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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 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.
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Johnson-Peretz J, Arunga T, Lee J, et al. (2024). International Journal of Qualitative Methods. Cultural rigour (Lock et al., 2021) “affirms the value of experiential knowledge and stresses a collaborative process” (Leung et al., 2004). Synopsis: We describe a newly-developed, digital approach that integrates findings from our qualitative team, which we call R-EIGHT (Remote and Equitable Inductive Analysis for Global Health Teams), to speed the inductive coding process without sacrificing rigour, while remaining accessible to geographically dispersed teams. This is especially crucial in global health partnerships where on-the-ground researchers may have less input into codebook development compared to in-the-office researchers.
Method: The method consists of eight steps. (1) participant interviews are transcribed, during which time... (2) A team member develops an a priori codebook from existing interview guides and study protocols. (3) Each team member is given a transcript or set of transcripts for initial or line-by-line coding using the ‘comment’ function in MS Word. (4) The team members then send their coded or commented-upon transcripts to a central teammate responsible for merging the commented-upon documents. This will produce a document in which teammate comments for a given section all appear together in a side column. (5) The team meets to review the comments, which are conveniently grouped together around the relevant text, to foster discussion and compare the language each coder is using. (6) The team compares these inductively-derived codes with any a priori codes (if used) in axial or second-cycle coding to develop focused codes, in order to... (7) Define the range of application of an a priori code, and to add new parent and child codes to the codebook as necessary. (8) Finalise the codebook for coding the remaining data sets. Key Contribution: The technique we developed a) speeds the process of inductive coding as a team, b) visually displays interpretive consensus, and c) when appropriate fosters streamlined integration of inductive findings into codebooks. Because it involves all team members, our approach helps break the divide between in-office and on-the-ground teams, fostering integrated and representative contributions from all globally-dispersed team members. |
AuthorJason Johnson-Peretz is a medical anthropologist and qualitative research analyst for multinational projects in rural East Africa that, through person-centred models of care, aim to improve community health and end AIDS in the region. Archives
August 2026
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