The lack of basic management skills of district-level health teams is often described as a major constraint to implementation of primary health care in developing countries. To improve district-level management in The Gambia, a 'management strengthening' project was implemented in two out of the three health regions. Against a background of health sector decentralization policy the project had two main objectives: to improve health team management skills and to improve resources management under specially-trained administrators. The project used a problem-solving and participatory strategy for planning and implementing activities. The project resulted in some improvements in the management of district-level health services, particularly in the quality of team planning and coordination, and the management of the limited available resources. However, the project demonstrated that though health teams had better management skills and systems, their effectiveness was often limited by the policy and practice of the national level government and donor agencies. In particular, they were limited by the degree to which decision making was centralized on issues of staffing, budgeting, and planning, and by the extent to which national level managers have lacked skills and motivation for management change. They were also limited by the extent to which donor-supported programmes were still based on standardized models which did not allow for varying and complex environments at district level. These are common problems despite growing advocacy for more devolution of decision making to the local level.
PIP: In recognition of the importance of developing strong district health teams in order to implement primary health care in developing countries, a district-level health management strengthening project took place during an 18-month period starting in 1991 in the Gambia. The objectives of the project were to teach regional health teams (RHTs) how to function as decentralized management units, improve team management skills, achieve improved resource management, and increase awareness of district health management problems at the national level. RHT training involved the introduction of a six-month planning cycle which identified priorities and problems and defined ways to address them. This analysis formed the basis for the RHTs to make realistic workplans and to begin to exhibit initiative in planning. New teamwork skills led to the delivery of more coordinated supervision and training support to health staff. The new planning process also involved initiating local analysis and use of local service delivery data and the improvement of problem analysis skills. Regional health administrators were hired to improve resources management, including repair and construction of health facilities and developing better transportation mechanisms. Project effectiveness was enhanced by a the motivation of the team members, the support of new team leaders, the problem-solving, hands-on approach, and better access to information. Restraints included national procedures that resisted decentralization, a lack of skilled national-level managers, the resistance of national-level health managers, and donor policy that created vertical and parallel programs and supported top-down decision-making. While the project resulted in some gains, it also demonstrated that the initiatives of district level health teams are not sufficient to achieve reform. Further improvements will rely on actions taken at the national level and by donors.