title: Factors influencing the work efficiency of district health managers in low-resource settings: a qualitative study in Ghana.
abstract: BACKGROUND
  There is increasing evidence that good district management practices can improve health system performance and conversely, that poor and inefficient management practices have detrimental effects. The aim of the present study was to identify factors contributing to inefficient management practices of district health managers and ways to improve their overall efficiency.
  
  
  METHODS
  Nineteen semi-structured interviews were conducted with district health managers in three districts of the Eastern Region in Ghana. The 19 interviews conducted comprised 90% of the managerial workforce in these districts in 2013. A thematic analysis was carried out using the WHO's leadership and management strengthening framework to structure the results.
  
  
  RESULTS
  Key factors for inefficient district health management practices were identified to be: human resource shortages, inadequate planning and communication skills, financial constraints, and a narrow decision space that constrains the authority of district health managers and their ability to influence decision-making. Strategies that may improve managerial efficiency at both an individual and organizational level included improvements to planning, communication, and time management skills, and ensuring the timely release of district funds.
  
  
  CONCLUSIONS
  Filling District Health Management Team vacancies, developing leadership and management skills of district health managers, ensuring a better flow of district funds, and delegating more authority to the districts seems to be a promising intervention package, which may result in better and more efficient management practices and stronger health system performance.
authors.affiliation: Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Socinstrasse 57, Basel, 4002, Switzerland. marc.bonenberger@unibas.ch.|University of Basel, Basel, Switzerland. marc.bonenberger@unibas.ch.
authors.forename: Marc
authors.initials: M
authors.lastname: Bonenberger
authors.affiliation: School of Public Health, University of Ghana, Legon, Ghana.
authors.forename: Moses
authors.initials: M
authors.lastname: Aikins
authors.affiliation: School of Public Health, University of Ghana, Legon, Ghana.
authors.forename: Patricia
authors.initials: P
authors.lastname: Akweongo
authors.affiliation: Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Socinstrasse 57, Basel, 4002, Switzerland.|University of Basel, Basel, Switzerland.
authors.forename: Kaspar
authors.initials: K
authors.lastname: Wyss
mesh_terms: D003142:Communication; D003657:Decision Making; D017598:Efficiency, Organizational / Q000592:standards; D005376:Financial Management; D005869:Ghana; D006285:Health Planning; D006295:Health Resources / Q000592:standards; D006296:Health Services / Q000592:standards*; D006280:Health Workforce / Q000706:statistics & numerical data; D006801:Humans; D007857:Leadership; D008507:Medically Underserved Area; D011216:Practice Management, Medical / Q000592:standards*; D011361:Professional Competence / Q000592:standards; D036301:Qualitative Research