Barriers and Enablers to Scaling the AURUM Management Development Programme(MDP): District Manager Perspectives from the Western Cape, South Africa

Background: Strong management capacity is essential for effective primary healthcare (PHC) service delivery and health system strengthening [1]. The AURUM Management Development Programme (MDP) was implemented to strengthen district and PHC leadership in the Western Cape province of South Africa. This study explored the contextual barriers and enabling conditions influencing the scalability of the programme within district health systems. Methods: This study employed a qualitative exploratory design to investigate barriers and enablers associated with scaling the MDP. In-depth interviews were conducted with purposively selected district health managers from three Western Cape districts. Interviews were audio-recorded, transcribed verbatim, and analysed thematically using NVivo 14. The study explored perceptions regarding programme adaptability, district readiness, implementation challenges, and enabling conditions for sustainability and scale-up. Results: Twenty participants (7 males and 13 females) from the Cape Winelands, Garden Route, and Cape Town Metro district health offices were interviewed. The MDP was viewed as relevant, practical, and adaptable to district health system contexts. District readiness for implementation emerged as an important determinant of perceived programme success. High readiness was characterised by clear team roles, strong management structures, decentralised decision-making, digital tool utilisation, ongoing mentorship systems, and prior exposure to PHC reforms such as the Ideal Clinic Realisation and Maintenance (ICRM) programme. Lower readiness was associated with staff shortages, operational pressures, limited leadership support, and partially functional health systems. Key enabling factors included integration with existing training structures, visible improvements in service delivery, mentorship support, and active engagement from district leadership. Conclusion: The MDP demonstrates potential for scalability within South Africas public health system. However, successful scale-up depends on district-level readiness, supportive leadership structures, integration into existing training and management systems, and sustained mentorship and implementation support.