District health managers (DHMs) are charged with turning policies and resources into accessible and high-quality health services, but resource uncertainty and limited decision-making authority limit their ability to do so. Successful capacity strengthening requires understanding individual, organizational, and contextual factors that influence the work of DHMs. Collaborating with DHMs and other local stakeholders using a systemic and participatory approach will generate culturally appropriate and contextualized approaches to reduce bottlenecks and inefficiencies.