"Small-world challenges and solutions identified by mid-level managers within a decentralized healthcare system during a tuberculosis-prevention therapy rollout study: 'When a big drum like the District Health Officer talks'"

Johnson-Peretz J, Christian C, Akatukwasa C et al (2026).  SSM-Health Systems

“I told <a colleague> that your <SEARCH-IPT trial> meetings are more engaging and they are task-oriented because in them you ask many questions, for instance: how, where, and what – among other questions. So in summary, your meetings are engaging, task-oriented, and informative – especially from the presentations that are usually given when the team meets.” DHO Intervention

“The most important thing that we did was to get the facility in-charges on board. The special thing that we did was that after our one-day MBA – before we forgot the concepts of customer care, the concepts of quality, and all that – we engaged the facility in-charges and TB focal person. So for us, we got a ‘one-day MBA’ <i.e., the leadership and management training component of the SEARCH-IPT intervention> and we gave them a 3-hour MBA. And it made a difference by the way, because by the time they left, they were all charged up.” DHO Intervention

Synopsis: Decentralisation involves a central government devolving decision-making and other administrative powers “to actors at lower levels in a political-administrative and territorial hierarchy”. Before being deployed in the health sector, the initial global movement towards decentralisation supposed that decentralisation would break up pre-existing social networks that were contributing to corruption or inefficiency in different sectors (e.g. political, financial), whilst fostering good governance by encouraging democratisation and innovation through empowering local communities, an assumption that relied on social network theory. Breaking up the nestedness of vertical hierarchies, however, sometimes resulted in a consequent loss of horizontal connectivity to mid-level colleagues, one of several possible unforeseen effects of decentralisation. As a result, although the fiscal and administrative attention of mid-tier actors became more directed locally, they often lost the ability to share and compare best practices directly with their mid-level peers in other districts since information no longer passed quickly and easily between them, leading to information assymetry. This paper, which drew on results from the the SEARCH-IPT study, which incorporated small-world theory to design an intervention targeting middle managers (both DHOs and DTLSs) in three regions of rural Uganda to boost provisioning of Isonaized prevention therapy (IPT) to people living with HIV (PLHIV), tackles the question of how to manage emergent, centrally directed health programmes within a decentralised context. In other words, how can the most effective small-world be fostered in a decentralised healthcare setting?

Key Findings: In-depth interviews with control group participants and focus group discussions with intervention districts revealed structural dynamics that hindered the establishment of inter-district bridging ties between their local networks. Training management and leadership skills in mini-collaboratives promoted mid-level manager agency to address several drawbacks associated with the decentralisation of healthcare systems through what we call ‘horizontal accountability’. DHOs learned to use their decision-making space to manoeuvre at the mid-management level and create horizontal ties with peers without the risk of vertically re-centralising the healthcare system, addressing obstacles also highlighted by DTLSs. Intervention participants overcame the key stumbling block of motivating teamwork in the District Health Team as a whole by strengthening small-world ties through open communication, the results of which DHOs could report to peers at the mini-collaboratives. Improving communication as a group, intervention participants encouraged teamwork in their districts, developed bridging ties with other districts and built a denser cluster of networks. Pairing transparency with a sense of reciprocal accountability moving in multiple directions, upwards to the Ministry of Health (MoH), downwards towards local communities, and horizontally towards peers, fostered the creation of small-world networks and improved information flows within a decentralised healthcare context.

Recommendations: Horizontal accountability facilitates the movement of information and practices, creating cultures of leadership and the capacity to realise achievable targets. To form a small world where horizontal accountability has meaning, links between actors must be actively fostered and developed. DHOs and DTLSs can be encouraged to develop horizontal accountability by sharing lessons and best practices with same-level colleagues from other regional districts in a collaborative, though not re-centralised context. This is an essential part of refining and assimilating knowledge among professions in high-stakes environments; the nature of horizontal accountability is to provide stimuli for learning.

​Collaborative opening-up of decision-making space, as exemplified in the Rwandan pre-colonial concept of imihigo, can link vertical accountability with horizontal accountability. While the pre-colonial meaning of imihigo concerned warriors vowing to succeed in various tasks in upcoming battles, the new context transformed this into a “self-defined policy target one vows to achieve for the public good”.  Imihigo aligns with African political systems that promote solidarity because of the emphasis on ‘unity of work’, and mutual participation in the realisation of the avowed project. This means the actors are equal partners and co-creators of a meaningful and realistic outcome.