Table 3 Barriers to implementation of best-practices observed in the participatory action research

Mismatch between hospital’s vision and reality

The hospital strategic planning was based on its vision to provide innovative and specialized health care contrary to the reality that majority of patients had common acute illnesses that did not require specialized care. There was a mismatch of infrastructure and the skill mix of the workforce did not sufficiently match the patient’s needs.

Poor communication

Poor communication was compounded by a centralized administrative system and limited forums where working relationships could be discussed thus hampering knowledge sharing.

Limited objective measures for evaluating quality of clinical care

Absence of more objectively assessed measures of patients’ care meant inadequacies in self- regulation could arise and persist without notice.

Limited capacity for strategic planning.

Inadequate structures to optimize efficiency of service delivery.

Inadequate management skills to introduce and manage change.

Unwillingness to do things differently reflected a general negativism towards innovation and limited ability of the managers to articulate, supervise and guide change efforts.

Hierarchical relationships among the staff and patients

Passage of knowledge was largely unidirectional with lower cadres being the recipients. Doctors as well other health workers maintained their primacy in care of patients and protected their profession.

Inadequate adaptation of ETAT + to the local context.

Among all cadres, there was inadequate knowledge in some basic procedures that were not the focus of ETAT+. Some of the existing job aids were outdated and did not permit staff to adopt best-practices.