Power Relations Among District Health Managers And The Delivery Of Health Centre Clinical Care In Ghana

ABSTRACT

Background: Power relations among district health managers border on which district health manager has formal as well as any informal powers to do what, and to what extent, and the manifestation of power among these managers. A healthy relationship between health institutions at the district level is dependent on the clarity of formal and informal rules governing the arrangements of these healthcare institutions. These rules translate into the power structure for district health managers in the discharge of their duties. However, in practice, these formal power arrangements are likely to be distorted by informal powers.

Objective: The study explored how power relations between district directors and medical superintendents were likely to affect the delivery of healthcare services, such as supervision of health centre clinical care from the district hospital and the patient referral system, which are pivotal to the quality of clinical care delivery in rural districts of Ghana.

Methods: The study was conducted in three districts in Ghana; Bongo, Kintampo North and Juaboso, using the constructivist / interpretivist approach. Purposive sampling technique was used to select study sites and the study participants. The study used participant observation, conducted 11 interviews, 9 focus group discussions (with 61 participants) and documentary review for data collection across the three case study districts. Transcription of the voicerecordings was done verbatim, cleaned and imported into the Nvivo version 11 platform for analysis. Data was analysed using the inductive content analysis approach. Ethical clearance was granted by the ethics review committee of Ghana Health Service.

Findings: The study revealed that, the district directors derive legitimate powers from their positions as heads of the district health services. The medical superintendents also have legitimate powers to oversee and supervise district hospitals’ activities. However, the study revealed that informal sources of power contribute to how district directors relate to medical superintendents in practice. These informal power sources are broadly described as financial and medical dominance. The study revealed that health centres organise and deliver a wide range of services. It was observed that health centre services delivery are supported by a borrowing system between district health institutions, knowledge sharing between health centres and district hospitals, and use of multi-task approach by healthcare providers; to minimise staff inadequacy challenges in the health centres in order to make clinical care services accessible to the rural communities. The study also found that power relations between district directors and medical superintendents affect the pivotal role of district hospitals in the delivery of clinical care at the health centre levels. It was reported that health centre clinical care is inadequately supervised and health centres delay in referring patients to district hospitals for further management.

Conclusion/Recommendations: The study concludes that legitimacy, medical dominance and financial dominance are sources of power for district health managers. The manifestation of these power relations among the district health managers affect clinical supervision of health centres and the patient referral system, which are integral to the organisation and delivery of health centre clinical care services. The study recommends that district health managers should be orientated to understand the power dynamics in the district health system.