Browsing by Author "Orgill, Marsha"

Now showing 1 - 10 of 10
  • Thumbnail Image
    Item
    Open Access
    A new methodology for assessing health policy and systems research and analysis capacity in African universities
    (2014-10-08) Lê, Gillian; Mirzoev, Tolib; Orgill, Marsha; Erasmus, Ermin; Lehmann, Uta; Okeyo, Stephen; Goudge, Jane; Maluka, Stephen; Uzochukwu, Benjamin; Aikins, Moses; de Savigny, Don; Tomson, Goran; Gilson, Lucy
    Abstract Background The importance of health policy and systems research and analysis (HPSR + A) has been increasingly recognised, but it is still unclear how most effectively to strengthen the capacity of the different organisations involved in this field. Universities are particularly crucial but the expansive literature on capacity development has little to offer the unique needs of HPSR + A activity within universities, and often overlooks the pivotal contribution of capacity assessments to capacity strengthening. Methods The Consortium for Health Policy and Systems Analysis in Africa 2011–2015 designed and implemented a new framework for capacity assessment for HPSR + A within universities. The methodology is reported in detail. Results Our reflections on developing and conducting the assessment generated four lessons for colleagues in the field. Notably, there are currently no published capacity assessment methodologies for HPSR + A that focus solely on universities – we report a first for the field to initiate the dialogue and exchange of experiences with others. Second, in HPSR + A, the unit of assessment can be a challenge, because HPSR + A groups within universities tend to overlap between academic departments and are embedded in different networks. Third, capacity assessment experience can itself be capacity strengthening, even when taking into account that doing such assessments require capacity. Conclusions From our experience, we propose that future systematic assessments of HPSR + A capacity need to focus on both capacity assets and needs and assess capacity at individual, organisational, and systems levels, whilst taking into account the networked nature of HPSR + A activity. A genuine partnership process between evaluators and those participating in an assessment can improve the quality of assessment and uptake of results in capacity strengthening.
  • Thumbnail Image
    Item
    Open Access
    A qualitative study of the dissemination and diffusion of innovations: bottom up experiences of senior managers in three health districts in South Africa
    (2019-03-29) Orgill, Marsha; Gilson, Lucy; Chitha, Wezile; Michel, Janet; Erasmus, Ermin; Marchal, Bruno; Harris, Bronwyn
    Background In 2012 the South African National Department of Health (SA NDoH) set out, using a top down process, to implement several innovations in eleven health districts in order to test reforms to strengthen the district health system. The process of disseminating innovations began in 2012 and senior health managers in districts were expected to drive implementation. The research explored, from a bottom up perspective, how efforts by the National government to disseminate and diffuse innovations were experienced by district level senior managers and why some dissemination efforts were more enabling than others. Methods A multiple case study design comprising three cases was conducted. Data collection in 2012 – early 2014 included 38 interviews with provincial and district level managers as well as non- participant observation of meetings. The Greenhalgh et al. (Milbank Q 82(4):581-629, 2004) diffusion of innovations model was used to interpret dissemination and diffusion in the districts. Results Managers valued the national Minister of Health’s role as a champion in disseminating innovations via a road show and his personal participation in an induction programme for new hospital managers. The identification of a site coordinator in each pilot site was valued as this coordinator served as a central point of connection between networks up the hierarchy and horizontally in the district. Managers leveraged their own existing social networks in the districts and created synergies between new ideas and existing working practices to enable adoption by their staff. Managers also wanted to be part of processes that decide what should be strengthened in their districts and want clarity on: (1) the benefits of new innovations (2) total funding they will receive (3) their specific role in implementation and (4) the range of stakeholders involved. Conclusion Those driving reform processes from ‘the top’ must remember to develop well planned dissemination strategies that give lower-level managers relevant information and, as part of those strategies, provide ongoing opportunities for bottom up input into key decisions and processes. Managers in districts must be recognised as leaders of change, not only as implementers who are at the receiving end of dissemination strategies from those at the top. They are integral intermediaries between those at the at the coal face and national policies, managing long chains of dissemination and natural (often unpredictable) diffusion.
  • Thumbnail Image
    Item
    Open Access
    Active purchasing mechanisms of private healthcare services: experiences of public and private purchasers in Kenya
    (2019) Chuma, Benson; Orgill, Marsha
    There has been growing global attention to Universal Health Coverage (UHC) and countries across the world have placed achievement of UHC amongst their top policy priorities. UHC is defined as ensuring that all citizens can access relevant health services whenever they need care in a manner that ensures they are not exposed to financial hardship. Health financing systems are critical to achieving UHC- one of the building blocks of a health system, health financing is concerned with the mobilization, accumulation and allocation of funds to cover the needs of a population. The purpose of a health financing system is to make funding available, set the right incentives to health care providers and to ensure all individuals have access to effective public and personal health services. A health financing system has three inter related functions; revenue collection, pooling and purchasing which all need to work together for achievement of UHC. Purchasing is defined as the allocation of pooled funds to providers in exchange for medical services. Purchasing can be passive (whereby purchasers simply pay bills presented by providers) or strategic (whereby purchasers continuously apply evidenced based decisions and processes when allocating funds to providers to maximize value). Many countries aiming to achieve UHC have prioritized shifting from passive to strategic purchasing as part of their health financing system reforms. Literature shows evidence that implementation of strategic purchasing can contribute to achieving UHC by: aligning funding and incentives with promised health services to promote access; linking transfer of funds to providers to performance with the goal of promoting quality in service delivery; and enhancing equity in resource distribution. Implementation of strategic purchasing mechanisms is however not a straight forward process as providers can use various sources of power such as: monopoly and bargaining capacity; some provider payment mechanisms such as fee-for-service; and information asymmetry to resist the adoption of strategic purchasing mechanisms. Providers are likely to resist implementations of those mechanisms that they perceive will shift too much of the risk of providing care to them or will erode their economic gains. Purchasers also have sources of power they can use to influence implementation such as: institutional regulatory authority; monopsony and bargaining authority; and some provider payment mechanisms such as capitation. Power in this study is defined as a relation between two parties whereby party A is said to have power over party B to the extent that A can get B to do something that B would not have otherwise done. Kenya has in the past decade formulated and implemented various policies towards achieving UHC, including reforming some of its purchasing functions. An example is the introduction of capitation (a provider payment mechanism) for private providers, by the public purchaser National Hospital Insurance Fund (NHIF). Private purchasers have, as part of strategic purchasing, intervened in clinical decision-making processes amongst private providers as a way of managing costs and improving quality. Existing literature shows public and private purchasers in Kenya are faced with multiple challenges when implementing strategic purchasing mechanisms such as lack of technical expertise, poor planning and resistance from some providers. This study explored the implementation of strategic purchasing mechanisms by NHIF and private purchasers amongst private providers in Kenya to understand the role of various sources of power in influencing implementation outcomes (acceptability and adoption) in order to contribute to work on how to implement strategic purchasing. Private providers in Kenya play a significant role in provision of care and over 40% of facilities in Kenya are privately owned. We employed a multiple case study design. The first case focused on implementation of capitation by the public purchaser NHIF. The second case focused on the implementation of select strategic purchasing mechanisms by private purchasers including intervening in clinical decision-making processes, use of preauthorization and use of specialists for second opinions amongst others. In total eight interviews were completed and eighteen documents(including newspapers articles, documents from websites, and provider-purchaser contracts) were included as data sources. Each case was analysed individually using thematic analysis, after which a cross case analysis was completed. Our findings show that in the first case of the NHIF purchaser, NHIF used its regulatory authority to gazette and hence dictate the capitation rate to providers. NHIF also used its monopsony to convince providers that there would be significant economic gains from the capitation model as NHIF had a huge number of beneficiaries. However, some of the large providers used their monopoly and bargaining capacity to walk away from the scheme as they still commanded significant market share even without the NHIF capitation business as they felt the proposed capitation rate was too low. In the second case, private purchasers used contracts as a source of power to give them some authority to control prices of services and ensure providers adhered to strategic purchasing mechanisms such as use of preauthorization processes. Some private providers on the other hand used various sources of power to resist implementation such as information asymmetry to by-pass some of the documentation requirements set by the private purchasers. Some providers also used monopoly and fee-for service payment mechanisms to dictate prices of services to purchasers. Some private providers did however willingly adopt some of the strategic purchasing mechanisms namely: preauthorization processes and use of step-down facilities as they felt these minimized the risk of unpaid claims. Across the two cases, NHIF seemed to have had relatively more power over providers compared to private purchasers. For example, NHIF gazetted the capitation rates and did not revise them despite strong opposition from some of the large private providers, whilst private purchasers complained that some of the large private providers always had their way by dictating prices of their services to the private purchasers. Whilst there have been a growing number of recent studies touching on strategic purchasing in Kenya, few of them have focused on the role of power and/or implementation of strategic purchasing in Kenya. This study focused on how various sources of power for providers and purchasers can affect implementation of strategic purchasing in order to provide insight into the implementation of strategic purchasing mechanisms. The study found that private providers can use their various sources of power to resist adoption of strategic purchasing mechanisms they do not deem acceptable; some mechanism are however deemed acceptable and are willingly adopted. The study also highlights that purchasers can use their sources of power to influence adoption of strategic purchasing amongst providers. The study hopes to provide insight to policy makers and purchasers on the need to consider the role of power when implementing strategic purchasing mechanisms and to plan accordingly. One general lesson on implementation includes the importance of early communication and dialogue when implementing strategic purchasing mechanisms.
  • Thumbnail Image
    Item
    Open Access
    Bottom-up innovation for health management capacity development: a qualitative case study in a South African health district
    (2021-03-24) Orgill, Marsha; Marchal, Bruno; Shung-King, Maylene; Sikuza, Lwazikazi; Gilson, Lucy
    Abstract Background As part of health system strengthening in South Africa (2012–2017) a new district health manager, taking a bottom-up approach, developed a suite of innovations to improve the processes of monthly district management team meetings, and the practices of managers and NGO partners attending them. Understanding capacity as a property of the health system rather than only of individuals, the research explored the mechanisms triggered in context to produce outputs, including the initial sensemaking by the district manager, the subsequent sensegiving and sensemaking in the team and how these homegrown innovations interacted with existing social processes and norms within the system. Methods We conducted a realist evaluation, adopting the case study design, over a two-year period (2013–2015) in the district of focus. The initial programme theory was developed from 10 senior manager interviews and a literature review. To understand the processes and mechanisms triggered in the local context and identify outputs, we conducted 15 interviews with managers in the management team and seven with non-state actors. These were supplemented by researcher notes based on time spent in the district. Thematic analysis was conducted using the Context-Mechanism-Outcome configuration alongside theoretical constructs. Results The new district manager drew on systems thinking, tacit and experiential knowledge to design bottom-up innovations. Capacity was triggered through micro-practices of sensemaking and sensegiving which included using sticks (positional authority, enforcement of policies, over-coding), intentionally providing justifications for change and setting the scene (a new agenda, distributed leadership). These micro-practices in themselves, and by managers engaging with them, triggered a generative process of buy-in and motivation which influenced managers and partners to participate in new practices within a routine meeting. Conclusion District managers are well placed to design local capacity development innovations and must draw on systems thinking, tacit and experiential knowledge to enable relevant ‘bottom-up’ capacity development in district health systems. By drawing on soft skills and the policy resources (hardware) of the system they can influence motivation and buy-in to improve management practices. From a systems perspective, we argue that capacity development can be conceived of as part of the daily activity of managing within routine spaces.
  • Thumbnail Image
    Item
    Open Access
    Exploring the complex policy formulation process of the draft Control of Marketing of Alcoholic Beverages Bill in South Africa
    (2017) Bertscher, Adam; Orgill, Marsha; London, Leslie
    International literature suggests that corporate influence is evident when governments attempt to regulate products implicated in non-communicable disease, such as tobacco, asbestos, pollution, and foods, such as trans-fat, salt and sugar. These lifestyle diseases are aptly referred to as 'industrial epidemic', since industries profit from the public's continued consumption of such products. Of these 'industrial epidemics', alcohol is a major contributor to the health burden in South Africa. In the year 2000, 7.1% of all deaths and 7% of total disability-adjusted life years have been ascribed to alcohol-related harm in the country. The tangible and intangible costs of alcohol-related harm amount to 10-12% of South Africa's 2009 Gross Domestic Product. Literature suggests that limiting alcohol use could prevent the incidence of violence, injury, risky sexual behaviours, several forms of cancer, and neuropsychiatric and physical diseases. The World Health Organisation (WHO) released two documents, The Global strategy to reduce the harmful use of alcohol (2010b) and The Global Status Report on Non-communicable Diseases (2010a), detailing the negative effects of alcohol consumption for societies. Both documents recommend that decreasing alcohol consumption through banning of alcohol advertising would have significant public health benefits, although an integrated strategy is necessary to mitigate alcohol abuse including taxation, increasing prices, limiting places of sales and increasing education on the topic. In response, the South African government proposed a draft regulation aimed at restricting alcohol advertising as an evidence-based upstream intervention. The draft Control of Marketing of Alcoholic Beverages Bill is in the process of undergoing impact assessments to determine the impact this regulation may have on South African society. Literature suggests that industry employs various political strategies to avoid such regulation. However, little is known about the strategies the alcohol industry potentially uses to influence policy development in South Africa. There is a lack of knowledge on the current strategies used by the alcohol industry to influence policy; the draft Control of Marketing of Alcoholic Beverage Bill is a case in point. This study sought to explore the complex policy formulation process in South Africa, using the draft Control of Marketing of Alcoholic Beverages Bill as a tracer case and focused on the alcohol industry, as a central actor, to understand how it - together with other actors - may influence this process. A qualitative case study approach was used, which included stakeholder mapping, 10 in-depth interviews and review of approximately 240 documents. This study makes use of two conceptual frameworks. The first framework, Berlan et al. (2014) is used to understand policy formulation as a process with multiple facets. The second framework, Roberts et al. (2004), provides four typologies of political strategies that health reformers/advocates/lobbyists employ to influence the policy process. A thematic analysis was used to analyse the data. Key themes identified were: (1) Competing and shared values - different stakeholders promote conflicting ideals for policymaking; (2) Inter-department jostling - different government departments seek to protect their own interests, hindering policy development; (3) Stakeholder consultation in democratic policymaking – policy formulation requires consultation even with those opposed to regulation; (4) Battle for evidence – industry sought to assemble evidence to use as 'ammunition' in opposition to the ban. It was concluded that networks of actors with financial interest use diverse strategies to influence policy formulation processes to contest proposed regulation. Using the policy formulation process of the draft Control of Marketing of Alcoholic Beverages Bill as a tracer case, this research is a critical enquiry into how the for-profit industry affects public health interests in South Africa; such a critical enquiry could also be applied to other non-communicable diseases. Research suggests that industries have more difficulty in pushing their agenda when policymakers are well informed, are aware of the evidence-based practice and are not motivated by economic arguments alone. There is also a lack of research that focuses on health policy analysis in low and middle-income countries, and there is a lack of research focusing on the policy formulation process in particular. Therefore, this research aims to fill a gap in addressing a lack of research on health policy analysis in the context of a middleincome country. The implications of the study are that measures to insulate policy development are needed to prevent industry influence potentially undermining public health goals, such as: government to moderate certain consultations with industry; industry to declare conflict of interest; guidelines for bureaucrats and policymakers to advise on whose evidence to consider; and guidelines for bureaucrats and policymakers to assess quality of evidence.
  • Thumbnail Image
    Item
    Open Access
    Linkage to treatment following RR-TB diagnosis in the Western Cape
    (2015) Tomlinson, Catherine Reid; Govender, Veloshnee; Orgill, Marsha
    Patients diagnosed with rifampicin resistant (RR) tuberculosis (TB) in South Africa frequently fail to link to appropriate drug resistant (DR) TB treatment. The aim of this study was to explore barriers and enablers to expedited linkage to treatment following RR-TB diagnosis in the Western Cape Province, within the context of ongoing decentralisation of DRTB services and the scale-up of Xpert MTB/RIF diagnostics. Methods: An embedded case study approach, using qualitative research methods, was employed to explore barriers and enablers to expedited treatment linkage following RR-TB diagnosis. The case of investigation in this study was 'treatment linkage following RR-TB diagnosis in the Western Cape Province during the ongoing decentralisation of DR-TB services and scale-up of Xpert diagnostics'. DR-TB is used in this study as an encompassing term to refer to RR, multidrug resistant and extensively drug resistant TB. The embedded units of analysis in this study were patients' linkage outputs, defined as: (1) expedited treatment initiation, (2) delayed treatment initiation and (3) non-initiation of treatment following sputum collection on which RR-TB was diagnosed. Seventeen patient, 8 family member, 49 healthcare worker and 4 key informant open-ended, in-depth interviews were conducted and 59 patient folders were reviewed. Additionally, an extensive literature review was conducted. The tools used for data collection in this study were developed from the literature review and Coker et al.'s (201) conceptual framework for evaluation of a communicable disease intervention. A framework approach using Coker et al.'s conceptual framework was applied for analysis. Results: This study identified multiple factors that enabled and constrained expedited treatment linkage following RR-TB diagnosis. Enabling factors included: 1) the availability of clinic level DR-TB counsellors and tracers; 2) living in walking distance of decentralised services and 3) having a strong social support network. Constraining factors included: 1) low usage of Xpert diagnostics, 2) delays in acting on results and missed (or unseen) results, 3) rotation of nurses or the lack of dedicated TB nurses in clinics, 4) limited clinic-level administrative support, 5) information systems challenges and 6) waiting lists for beds and limited access to transport services in rural areas . In linking to treatment, patients commonly face challenges due to competing subsistence needs and household or employment responsibilities. Additionally, substance addiction, having a history of treatment interruption, hopelessness regarding treatment, as well as not having a stable place to stay or social support may increase patients' risks of linkage failure. Conclusion: Within the Western Cape Province, there is significant opportunity to improve linkage to treatment through strengthening the health systems mechanisms to link patients to treatment following RR-TB diagnosis. Expanding access to psychosocial services (substance abuse rehabilitation and psychosocial evaluations) following RR-TB diagnosis may assist in linking high-risk patients to treatment. Additionally, the provision of food support (in addition to social grants) should be evaluated as a tactic to improve treatment linkage and adherence.
  • Thumbnail Image
    Item
    Open Access
    Medicine stock Management at primary health care facilities in one South African province
    (2018) Munedzimwe, Fadzai Eunice; Honda, Ayako; Orgill, Marsha
    As nations are encouraged to move towards achieving Universal Health coverage (UHC), access to essential medicines needs to be prioritized. In ensuring access to medicines, an important factor to be considered is the uninterrupted availability of essential medicines at the primary health care (PHC) level which is usually the first point of entry into the health system for patients. If South Africa is to move towards achieving UHC, the government must address the issue of unavailability of medicines due to frequent stock outs at the public health facilities. The increase in prevalence of HIV/AIDS and TB has resulted in an increase in the demand for medicines used in the management and treatment of these diseases. Surveys have revealed the extent of stock outs and shortages of medicines used in the management of HIV and TB in South Africa. It has also been predicted that the burden of disease in relation to these diseases is likely to increase in the coming years therefore, it is important for the South African government to address the issues of stock outs. Using a qualitative multiple case study approach, we explored the factors which may influence the management of medicine stock thus causing medicine stock outs at four PHC facilities in two of the districts in the study province. A conceptual framework on the factors influencing medicine stock outs at health facilities was developed from reviewing literature on the subject and this was used to guide data collection and analysis. Our findings revealed that the factors influencing the management of medicine stock leading to medicine stock outs include the lack of capacity in terms of human resources and physical resources at the PHC facilities. Insufficient supervision and support from the district level also had an influence as health workers at the facilities did not always follow the recommended procedures for medicine stock management. We also found that there were gaps in communication between the health workers at the facilities and stakeholders at other levels, particularly the pharmaceutical depot from which the facilities obtained their medicines. The inadequate information systems contributed to this gap in communication. Whilst many studies have focused on the factors that may influence the availability of medicine at higher levels, this study focused on what may influence it at the ground level, the PHC facility level. We anticipate that our findings will inform policy makers on how the availability of medicines at PHC facilities may be improved by focusing on improving the processes in medicine stock management at this level.
  • Thumbnail Image
    Item
    Open Access
    Political prioritisation for performance-based financing at the county level in Kenya: 2016 to 2019
    (2021) Waithaka, Dennis Wambiri; Orgill, Marsha; Gilson, Lucy
    Background: Performance based financing was introduced to Kilifi county actors in Kenya in 2015. Kilifi was identified by the Kenyan national government as one of the 20 arid and semi-arid counties (out of 47 counties) mandated to start the implementation of the scheme and potentially inform the development of a nation-wide PBF policy. This study investigates how political and bureaucratic actors at the local level in Kilifi county have subsequently influenced the extent to which PBF has been politically prioritised at the sub-national level. Methods: The study employed a single-case study design. The Shiffman and Smith (2007) political priority setting framework with adaptations proposed by Walt and Gilson (2014) was used. Data was collected through document review (n=19) and in-depth interviews (n=8). Framework analysis was used to analyse data and generate findings. Results: Throughout the study period (2015-2018), national policy elites gave sustained attention to PBF as a priority issue for implementation, this sustained attention was however not present at the sub national level in Kilifi county and funding for PBF was not prioritised post donor funding. Key factors that contributed to this in Kilifi county included: redistribution of power from national actors to sub-national actors following devolution, this affected the national Ministry of Health's ability to lead and be an effective guiding organisation; misalignment between the globally advocated idea of ‘pay for performance' and the local pre-existing centralised and rigid approaches to public financial management; and actors at the sub national level who contested the PBF intervention design features and its framing as ‘additional funding'. As a consequence, the implementation of PBF in Kilifi was for a short time only using donor resources and did not last beyond donor timelines and funding. Conclusion: This research shows that for health reforms to gain political priority in highly devolved contexts, there is need to recognise the formal and informal institutions existing at the devolved level of governance and for adequate early involvement and leadership from sub-national bureaucratic and political actors, in health and beyond the health sector. In addition, advocacy for the health reforms should embody frames that align with the political context to increase the chances of gaining political traction. Finally, the political context including political and bureaucratic power at different levels of government are crucial features that will also influence the acceptability of reform and ultimately political prioritisation.
  • Thumbnail Image
    Item
    Open Access
    Whole-system change: case study of factors facilitating early implementation of a primary health care reform in a South African province
    (BioMed Central, 2014-11-29) Schneider, Helen; English, Rene; Tabana, Hanani; Padayachee, Thesandree; Orgill, Marsha
    Background: Whole-system interventions are those that entail system wide changes in goals, service delivery arrangements and relationships between actors, requiring approaches to implementation that go beyond projects or programmes. Methods: Drawing on concepts from complexity theory, this paper describes the catalysts to implementation of a whole-system intervention in the North West Province of South Africa. This province was an early adopter of a national primary health care (PHC) strategy that included the establishment of PHC outreach teams based on generalist community health workers. We interviewed a cross section of provincial actors, from senior to frontline, observed processes and reviewed secondary data, to construct a descriptive-explanatory case study of early implementation of the PHC outreach team strategy and the factors facilitating this in the province. Results: Implementation of the PHC outreach team strategy was characterised by the following features: 1) A favourable provincial context of a well established district and sub-district health system and long standing values in support of PHC; 2) The forging of a collective vision for the new strategy that built on prior history and values and that led to distributed leadership and ownership of the new policy; 3) An implementation strategy that ensured alignment of systems (information, human resources) and appropriate sequencing of activities (planning, training, piloting, household campaigns); 4) The privileging of ‘community dialogues’ and local manager participation in the early phases; 5) The establishment of special implementation structures: a PHC Task Team (chaired by a senior provincial manager) to enable feedback and ensure accountability, and an NGO partnership that provided flexible support for implementation. Conclusions: These features resonate with the deliberative, multi-level and context sensitive approaches described as the “simple rules” of successful PHC system change in other settings. Although implementation was not without tensions and weaknesses, particularly at the front-line of the PHC system, the case study highlights how a collective vision can facilitate commitment to and engagement with new policy in complex organisational environments. Successful adoption does not, however, guarantee sustained implementation at scale, and we consider the challenges to further implementation.
  • No Thumbnail Available
    Item
    Open Access
    Workplace based learning in district health leadership and management strengthening: A qualitative evidence synthesis
    (2023) Kiarie, Grace; Orgill, Marsha; Gilson Lucy
    Effective leadership and management has been identified as a critical foundation to enable health systems to respond adequately to their population needs. The changing nature of low-and middleincome countries' health systems in the midst of resource scarcity and a high disease burden, has placed learning as a key factor for health system reform and transformation, with workplace based learning (WPBL) as contributing to this learning process. This qualitative evidence synthesis (QES) used the ‘best fit' framework approach to synthesize evidence on WPBL, to identify and analyse how WPBL works to support and impact (or not) leadership and management development in the district health system. Findings from qualitative studies, mixed-methods and quantitative studies were synthesized and conclusions drawn from the data. The QES sought to answer the research question: ‘What forms of workplace based learning support leadership and management development and how does it impact district health leadership and management strengthening?' Four electronic databases were used to search for empirical studies and published grey literature. Twenty-four articles were included in the synthesis. The findings reveal that over the last decade, WPBL has received consideration as an approach for leadership and management development. However, while the WPBL interventions differed in the type and nature of the intervention, as well as the length of delivery of each intervention, there was no evidence that pointed to which strategy had a greater influence than others on strengthening district health leadership and management. Furthermore, the synthesis demonstrates the need for a focus on sustainability and institutionalization of interventions, including the need to integrate WPBL interventions in health systems, and offering elements of WPBL through national or regional institutions while ensuring flexibility of WPBL design and delivery.