• Benjamin Malakoane, Perpetual Chikobvu, James Christoffel Heunis, Nanteza Gladys Kigozi, and Willem Hendrik Kruger.
• Department of Community Health, University of the Free State, PO Box 339, Bloemfontein, 9300.
• Afr Health Sci. 2023 Mar 1; 23 (1): 469482469-482.

BackgroundBased on the World Health Organization's health systems strengthening framework, the Health Systems Governance and Accountability (HSGA) intervention to strengthen public health leadership/management, service integration and outcomes was developed in the Free State.ObjectivesThis study describes the process to implement and measure the effects of the HSGA intervention for system-wide improvement of leadership/management under routine conditions in a resource-constrained setting.MethodsBased on normalisation process theory, participatory discussions were held with health managers, staff and local stakeholders to attain buy-in. Evaluation of the implementation process considered progress in improving leadership/management through application of the Balanced Scorecard (BSC). All provincial reporting units were assessed during 2014/15 and again during 2015/16.ResultsThe mean scores on three BSC perspectives improved statistically significantly from 2014/15 to 2015/16: customer (p=0.0085), internal business processes (p=0.0008) and finance (p=0.0001). Overall leadership/management also improved significantly (p=0.0007).ConclusionImprovement in leadership/management resulting from implementation of the HSGA intervention was observed during the two years under study. From this experience, successful implementation of a health systems strengthening intervention hinges on a participatory design, appropriate use of theory, as well as application of an evaluation approach to assess the success of implementation.© 2023 Malakoane B et al.

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