Small-world challenges and solutions identified by mid-level managers within a decentralised healthcare system during a qualitative sub-study of a tuberculosis-prevention therapy rollout intervention in Uganda: “When a big drum like the District Health Officer talks”

Background Decentralisation policies that devolve certain administrative and decision-making powers to local levels can pose challenges for public health and healthcare systems. For a decentralised health system to function optimally, mid-level systems must rely on tightly clustered, so-called “small-world” networks to efficiently scale-up national health campaigns and share best practices. Few studies have qualitatively tackled the mechanisms of small-world creation and their potential effects on public health promotion during centralized national campaigns in a decentralised, mid-level healthcare system tier. Methods We performed a thematic analysis using a rigorous and accelerated data reduction (RADaR) technique on 23 in-depth interviews and six focus group discussions with mid-level healthcare managers in a cluster-randomised trial from 2019 to 2021, whose intervention component aimed to increase isoniazid preventive therapy (IPT) uptake to prevent tuberculosis among people living with HIV in Uganda. Results Training mid-level managers on management and leadership skills fostered the creation of small-world networks within a decentralised healthcare context and promoted mid-level manager agency to address several drawbacks associated with the decentralisation of healthcare systems. Through improved communication, intervention groups encouraged teamwork within their districts, building a denser cluster of networks. This in turn fostered small world ties that paired 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. Conclusions Increased collaboration demonstrably strengthened the clustering of small-world network ties at a horizontal level to disseminate knowledge of best practices more quickly and efficiently in promoting the uptake of IPT while ensuring accountability to peers, the MoH, and local communities, sustaining these levels after a centralized national campaign ended. Trial registration NCT03315962. Registered 20 October, 2017