor or the medical super- General of the GHS after going through the appointment intendent, definitely he/she will run into problems processes. These appointments serves as the primary because when you compare a lot of things, it cannot power source for district health managers based on the be so […] (Interview, Medical Superintendent). existing legal and policy framework of the GHS. Legiti- Another participant indicated: macy is identified as power source which gives appointed officials the right and authority to perform their job roles […] Some doctors do not think that a public health within the formal organisational arrangements [4]. Thus, nurse or a disease control officer or any other health as some authors acknowledged, this source of power professional should be a district director and ask is a formal and positional power, which is vested in the them to do things; they will think the person is lord- office rather than the person [19, 20]. This power source ing over them […] (Interview, Deputy Regional presupposes that the legitimate power of medical super- Director, Clinical Care). intendents is at par with that of district directors, intro- ducing a horizontal power structure which potentially In the second scenario where both actors (district distorts the hierarchical power structure of GHS at the director and medical superintendent) are medical doc- district level. tors, it was reported that medical dominance was non- By legitimate power, it was evident that both district existent to some extent. The district director relates to directors and medical superintendents have additional the medical superintendent as a colleague, supporting powers such as coercive and rewards. For instance, dis- and coordinating each other’s efforts to ensure quality trict directors and medical superintendents appraised healthcare delivery: and recommend their staff for promotion to higher posi - […] If the district director is a medical doctor, you tions, implying they have rewards power. However, from see each other as colleagues […] When you are hot the findings, district directors exercise coercive, rewards he comes in to help you, if you are travelling, he and referent power at the district health directorate level, comes and takes over from you; the cooperation is which includes the sub-districts and CHPS zones, but better with a colleague medical doctor as a district not at the district hospital level. u Th s, staff of the district director […] (Interview, Medical Superintendent). hospital are not likely to recognise and accept the district director as legitimate head, a situation district directors Nonetheless, in the absence of medical dominance, as are worried about. This is in spite of the fact that dis - in the case of colleague medical doctors working together trict hospitals are integral parts of district health systems as district director and medical superintendent in one where district directors are expected to be the overall district, the issue of who has power, and who has control heads of the district health services. These findings con - over who still exist: form to the literature that the management and services […] Even the doctor-doctor scenario, they quarrel, of district hospitals are separated from the management they do not accept instructions from each other […] and services of Primary Health Care (PHC) institutions (Interview, Deputy Regional Director, Clinical [21, 22]. Care). Medical superintendents on the other hand exert their powers over only staff of district hospitals and may not be able to extend these powers to the staff of health cen - Discussion tres and CHPS zones. Yet, an interesting finding of this This study explored how and why district health manag - study relates to the fact that health centre staff recog - ers, such as district directors of health services and dis- nise district hospitals as superiors and constantly discuss trict hospital medical superintendents, gain what power, medical issues with medical superintendents and their over whom, and to what extent, in the discharge of their staff. This implies that medical superintendents have duties. The study employed cross-sectional study design expertise and potentially draws some referent powers in a multiple case study involving 3 districts in Ghana. from the health centre staff. Thus, as compared to district The findings revealed that district directors and medical Ba wontuo et al. BMC Primary Care (2022) 23:68 Page 7 of 9 directors, medical superintendents potentially have influence over other health professions [6]. In the same enough powers from the perspective of the health centre way, this study revealed that medical superintendents staff. This poses as a threat to district directors as persons (who are usually medical doctors) do not accept nurses who directly manage the sub-districts. This is likely to or other health professionals when appointed as district introduce power struggle between district directors and directors, since they are not colleague medical doctors. medical superintendents and has the potential to affect This implies that medical dominance puts constraints the organisation and delivery of clinical services at the on effective management of the district health systems, health centre level. as district directors who are not medical doctors are not Adding to the layer of complex horizontal power rela- able to exercise control over medical superintendents. tions between district directors and medical superinten- However, this trend of having medical doctors in man- dents are various informal power sources such as medical agerial positions is progressively changing in Ghana’s dominance and financial dominance. It was clear that health system. Currently, the position of district direc- knowledge and expertise serve as power source leading to tors, which used to be the preserve of medical doctors the concept of expert power [4]. This was evident in the with public health background [27], has been opened findings since the medical profession is often perceived to all health professionals who have public health back- as the giant of the health sector workforce. medical dom- ground. The outcome of this policy implementation inance was thus, a prominent informal source of power, contributes to strained power relations between district and contributed significantly to the distraction of formal directors and medical superintendents. power structure in the district. It is in this light that this Conversely, the findings also revealed that medical study revealed that medical superintendents exert expert dominance was absent in  situations where both district power over district directors who are not medical doc- directors and medical superintendents were medical doc- tors. This is consistent with the position of a study which tors. It was indicated that they regard each other as col- argued that doctors use their powers as experts to influ - leagues having the same expertise, and therefore, unable ence other health professions [23]. to exercise superiority based on that. As a result, such In Ghana, medical doctors are very prominent in circumstance requires both parties to rely on each oth- the health sector, and occupy most key positions in the er’s power source, which could be legitimacy or access to health sector. For instance, in typical healthcare settings financial resources. The bottom line is that, in most cases like the hospital, the medical doctor, irrespective of his/ where district directors and medical superintendents are her experience, assumes the most senior position as the both medical doctors, their relationships are more cor- medical superintendent. The findings are also consistent dial than when district directors have a different back - with the findings of another study which indicated that ground such as nursing or disease control as revealed by medical doctors are dominant and influential in health - the findings of this study. care organisational management [24]. This probably This study findings revealed that central government explains why many managerial positions in the health subvention to district health institutions has dwindled sector are filled with medical doctors. This also suggests leaving district directors and medical superintendents that medical doctors are the ultimate decision-makers, with limited control over financial resources. u Th s, access both at the service provision and management levels. to cash and control of same, has significant influence on It was widely reported that medical doctors are unable the power base of the district health managers. District to work under, and/or accept instructions from other hospital derive financial resources from the NHIS claims health professionals, and therefore, have dominion over repayments. This is consistent with the findings of a all other health professionals. This finding corroborates study which indicated that NHIS contributes significantly the literature that medical dominance was considered to healthcare financing in Ghana [28]. Financing health - a structural barrier to health services delivery, posing care through NHIS claims repayments implies that dis- workplace dissatisfaction among nurses [25]. Similarly, trict health institutions that provide services are likely to the findings agree with another study about mobile have and control funds. health teams in the Brazilian health system, where there Consequently, the study findings revealed that the was dominance of the medical profession over the other effects of district health institutions financing their own health professions leading to constrained functions [26]. activity budgets through their Internally Generated The authors concluded that the medical dominance dis - Funds (IGF) have left district directors in a vulnerable sit- rupted service provision as some team members felt dis- uation. That is, they have no funds to support their budg - regarded by the medical professionals on some occasions. ets. This implies that district directors have no option, The literature argues that the supremacy of medicine but to depend on the district hospital’s IGF for survival. as the scientific framework gives doctors significant This finding is consistent with the literature that the Bawontuo et al. BMC Primary Care (2022) 23:68 Page 8 of 9 and Health Services Management, Business School, University of Ghana, Accra, district health directorates rely on district hospital’s for Legon, Ghana. Department of Public Health Medicine, School of Nursing financial support [29]. The authors concluded that this and Public Health, University of KwaZulu‑Natal, 4001 Durban, South Africa. dependence makes the district health directorates have Ghana Health Service, Accra, Ghana. less power over district hospitals. Received: 21 May 2021 Accepted: 30 March 2022 Conclusions The study concludes that both district directors and References medical superintendents have legitimate power which 1. 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Abimbola S, Baatiema L, Bigdeli M: The impacts of decentralization on We are thankful to African Population and Health Research Center (APHRC) health system equity, efficiency and resilience: a realist synthesis of the through the African Doctoral Dissertation Research Fellowship (ADDRF), evidence. Health Policy and Planning 2019, 34(8):605–617. Nairobi, Kenya for providing financial support for this study. 8. Sumah AM, Baatiema L, Abimbola S: The impacts of decentralisation on health‑related equity: A systematic review of the evidence. Health Policy Authors’ contributions 2016, 120(10):1183–1192. VB, AAA, and IAA conceptualised and designed the study. VB and RAA did the 9. Sumah AM, Baatiema L: Decentralisation and management of human data analysis and wrote first draft of the paper which was reviewed by AAA, resource for health in the health system of Ghana: a decision space DK, and IAA. All authors read and approved the final manuscript. analysis. 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Power interde ‑ Department of Health Services Management and Administration, School pendence in organizations 2009:224. of Business, SD Dombo University of Business and Integrated Development 21. Independent Review Health Sector Programme of Work 2010 [https:// Studies (SDD‑UBIDS), Bamahu‑ Wa, Ghana. Research for Sustainable Develop‑ www. moh. gov. gh/ wp‑ conte nt/ uploa ds/ 2016/ 02/ Review‑ of‑ Ghana‑ ment Consult, Fiapre, Sunyani, Ghana. School of Public Health, University Health‑ Sector‑ 2010. pdf ] of Ghana, Accra, Legon, Ghana. Department of Public Administration Ba wontuo et al. BMC Primary Care (2022) 23:68 Page 9 of 9 22. Le Roux K, Couper I: Rural district hospitals‑ essential cogs in the district health system‑and primary healthcare re ‑ engineering: forum‑healthcare delivery. South African Medical Journal 2015, 105(6):440–441. 23. Spehar I, Frich JC, Kjekshus LE: Clinicians in management: a qualitative study of managers’ use of influence strategies in hospitals. 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Kwamie A, van Dijk H, Ansah EK, Agyepong IA: The path dependence of district manager decision‑space in Ghana. Health policy and planning 2016, 31(3):356–366. Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in pub‑ lished maps and institutional affiliations. Re Read ady y to to submit y submit your our re researc search h ? Choose BMC and benefit fr ? Choose BMC and benefit from om: : fast, convenient online submission thorough peer review by experienced researchers in your field rapid publication on acceptance support for research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year At BMC, research is always in progress. Learn more biomedcentral.com/submissions http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Primary Care Springer Journals

Power sources among district health managers in Ghana: a qualitative study

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Abstract

Background: In Ghana district directors of health services and district hospital medical superintendents provide leadership and management within district health systems. A healthy relationship among these managers is depend‑ ent on the clarity of formal and informal rules governing their routine duties. These rules translate into the power structures within which district health managers operate. However, detailed nuanced studies of power sources among district health managers are scarce. This paper explores how, why and from where district health directors and medical superintendents derive power in their routine functions. Methods: A multiple case study was conducted in three districts; Bongo, Kintampo North and Juaboso. In each case study site, a cross‑sectional design was used to explore the research question. Purposive sampling technique was used to select study sites and 61 participants for interview and focus group discussion. A total of 11 interviews (3 in each district and 2 with deputy regional directors), and 9 focus group discussions (3 in each district) were conducted. Transcriptions of the voice‑recordings were done verbatim, cleaned and imported into the Nvivo version 11 software for analysis using the inductive content analysis approach. Results: The findings revealed that legitimacy provides formal power source for district health managers since they are formally appointed by the Director General of the Ghana Health Service after going through the appointment processes. These appointments serve as the primary power source for district health managers based on the existing legal and policy framework of the Ghana Health Service. Additionally, resource control especially finances and medical dominance are major informal sources of power that district health managers often employ for the management and administration of their functional areas in the health districts. Conclusions: The study concludes that district health managers derive powers primarily from their positions within the hierarchical structure (legitimacy) of the district health system. Secondary sources of power stems from resource control (medical dominance and financial dominance), and these power sources inform the way district health managers relate to each other. This paper recommends that district health managers are oriented to understand the power dynamics in the district health system. Keywords: Power, District health system, District health managers Background Health systems functions with diverse health profes- sionals responding to a range of healthcare needs across populations. Healthcare is routinely delivered by a com- *Correspondence: desmondkuupie198@hotmail.com bined efforts of clinicians and non-clinicians who func - Department of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu‑Natal, 4001 Durban, South Africa tion with their own set of cultures, norms, educational Full list of author information is available at the end of the article © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Bawontuo et al. BMC Primary Care (2022) 23:68 Page 2 of 9 backgrounds and identities [1]. Everyday interface In Ghana, studies have highlighted how micro health between and across different health professionals is managers variously drive power [9, 10]. An important characterised by power relations that define managerial source of such power is linked to the existing leadership functions and healthcare delivery. Power play and power hierarchies embedded in decentralised systems. In every sources have thus become fundamental to understanding district health system, the district director and the medi- how health systems function to achieve equity, respon- cal superintendent play complementary roles in the day- sive, effective and efficient care [2]. Power has been vari - to-day administration of the district health system. The ously defined but can simply be described as the ability or district director who can be a clinician or non-clinician capacity to direct or influence a person’s behaviour or act has oversight responsibilities over resource allocation in a way to bring about changes in an event or outcome (human, financial, materials), supervision, and project [2]. and programme coordination [11]. Generally, the district Literature has acknowledged that managerial and lead- director presides over all managerial aspects of the dis- ership practices in health systems are characterised by trict health system and reports to the regional director structural, economic and social power dynamics which of health services in the line of duties [12]. The medical shapes how people behaviour, act or make choices [3]. superintendent, who is a medical doctor, heads the dis- But how do individuals gain power over others within trict hospital which is the referral point for lower level the social structures of health systems and organisations? facilities. The medical superintendent coordinates, con - Answers to this question are embedded in how health trols, directs and plans health service delivery in the systems are organised and managed, as well as the diver- district hospital. Both the district director and medical gent sources of power discussed in the literature [3]. This superintendent are members of the district health man- study employed and analysed power from the perspective agement team (DHMT) – which is the highest decision of French and Raven’s [4] typology of power (cohesion, body on health issues in the district. The complexity of legitimate, rewards, reference and expert), Finkelstein’s the functional and professional differences between sources of power (structure, ownership, expert and pres- the director and medical superintendent often invoke tige) [5] and Lucio’s theory of resource control [6]. implicit and explicit power dynamics in determining who Health systems are generally structured and man- gets what power and how [8, 10]. These power dynamics aged in a top-down approach and this provides incen- span from routine reporting channels, negotiations, and tives for power play. Such power dynamics manifest interaction to decision space on resource allocation and greatly in decentralised systems where power, authority distribution [8]. and resources are often devolved to peripheral units by In principle, for example, the medical superintendent the central administration [7]. In sub-Saharan Africa, reports to the district director, but in practice, it is not decentralisation is a common reform implemented to strictly followed especially when the latter is not a doc- enable district health systems to function effectively tor [13]. This is partly attributed to the medicalisation of in improving equity, efficiency and meeting the health healthcare, giving doctors strong control and dominance needs of peripheral populations [8]. Given the complex- over other health professionals [14]. The district director ity of health systems, decentralisation is widely seen as a in turn can constrain the functions of the medical super- vehicle of promoting decisional control of district health intendent by failing to provide requisite medical and managers to navigate routine challenges confronting the human resources to support care delivery at the district provision of health services [9]. With bottom-up deci- hospital. Given the complex adaptive nature of health sion making approach, decentralisation is argued to lead systems in general and micro health systems in particular, to better coordination, planning, greater participation in power play and competition over power can considerably health and increased power for sub-national managers stifle progress in achieving target health incomes. Identi - [3]. However, questions abound as to whether decentrali- fying and dealing with the mechanisms in which district sation actually results in achieving intended outcomes health managers draw on and exercise power is crucial such as better population health and managerial effi - to promote a healthy relation for efficient public health ciency. Too often, the discretionary exercise of power and management. In addition, an understanding of how and authority by decentralised health managers tend to stifle why social and political factors interact to shape maldis- quality healthcare delivery or negatively shape the way in tribution of resources in district health systems requires which policies and programmes are executed leading to exploring and analysing the sources that give rise to poor outcomes. Yet, an understanding of how and from power imbalances and privileges among district health where decentralised health managers draw on power and managers. Accordingly, this study sought to explore how exercise same for their own gains is poorly understood and why district directors and medical superintendents empirically. This knowledge gap occasioned this study. derive power in the discharge of their duties. Ba wontuo et al. BMC Primary Care (2022) 23:68 Page 3 of 9 Table 1 Summary of study participants showing their categories Methods and districts/regions Study design and participants The study used multiple case study design involving 3 Study Site Health Frontline managers Healthcare districts selected from the northern (Bongo district), Providers middle (Kintampo North district) and southern (Jua- boso district) belts of Ghana. A ‘case’ is defined as a com - Male Female Male Female Total plex functioning unit, investigated in its natural context Bongo District/Upper East Region 6 4 10 5 25 [15]. Cross-sectional data collection was implemented Kintampo North / Brong Ahafo 7 3 9 5 24 Region in each study site. Within each district, the target par- Juaboso district/Western Region 7 2 8 6 23 ticipants were health managers (Deputy Regional Health Directors - Clinical Care, district health management Total 20 9 27 16 72 team members, hospital management team members and sub-district health leaders) and frontline providers: sectional heads and hospital ward in-charges (nurses, meeting venues were pre-arranged with the participants midwives, lab. technicians, health information officers, in order to ensure commitment. All interviews were tape physician assistants), and midwives, nurses, lab tech- recorded alongside note taking. nicians, records officers and dispensing technicians in health centres. All the 3 district health directors sampled Data analysis were nurses with public health background. Interviews notes and tape recordings were transcribed verbatim by the authors. The transcripts of the voice- recordings and field notes were cleaned and imported Sampling into the Nvivo (version 11) software. The analysis was The 3 regions sampled purposively based on the 3 eco - done using the inductive content analysis approach by logical belts of the country and health sector perfor- coding to identify common patterns [18]. Common pat- mance indicators. The health sector performance reports terns in the dataset were categorised into two major described the selected regions in each belt as best per- themes: formal sources of power (sub-themes were; legit- forming [16]. We used district health systems that have imate source of power for district directors, and legiti- a district health directorate, a district hospital and a mate source of power for medical superintendents), and functioning health centre. Bongo district was used as a informal sources of power (sub-themes were; financial nucleus district, while Kintampo North and Juaboso dis- dominance and medical dominance). tricts served as triangulation districts [17]. Bongo-Soe health centre was selected in the Bongo District, New Longoro health centre in the Kintampo North Munici- Results pality and Bonsu-Nkwanta health centre in the Juaboso The results are structured around the themes that District. The health managers and frontline providers emerged from the data analysis. These themes are related were sampled purposively because of the critical roles to the formal (legitimate) as well as informal power that they play in providing health services. A summary of sources that define how district directors and medical the study sampled participants in the 3 districts is pre- superintendents exercise power, with whom and over sented in Table 1. who, and why. Legitimate source of power ‑ district directors Data collection Even though there are relational gaps in the district Interviews and Focus Group Discussion (FGDs) were health system, the findings revealed that district direc - used to collect data. Eleven (11) in-depth interviews tors are still recognized as formal heads of the district involving 3 district directors, 3 medical superintendents, health systems and derive powers from their legitimate 3 sub-district leaders and 2 deputy regional directors - positions. Legitimate power is derived from the position clinical care; were conducted. Also, nine (9) FGDs in each a person holds in an organization’s hierarchy. Thus, the case study site, were conducted. The FGDs were con - study found that district directors gain power because ducted among selected district health managers, frontline district health directorates are the apex of all health insti- providers in the hospitals and health centres. An inter- tutions at the district health system. As to why district view guide with probes and prompts on power sources directors have legitimate power, the findings revealed and power relations was used to collect data across the that they serve as figureheads and represent the district selected districts. Interview and FGD dates, times and in various meetings. For instance, they represent the Bawontuo et al. BMC Primary Care (2022) 23:68 Page 4 of 9 health sector during district assembly meetings – a meet- though the organisational structure of district health sys- ing of assembly members and heads of various institu- tems shows that district directors head all health insti- tions in the district - to discuss developmental issues of tutions, participants reported that district hospitals and concern. However, the medical superintendent or hos- district health directorates have separate heads: pital administrator represents the health sector in such […] The district director is the head of the district assembly meetings in the absence of the district director: health directorate, and the medical superintendent […] If I (district director) am not able to attend any is the head of the district hospital, which is part of district assembly meeting, the medical superinten- the district health directorate […] (Interview, Dep- dent or the hospital administrator attends on my uty Regional Director, Clinical Care). behalf and brief me afterwards. […] (Interview, Another reason for which medical superintendents District Director). acquire legitimate power was that district hospitals are In such meetings, the district directors have power to autonomous and deal directly with the Regional Direc- negotiate and dialogue with the assembly, thus pushing tors of Health Services in spite of the fact that district the entire district health agenda for consideration by the hospitals are integral part of the district health systems. assembly. This was confirmed in this statement: The findings also revealed that district directors repre - […] Theoretically, the district hospital is part of the sent the district during regional health management team district health directorate, but practically or in real- meetings. Regional health directorates provide manage- ity it is not […] In terms of management, the hospital rial support to the district health services, and periodi- does not report to the district health directorate, but cally hold management meetings involving all districts in directly to the regional director […] (FGD, Nurse). the region to discuss healthcare delivery issues. Addition- ally, regional health directorates organise periodic perfor- Consequently, the annual performance appraisals of mance review meetings to monitor the performance of medical superintendents are not done by the district the districts. In such meetings, district directors present directors, but by their respective regional directors of a composite report of all health activities carried out at health services. As pointed out by this participant: the district hospital, health centres and the CHPS zones/ […] Though the hospital is an integral part of the compounds during these regional performance review district, I (district director) do not appraise him meetings: (medical superintendent); we are both appraised by […] The district is preparing for the annual regional the regional director every year […] (Interview, Dis- performance review meeting, and the district direc- trict Director). tor will lead the team to present the district annual While the established policies prescribed the formal activities in one composite report […] (Interview, power relationships between the district director and the Medical Superintendent). medical superintendent, there were perceived conflicts This clearly shows that the district director derive due to the kind of informal sources of power that exist in power as a legitimate head of the district; present and practice. Such informal power sources also inform how defend healthcare activities for the year under review and these district health managers relate to each other within set targets for the next year. the district health system. Informal power sources of district health managers Legitimate source of power ‑ medical superintendent The findings further revealed that the availability and It was found that medical superintendents derive power control of resources (finances) as well as knowledge and from their positions as heads of the district hospitals. A expertise were additional layers of legitimate power of review of the Ghana Health Service and Teaching Hospi- the district health managers. These are further explored tals Board Act 525 (1996) showed that district hospitals below. have financial and administrative authority to operate as independent budget management centres (BMCs) within the district health systems. With this policy, district hos- Financial dominance as an informal power source pitals are devolved from the district health directorates The study participants attributed this form of power to and have the power to make decisions for the smooth government’s inability to directly finance district health functioning of the hospitals. This demonstrates how med - activities through subventions. Instead, government ical superintendents gain legitimate power to oversee and is funding district health activities through funds gen- supervise district hospital activities. Consequently, even erated internally at the point of care. This means that Ba wontuo et al. BMC Primary Care (2022) 23:68 Page 5 of 9 district health institutions must maximise the use of their accessed in different forms contingent on the needs of resources in order to generate enough funds to ensure the directorates: sustainability. For this reason, district health institutions […] There was a letter asking hospitals to be sup - that generate funds, and are able to generate more, have porting the district health directorate […] What we access to finances to support and sustain their healthcare normally do here is that, anytime we are in need of activities: something and we are tight; we call on them (hospi- […] Budgetary allocations to the BMCs have dwin- tal management) for support […] (Interview, Dis- dled or stopped completely […] Government is now trict Director). funding our budgets through the services we provide Even though the support system is mandatory, study […] So we just have to generate more money to sur- participants reported that some medical superintendents vive […] (FGD, Nurse). are reluctant to comply with directive. This implies that Medical superintendents derive financial power by vir - implementation of the directive depends on the rela- tue of their internally generated funds (IGF) and make tionship between medical superintendents and district independent decisions on the use of financial resources directors, and how much district directors can negotiate without consulting the district directors. The study par - for their packages. This confirms why medical superin - ticipants disclosed that district hospitals provide ser- tendents have so much resource power over the district vices that are paid for either at the point-of-care (cash directors. and carry) by the service recipients, or retrospectively by the National Health Insurance Scheme (NHIS). In this Medical dominance as an informal power source instance, medical superintendents have strong control The findings revealed how and why medical dominance over financial resources generated through the services serves as another source of power for district health delivered at the hospital: managers. For instance, it was reported that medical doctors use their knowledge and expertise to gain power […] District hospitals generate funds from their over other health professionals in the health sector. This services, and as medical superintendents, we have suggests that medical doctors derive power from their authority to make independent decisions on the training and profession. Consequently, it was suggested funds we generate […] Yes, we have that power […] that medical doctors should be positioned higher in the (Interview, Medical Superintendent). hierarchical ladder of any health system. This suggests On the contrary, the district health directorates do not that no other health professional can exercise power over generate any revenue and solely depend on government the medical doctor: subvention. This is because district health directorates, […] The districts should be manned by medically per the policy guidelines of the Ghana Health Service trained persons, meaning persons who have gone provide preventive health services which are not income through medicine and passed out […] The post/posi - generating. This poses financial challenge in the day-to- tion should be a preserve for doctors, so that all the day administration of the district health directorates. At other categories of health professionals can fall in the same time, financial support from government has place without any qualms […] (Interview, Deputy dwindled leaving directorates with budgetary deficits: Regional Director, Clinical Care). […] We do not generate any income from the direc- A review of the GHS job description and specification torate here, we normally depend on central govern- for medical superintendents and district directors con- ment subventions to carry out our planned activi- firmed that medical superintendents are medical doc - ties, but these days we hardly get money from the tors (preferably specialists), and district directors are central government […] (Interview, District Direc- either medical doctors (with public health background) tor). or any other health professionals who have public health Furthermore, the district directors rely on the hos- background. One of two scenarios, therefore, exist in a pitals for financial support to implement health and district. Firstly, a district director who is not a medical administrative activities at the district health directo- doctor works with a medical doctor as the medical super- rate levels. Study participants confirmed that district intendent. Secondly, a district director who is a medi- directors receive various forms of support (including cal doctor works with a colleague medical doctor as the traveling expenses, financing health programmes and medical superintendent in the district hospital. administrative support) from the medical superinten- The findings revealed that in the first scenario where dents. This financial support is mandatory, and can be the medical superintendent is a medical doctor and the Bawontuo et al. BMC Primary Care (2022) 23:68 Page 6 of 9 district director is not, the former derives power and superintendents have diverse sources of power including exercise same over the district director. Participants legitimacy, medical dominance and financial dominance, reported that in districts where a district director (who and these power sources inform how district directors is not a medical doctor) attempts to show superior- and medical superintendents relate to each other in the ity over the medical superintendent, he/she often faces discharge of their duties. challenges: The findings revealed how legitimacy serves as power source for both district directors and medical superinten- […] If the district director thinks that he/she is a boss dents since they are formally appointed by the Director to somebody like the doctor or the medical super- General of the GHS after going through the appointment intendent, definitely he/she will run into problems processes. These appointments serves as the primary because when you compare a lot of things, it cannot power source for district health managers based on the be so […] (Interview, Medical Superintendent). existing legal and policy framework of the GHS. Legiti- Another participant indicated: macy is identified as power source which gives appointed officials the right and authority to perform their job roles […] Some doctors do not think that a public health within the formal organisational arrangements [4]. Thus, nurse or a disease control officer or any other health as some authors acknowledged, this source of power professional should be a district director and ask is a formal and positional power, which is vested in the them to do things; they will think the person is lord- office rather than the person [19, 20]. This power source ing over them […] (Interview, Deputy Regional presupposes that the legitimate power of medical super- Director, Clinical Care). intendents is at par with that of district directors, intro- ducing a horizontal power structure which potentially In the second scenario where both actors (district distorts the hierarchical power structure of GHS at the director and medical superintendent) are medical doc- district level. tors, it was reported that medical dominance was non- By legitimate power, it was evident that both district existent to some extent. The district director relates to directors and medical superintendents have additional the medical superintendent as a colleague, supporting powers such as coercive and rewards. For instance, dis- and coordinating each other’s efforts to ensure quality trict directors and medical superintendents appraised healthcare delivery: and recommend their staff for promotion to higher posi - […] If the district director is a medical doctor, you tions, implying they have rewards power. However, from see each other as colleagues […] When you are hot the findings, district directors exercise coercive, rewards he comes in to help you, if you are travelling, he and referent power at the district health directorate level, comes and takes over from you; the cooperation is which includes the sub-districts and CHPS zones, but better with a colleague medical doctor as a district not at the district hospital level. u Th s, staff of the district director […] (Interview, Medical Superintendent). hospital are not likely to recognise and accept the district director as legitimate head, a situation district directors Nonetheless, in the absence of medical dominance, as are worried about. This is in spite of the fact that dis - in the case of colleague medical doctors working together trict hospitals are integral parts of district health systems as district director and medical superintendent in one where district directors are expected to be the overall district, the issue of who has power, and who has control heads of the district health services. These findings con - over who still exist: form to the literature that the management and services […] Even the doctor-doctor scenario, they quarrel, of district hospitals are separated from the management they do not accept instructions from each other […] and services of Primary Health Care (PHC) institutions (Interview, Deputy Regional Director, Clinical [21, 22]. Care). Medical superintendents on the other hand exert their powers over only staff of district hospitals and may not be able to extend these powers to the staff of health cen - Discussion tres and CHPS zones. Yet, an interesting finding of this This study explored how and why district health manag - study relates to the fact that health centre staff recog - ers, such as district directors of health services and dis- nise district hospitals as superiors and constantly discuss trict hospital medical superintendents, gain what power, medical issues with medical superintendents and their over whom, and to what extent, in the discharge of their staff. This implies that medical superintendents have duties. The study employed cross-sectional study design expertise and potentially draws some referent powers in a multiple case study involving 3 districts in Ghana. from the health centre staff. Thus, as compared to district The findings revealed that district directors and medical Ba wontuo et al. BMC Primary Care (2022) 23:68 Page 7 of 9 directors, medical superintendents potentially have influence over other health professions [6]. In the same enough powers from the perspective of the health centre way, this study revealed that medical superintendents staff. This poses as a threat to district directors as persons (who are usually medical doctors) do not accept nurses who directly manage the sub-districts. This is likely to or other health professionals when appointed as district introduce power struggle between district directors and directors, since they are not colleague medical doctors. medical superintendents and has the potential to affect This implies that medical dominance puts constraints the organisation and delivery of clinical services at the on effective management of the district health systems, health centre level. as district directors who are not medical doctors are not Adding to the layer of complex horizontal power rela- able to exercise control over medical superintendents. tions between district directors and medical superinten- However, this trend of having medical doctors in man- dents are various informal power sources such as medical agerial positions is progressively changing in Ghana’s dominance and financial dominance. It was clear that health system. Currently, the position of district direc- knowledge and expertise serve as power source leading to tors, which used to be the preserve of medical doctors the concept of expert power [4]. This was evident in the with public health background [27], has been opened findings since the medical profession is often perceived to all health professionals who have public health back- as the giant of the health sector workforce. medical dom- ground. The outcome of this policy implementation inance was thus, a prominent informal source of power, contributes to strained power relations between district and contributed significantly to the distraction of formal directors and medical superintendents. power structure in the district. It is in this light that this Conversely, the findings also revealed that medical study revealed that medical superintendents exert expert dominance was absent in  situations where both district power over district directors who are not medical doc- directors and medical superintendents were medical doc- tors. This is consistent with the position of a study which tors. It was indicated that they regard each other as col- argued that doctors use their powers as experts to influ - leagues having the same expertise, and therefore, unable ence other health professions [23]. to exercise superiority based on that. As a result, such In Ghana, medical doctors are very prominent in circumstance requires both parties to rely on each oth- the health sector, and occupy most key positions in the er’s power source, which could be legitimacy or access to health sector. For instance, in typical healthcare settings financial resources. The bottom line is that, in most cases like the hospital, the medical doctor, irrespective of his/ where district directors and medical superintendents are her experience, assumes the most senior position as the both medical doctors, their relationships are more cor- medical superintendent. The findings are also consistent dial than when district directors have a different back - with the findings of another study which indicated that ground such as nursing or disease control as revealed by medical doctors are dominant and influential in health - the findings of this study. care organisational management [24]. This probably This study findings revealed that central government explains why many managerial positions in the health subvention to district health institutions has dwindled sector are filled with medical doctors. This also suggests leaving district directors and medical superintendents that medical doctors are the ultimate decision-makers, with limited control over financial resources. u Th s, access both at the service provision and management levels. to cash and control of same, has significant influence on It was widely reported that medical doctors are unable the power base of the district health managers. District to work under, and/or accept instructions from other hospital derive financial resources from the NHIS claims health professionals, and therefore, have dominion over repayments. This is consistent with the findings of a all other health professionals. This finding corroborates study which indicated that NHIS contributes significantly the literature that medical dominance was considered to healthcare financing in Ghana [28]. Financing health - a structural barrier to health services delivery, posing care through NHIS claims repayments implies that dis- workplace dissatisfaction among nurses [25]. Similarly, trict health institutions that provide services are likely to the findings agree with another study about mobile have and control funds. health teams in the Brazilian health system, where there Consequently, the study findings revealed that the was dominance of the medical profession over the other effects of district health institutions financing their own health professions leading to constrained functions [26]. activity budgets through their Internally Generated The authors concluded that the medical dominance dis - Funds (IGF) have left district directors in a vulnerable sit- rupted service provision as some team members felt dis- uation. That is, they have no funds to support their budg - regarded by the medical professionals on some occasions. ets. This implies that district directors have no option, The literature argues that the supremacy of medicine but to depend on the district hospital’s IGF for survival. as the scientific framework gives doctors significant This finding is consistent with the literature that the Bawontuo et al. BMC Primary Care (2022) 23:68 Page 8 of 9 and Health Services Management, Business School, University of Ghana, Accra, district health directorates rely on district hospital’s for Legon, Ghana. Department of Public Health Medicine, School of Nursing financial support [29]. The authors concluded that this and Public Health, University of KwaZulu‑Natal, 4001 Durban, South Africa. dependence makes the district health directorates have Ghana Health Service, Accra, Ghana. less power over district hospitals. Received: 21 May 2021 Accepted: 30 March 2022 Conclusions The study concludes that both district directors and References medical superintendents have legitimate power which 1. 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Kwamie A, van Dijk H, Ansah EK, Agyepong IA: The path dependence of district manager decision‑space in Ghana. Health policy and planning 2016, 31(3):356–366. Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in pub‑ lished maps and institutional affiliations. Re Read ady y to to submit y submit your our re researc search h ? Choose BMC and benefit fr ? Choose BMC and benefit from om: : fast, convenient online submission thorough peer review by experienced researchers in your field rapid publication on acceptance support for research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year At BMC, research is always in progress. Learn more biomedcentral.com/submissions

Journal

BMC Primary Care – Springer Journals

Published: Apr 4, 2022

Keywords: Power; District health system; District health managers

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