Abstract
OBJECTIVE: This paper examines the challenges frontline health workers face, as well as their coping practices following district splitting. It also has ramifications for the need to take into account the nexus between district splitting and subnational health system functioning. DESIGN: A qualitative cross-sectional study employing an exploratory design. Data were collected using an in-depth interview guide for individual interviews. We used a deductive thematic analysis to identify and structure challenges faced and coping mechanisms by health workers in new districts. The data were analysed deductively using Braun and Clarke's six-step thematic analysis. SETTING: Frontline health workers from four randomly selected regions with one parent district selected randomly from each region and a respective child district that had been split from it between 2005 and 2015. Interviews were conducted between June and November 2018. PARTICIPANTS: In-depth interviews were conducted with 24 frontline health workers whose age ranged from 33 to 51 years and these had changed locations between districts after district splitting occurred. RESULTS: The challenges frontline health workers faced included work-related role changes, social demands, team integration and health system inadequacies. Health workers switched roles across districts, adapting to leadership while balancing clinical and administrative duties. Overall, five themes emerged during analysis. Newly promoted staff faced knowledge gaps in facility management. Social demands included accommodation issues and family/community pressures. Team integration impacted daily work, requiring newcomers to navigate hierarchy and culture. Health system issues, such as understaffing, poor infrastructure, drug shortages and strained work relations, worsened working conditions. Coping practices included induction, leadership training, staff appraisals, duty rosters, supervision, team building, partner support and financial/community planning. CONCLUSIONS: District splitting worsens challenges for frontline health workers. While they show resilience through coping strategies, systemic improvements remain essential. Addressing root causes like better resource distribution, expanded training and stronger administrative support is crucial to achieving the district splitting goal of improving healthcare delivery in newly formed districts in Uganda.