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This mismatch in contextual uncertainty and organisational culture may very well account for the lack of effective management at district level.
Furthermore, we aimed at assessing urban-rural differentials, linking interventions to outcomes and evaluating the feasibility of the UON approach for health service management at district level.
Hence, human resource management at district level as well as at hospital level was often cited as a reason for the unfairness experienced.
The support of senior management at district and facility level – psychological, budgetary, and in-kind – was perceived to play a role in staff motivation and the ability of facilities to move forward with KMC.
To overcome this impasse, some countries propose a health system that combines an outpatient referral unit, a defined team for specialized management at district level, which is responsible for treatment, supervision and monitoring, including PHC participation and responsibility in case search and Directly Observed Therapy (DOT) supervision activities.
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The intervention is a capacity-building programme that seeks to improve management capacities of health managers at district and subdistrict levels through periodic classroom-based teaching and mentoring support at the workplace.
Therefore, it is worth strengthening human resource management skills at district level and supporting district health managers to implement retention strategies.
Our findings indicate that effective human resource management practices at district level influence health worker motivation and job satisfaction, thereby reducing the likelihood for turnover.
Management capacity at district levels has for some time been recognized as key to delivering quality health services, both in South Africa and globally [ 40, 41].
At the time of the study devolution being in transition, weak planning and management capacity at district level has been highlighted in our study as the main factor hindering establishment of CMWs in communities.
Developing HR planning and management capacity at district level and generating HR information systems should accompany decentralization processes [ 19- 21] so that decentralization does not result in decentralized chaos [ 19].
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Justyna Jupowicz-Kozak
CEO of Professional Science Editing for Scientists @ prosciediting.com