What Governs District Manager Decision Making? A Case Study of Complex Leadership in Dangme West District, Ghana

Aku Kwamie, Irene Akua Agyepong, Han Van Dijk

Research output: Contribution to journalArticleAcademicpeer-review

19 Citations (Scopus)


Management and leadership in complex health systems
have been little addressed as contributors toward improving maternal
and newborn health. Widespread perceptions of weak district-level
management and leadership have encouraged capacity strengthening
interventions with a predominant focus on individual rather than
systemic capacities. However, both types of capacities matter. Greater
understanding is required about how managerial decision making and
policy implementation are influenced by the systems in which
managers operate. This article presents an exploratory case study to
understand the balance of top-down and bottom-up dynamics
influencing district manager decision making in one district in the
Ghanaian health system. Our study was theory driven, drawing on
concepts of decision space, power, and trust from the literature. Data
collection methods included document review, participant observation,
and semistructured interviews. Using analysis that drew upon complex
leadership theory, we found that contexts of hierarchical authority and
resource uncertainty constrained district manager decision space. These
constraints also gave rise to a leadership type oriented toward serving
the bureaucratic functions of the health system (more top-down than
bottom-up). The analysis of this case study showed that, as a result,
district-level management and leadership were less responsive to
maternal and newborn health service delivery challenges.
Original languageEnglish
Pages (from-to)167-177
JournalHealth Systems & Reform
Issue number2
Publication statusPublished - 2015

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