The decentralisation of the health sector has been identified as a key factor in delivering better health services in developing economies.1 In decentralised systems, giving responsibility to districts to plan health services can bring healthcare decision-making closer to communities and foster greater openness to community priorities.2 Over the past three decades, several governments, particularly in Africa, have adopted decentralised health systems, where districts are granted the authority and mandate to plan and allocate resources for health service provision within their respective regions of operation.1 Since decentralisation extends services to most of the population, it is sensitive to the contextual needs of various communities and promotes equity in healthcare.3 In Uganda, planning for health services at the district level is primarily the responsibility of district health managers, with support from the Ministry of Health and health development partners (HDPs).4 The implementation of decentralisation in Uganda has attracted several HDPs supporting different districts' health services based on specific areas of interest.5 Some of the HDPs are international organisations, such as Plan International and Marie Stopes, while others are domestic, including The Aids Support Organisation and Reproductive Health Uganda. A few are religion-based organisations, like the Uganda Protestant Medical Bureau. However, despite wide-scale decentralisation of health services in low-resource settings and an increase in the number of support partners, planning and delivery of quality health services in several areas remains a challenge5 and has been described as ad-hoc and seldom evidence-based,6 partly due to the lack of tools to aid priority setting and decision-making,7 8 limited capacity to carry out evidence-based planning among the district health management teams (DHMTs) and the inconsistency in the involvement of HDPs in the planning process.6

Collaboration between government and non-government actors has been suggested to improve service delivery and to extend services to areas where they would be hard to access,9 but the effectiveness of such collaborations demands a partnership approach built on mutual planning and commitment from all actors involved.10 Support from HDPs is a vital source of funding for health service provision in low-resource settings,11 but aligning the priorities of the HDPs and the district health teams in charge of planning health service delivery remains a challenge.3 In studies conducted in Tanzania, factors such as differences in planning cycles between partners and government, lack of transparency and uncertainty of funding from mother donors (organisations like U.S. Agency for International Development that fund some HDPs) were identified as key challenges to a collaborative planning process between HDPs and district health teams.3 11

In Uganda, several studies have documented the challenges and barriers to health service delivery in the country.5 12 13 Limited attention has been paid to exploring the intricacies of the relationships and engagement between HDPs and district health planning teams, along with the challenges and opportunities for joint planning to improve health service delivery. Since the delivery of health services involves multiple actors, identifying barriers to successful engagement and opportunities to enhance participation in district health planning can help strengthen the working relationships among partners, eliminate duplication of services and wastage of resources and result in better use of the few available resources.3 Effective delivery of health services at the sub-national level requires evidence-based planning, but many district health managers lack the skills to do this independently and need support from expert partners.4 Therefore, close collaboration between district health teams and support partners is essential to improve service planning and delivery.4 This study aimed to engage key stakeholders in district health planning to identify challenges to collaborative engagement and planning and to identify opportunities that can enhance the involvement of HDPs in the planning of health services at the sub-national level, thereby improving service delivery.

This was an exploratory qualitative study conducted in the northern region of Uganda. The region comprises the Lango sub-region, with nine districts, and the Acholi sub-region, with eight districts, totalling 17 districts. We randomly selected 12 districts for participation, with seven from the Lango sub-region and five from the Acholi sub-region. In the Lango sub-region, the selected districts included Alebtong, Dokolo, Otuke, Lira, Kole, Oyam and Apac. In the Acholi sub-region, the selected districts included Gulu, Kitgum, Amuru, Agago and Nwoya. Northern Uganda was an ideal setting for the study because the region has many HDPs supporting the health system in response to the wreckage caused by civil conflicts that lasted over a decade in the area.14

We targeted n=24 participants from the 12 districts for interviews. We contacted each district to share a list of HDPs with a history of participating in district health planning for potential interviews. However, since the names suggested were almost the same across the districts, we aimed for a varied sample of 12 representatives. After recruiting HDPs, we contacted districts to arrange an interview with a representative from the DHMT. 18 participants out of the 24 agreed to participate. The six participants who declined participation cited lack of time as the main reason. However, a sample between 9 and 50 is considered sufficient to reach saturation in an exploratory study.15 Thus, we were still within the recommended range of interviews for an exploratory study and were confident that we had sampled HDPs and DHMTs appropriately and captured a representative dataset. Recruitment started on 2 February 2023 and ended on 1 March 2023. Participants were contacted either face-to-face or by phone using telephone contacts provided at the district level. The criteria for inclusion were working for a district local government in the study region or for an HDP, being involved in the planning or delivery of healthcare services, being 18 years of age or above, and being willing to provide written informed consent.

Data were collected through one-on-one, in-depth interviews conducted with the participants. The interviews were conducted by two female members of the research team, EBN and RFM, who hold master’s degrees in public health and are career researchers. The interviews, which lasted between 40 and 50 min, were guided by a semi-structured interview guide developed by the research team and piloted with a DHMT in Eastern Uganda. Sample questions in the interview guide include “Does your organisation get involved in planning health services at the district level? If yes, how do you participate? Are all HDPs in your area of operation involved in district health planning? If not, why? What are the considerations of having a health development partner involved in district health planning? What needs to be done to have all partners involved in planning health services at the district level?”(online supplemental text S1). Interviews were conducted in English and were audio recorded. Participants’ consent was obtained before recording. All 18 interview recordings were transcribed verbatim by two research assistants at a master’s degree level. The lead researcher, KM, who holds a PhD in health sciences, sampled the transcripts, listened to the accompanying audio recordings and reviewed field notes to ensure accuracy and consistency. Participants also read through their transcripts to ensure there was no misrepresentation. Once the transcripts were tested for accuracy, data analysis began.

Two research team members, KM and GCR, inductively analysed the data in six steps. First, they read through all the transcripts to familiarise themselves with the data and identify relevant demographic information. In step 2, the analysts selected two transcripts, which they independently open-coded to generate initial codes. In step 3, the analysts reviewed and discussed the emerging codes, defined and agreed on the code definitions and developed a set of final codes to be used for the final analysis. In step 4, the analysts developed an analysis framework, which was then applied to the remaining transcripts. In the next step, the analysts used ATLAS.ti, version 23, to analyse the remaining transcripts. The analysts, however, remained open to including other codes that emerged as the analysis proceeded. Given that new information was still being revealed by the 16th transcripts, we opted to analyse all 18 transcripts. In the final step, once the analysis was completed, the interpretation of the results commenced.

We employed several techniques to ensure the validity and reliability of the study results. First, the development of the data collection tool, specifically the interview guide, was supervised by an expert in qualitative research. Second, the study team kept close contact with the participants after transcribing. Participants had a chance to review their transcripts to ensure there was no misrepresentation. Furthermore, to enhance the credibility of the results, the data collection team attended two training sessions on interviewing participants before deployment. This level of preparation ensured that every team member was sufficiently competent to collect high-quality data. Relatedly, we also held daily debriefs after data collection to discuss the process and share experiences. Furthermore, to ensure that our findings can be replicated, we developed a detailed codebook that guided the analysis and is available on request. Finally, to enhance the transferability of the study results, we worked within the recommended range in which saturation can be achieved and believe our results to be generalisable to other settings.

The study did not involve patients, but the public was at the centre stage. We worked closely with the participants to incorporate their feedback into the research proposal. As a requirement by the Uganda National Council of Science and Technology, we obtained administrative approval from potential participating organisations before data collection. We designed a summary proposal, which we shared with all 12 participating districts, and they provided their input before granting approval letters. Furthermore, we piloted the interview guide in a nearby district involving both DHMTs and selected HDPs, and the feedback guided the refinement of the tool. Our initial plan was to collect data through focus group discussions, but stakeholders preferred interviews because they believed this approach would elicit deep-seated opinions, and this is what we ultimately settled on. Furthermore, the districts guided us on the HDPs to approach for participation, as identified in their database, who had a history of involvement in district health planning. Finally, we agreed with all participants to hold a joint dissemination workshop where they could hear the results.

The purpose of this study was to understand the challenges to involvement and the opportunities to improve the engagement of HDPs in district health planning in Northern Uganda. The study’s findings aim to drive discussions on collaborative partnerships between DHMTs and HDPs as a means of improving the delivery of healthcare services in a decentralised system of operation, where health service planning occurs at the district level.

The study revealed that HDPs play a crucial role in delivering healthcare services, and their involvement in district health planning is essential, as they are engaged in activities ranging from data collection to monitoring the provision of specialised healthcare, infrastructure development and planning, and the delivery of healthcare services. HDPs cover areas that the government may not fund due to budget constraints and competing demands. Thus, attempts to streamline the intricate relationship between DHMTs and HDPs serve the public interest.

Beyond identifying areas of participation, challenges to the involvement of HDPs in planning healthcare services at a sub-national level were identified. Factors such as corruption, differences in planning cycles, differing interests, a lack of transparency and power dynamics were highlighted. These challenges were identified as sources of misunderstandings between the DHMTs and HDPs that can affect collaborative planning. Several studies conducted in Uganda have documented challenges to the provision of health services in the country.5 16 17 Solutions to some of the challenges were identified, including regular engagement between both parties, fostering mutual respect, setting realistic expectations and adhering to the provisions of the MOU signed between the parties. To the best of our knowledge, this is the first study to explore the perspectives of both DHMTs and HDPs regarding the challenges to collaborative planning for health services and opportunities for strengthening collaboration.

Issues of financial mismanagement and a lack of transparency have long impacted the delivery of health services in developing economies, often deterring well-intentioned development partners and compromising service delivery. The evidence from the study highlighted financial management, including differing funding priorities, transparency and corruption as key barriers to joint planning and collaborative engagement between the HDPs and DHMTs. The current findings align with a related study conducted in Tanzania, which identified resource mismanagement, differing planning cycles and misalignment between recipient needs and the partner’s priorities as some of the reasons for the low engagement of HDPs in healthcare planning.3

Relatedly, coordinating partner activities while integrating district priorities seemed to be a point of departure when attempting to conduct integrated planning. Unfortunately, the lack of clear direction limits the ability to address the most pressing community needs. This study’s findings are supported by the literature, which indicates that poor coordination and selective interests between HDPs and district leadership disrupt the delivery of services, deny the target community the needed benefits and encourage the duplication of services, resulting in wastage.11 Any form of collaboration that drives service delivery thrives on proper coordination. Thus, efforts to streamline coordination must take centre stage in any partnership. Designing a function allocation chart is one approach that has frequently been mentioned in the literature as a tool for mapping collaborations and activities.18 This chart is a visual representation of all activities available in the district. On consultation and continuous engagement with the HDPs, the DHMTs can allocate activities on the chart to the HDPs, and the parties retain responsibility for monitoring the chart throughout the operational cycle. This approach can help streamline inconsistencies that arise from back-and-forth communication.

Another significant challenge that makes joint planning difficult, as identified by the study, is the difference in the planning cycles. District local governments follow the government financial year, which ends in June and starts in July. In contrast, most HDPs run cycles that either end in March or September, and these cycles are determined by the parent funder, making adjustments difficult. Thus, collaborative planning will require innovative participation, which is cognisant of this reality. Since aligning the planning period is not within the control of stakeholders, using internet-powered platforms or systems that facilitate access to information from both sides can enhance planning outcomes. Several participants highlighted the lack of timely information as a significant obstacle to the planning process. Working with an information support system that is jointly updated and accessed can help address this problem. In a related study conducted in Tanzania, using web-based aids in planning was appraised as a solution that accelerated knowledge sharing in planning sub-national healthcare.3

Future initiatives that prioritise flexibility as a means of creating an enabling environment for collaborative engagement, while respecting operating realities, are also encouraged.19 The study findings, however, do not align with the literature, which indicates that in some regions of the world, the planning of health services can occur smoothly even when collaborating partners have differing planning cycles. The authors suggest that the DHMTs need to develop competencies to manage and integrate the differing planning cycles into the broader district health planning.20 Nevertheless, each context is unique, and what works in one region may not necessarily work in another.

The findings suggest that to improve collaborative planning, mutual respect between the HDPs and district health teams is necessary. Respect encompasses a commitment to the interests outlined in the MOU, being accountable for both resources and time, communicating properly and listening to one another. The DHMTs are responsible for guiding operations in the district as representatives of the government in a decentralised system. At the same time, the HDPs bring in resources and expertise to fund areas where the government is falling short or complement available care services. While this relationship may appear straightforward and suggest balanced power relations, the findings revealed that aspects of disrespect often emerge. First, the DHMTs occasionally exceed their powers and attempt to force HDPs to operate outside the scope of the MOUs signed. The HDPs also use their financial strength and try to dictate the direction of operations at the district level.

Collaborations thrive on mutual respect; thus, if district health planning is to be improved, both parties involved should be intentional and committed to respecting one another. One intervention that can improve communication and respect is organising stakeholder forums where accusations and blame can be openly discussed and misunderstandings can be resolved. From the findings, it was evident that DMHTs and HDPs were not meeting often until the planning cycle was due. In a Tanzanian study, stakeholder forums enhanced collaboration between development partners and local district governments and were viewed as avenues for resolving differences.3 The study findings are further supported by a systematic review of the literature, which identified mutual respect and continued dialogue as opportunities for improving collaborations between government and non-government actors in planning health services.9

A key strength of this study is its generalisability. Recruitment of participants from 12 districts in Northern Uganda, in a region with a considerable concentration of HDPs, allowed us to tap into varied voices and capture the unique experiences of different DHMTs, resulting in a broad range of perspectives and a representative dataset. Thus, the study’s findings can be applied beyond the study area. Second, collecting data from both sets of stakeholders (HDPs and DHMTs) resulted in more balanced findings. Studies that focus on a single group of stakeholders often yield results that are biased. Therefore, being able to triangulate enhances the credibility and validity of our findings.

Notwithstanding these strengths, this study had limitations. Foremost, being a qualitative study that relied on the subjective experiences of people interviewed, it was susceptible to response bias. Participants could have shared information that gave a positive image of the sides they represented or shifted blame. Nevertheless, given that both sets of stakeholders were involved, we assume we made a balanced representation. Relatedly, although we aimed to have equal representation from both sets of participants, in the end, more HDPs were interviewed compared with DHMTs, which could potentially influence the results by leading to biased findings. However, according to Morse, a minimum of six participants in a targeted population is adequate to give a representative voice in a qualitative study.21 Thus, since the DHMTs that participated were more than six, our results can generate valid and unbiased conclusions. Although the study has some limitations, it offers a starting point for meaningful engagements between HDPs and DMHTs.