Background
The local setting: DHS in South Africa
• Identification of client and stakeholder needs | |
• Identification of critical health and systemic challenges and understand source of the challenges | |
• Take decisions and set priorities (public health interventions) | |
• Balance competing demands by taking decisions on key District Actions, which respond to key priorities, client and stakeholder needs and challenges | |
• Allocate resources (time from personnel, goods and services and capital costs). Ensure that capacities are matched with planned Actions. Refine the Actions until the allocated resources meet the Actions | |
• Monitor and reflect on progress against plans | |
• Strengthen processes where necessary (to implement the plan) |
Bottom-up innovation
The suite of inter-linked innovation
Methods
Study aim
Research question
Eliciting the programme theory (PT)
Hypothesized mechanisms
Micro practices | |
Translating | Translating is an act of authoring, involving selecting the content to be shared and then using material and discursive symbols in the language of the receiver to bring the elements together. Elements and symbols are chosen purposefully to establish shared meaning, managers use their tacit knowledge of people and situations to shape the content. |
Over-coding | Inscribing speeches and acts in the appropriate professional and socio-cultural codes of the receiver to reinforce meaning. Different social contexts are home to different social codes, social codes are intrinsic to meaning creation. |
Disciplining the client | In routines and conversations, managers produce subjective and emotional effects around the change. Disciplining clients therefore consists of using diverse tactics – including symbolic (e.g. speaking in someone’s language, invoking common cultural roots to create shared meaning), and discursive consciousness (conscious use of implicit knowledge to construct and tell stories – to subjectively influence and convince recipients to adopt change). Through their implicit knowledge managers create sense for others and diffuse meanings around the change. This includes the use of space and body to create an environment which resonates with what is trying to be achieved. |
Justifying the client | Providing a set of good reasons for actors to adopt the change. |
Sticks, carrots and sermons | Sticks reflect the use of tools to mandate compliance (e.g. regulation). Carrots represent the use of incentives or rewards to motivate for a change in behaviour (e.g. the offer of a subsidy). The use of sermons is the attempt to “influence people through the transfer of knowledge, the communication of reasoned argument” (e.g. sharing information). |
Proximal outputs
Outcomes
The core capability to commit and engage | Actors can mobilize resources (financial, human, organizational); create space and autonomy for independent action; motivate unwilling or unresponsive partners; plan, decide, and engage collectively to exercise their other capabilities |
The capability to carry out technical, service delivery and logistical tasks | Actors produce acceptable levels of performance; generate substantive outputs and outcomes (e.g., health or education services, employment opportunities, justice, and rule of law); sustain production over time; and add value for their clients, beneficiaries, citizens, etc |
The core capability to relate and to attract support | Actors can establish and manage linkages, alliances, and/or partnerships with others to leverage resources and actions; build legitimacy in the eyes of key stakeholders; deal effectively with competition, politics, and power differentials |
The capability to adapt and self-renew | Actors can adapt and modify plans and operations based on monitoring of progress and outcomes; proactively anticipate change and new challenges; learn by doing; cope with changing contexts and develop resiliency |
The capability to balance diversity and coherence | Actors can develop shared short- and long-term strategies and visions; balance control, flexibility, and consistency; integrate and harmonize plans and actions in complex, multi-actor settings; and cope with cycles of stability and change |
Study design
Definition of the case and of the unit of analysis
Site selection
Data collection
Data analysis
Synthesis and comparison of CMO findings with the programme theory
Results section
Context and actors
The extended monthly DMT meeting needed to change, as it was a space mainly used for complaining. The use of information by hospital and sub-district managers for problem diagnosis, decision making, and accountability needed to be improved:“I think the preparation for NHI relies heavily on innovation and in order to innovate properly, you need a stable system. This is an extremely unstable system, so you have got to innovate and stabilise at the same time, which I think adds a lot to the complexity of what we do (The new DM, 09/09/2014).
The information manager (IM) was carrying the burden of information preparation and presentation for the meeting. She had a sense that managers were afraid of working with numbers and this resulted in a general culture of avoidance and deferring queries back to her:“I think that there were lots of meetings, or there are lots of meetings that happen, but not lots of structured meetings. Not lots of minutes and not lots of agendas, so you cannot go to a meeting and you sit there the whole day and you don’t have something tangible to show …. We get a lot of whining sessions, but they actually don’t help at all …. That is more the approach than to listen, because you can spend ninety percent of your time listening to or whining, and then only ten percent looking at solutions, whereas we would like to reverse that … It is about looking at the indicators and asking: “Why we are doing well or why we are doing badly? … It has worked before and it is kind of standard practice in functional systems. I am sure it will work” (The new DM, 19/02/2014).
The IM already had a huge workload, including managing all the aggregate information, quality-checking data and being responsive to information requests in the district. Additional data capturers had been sent to the district as it was an NHI pilot site, but they did not have the skills to do the work required. In the past, reports had sometimes been generated but the problems managers raised in them were at times not acted upon reducing motivation to produce new reports.“… because even things that they can do themselves, they will also say: “No give it to [the] information person.” … They would make it a big deal when it comes to compilation of other reports. Anything that is computer-related, they associate it with anything that relates to numbers. They will just give it to someone to add it in … they don’t want to use numbers” (Manager 1, 09/09/2013).
The suite of inter-linked innovations to develop management capacity
-
(1a) The introduction of a new agenda that focused on the core functions of the district (‘services’, ‘corporate governance’ and ‘quality’, with time allocated for each item), and the introduction of a routine procedure to support decision making - whereby managers had to produce reports, covering core indicators for reading, which were distributed before the meeting. Additional file 5 presents an overview of key agenda items.
-
(1b) An explicit effort to institutionalise the engagement with and application of information by all managers, backed up by the DM’s purposeful enforcement of the national District Health Management and Information Systems (DHMIS) policy. Linked to this, the DM also established the routine procedure that managers must first investigate problems by collecting information on the ground before bringing them to the monthly meeting, and be ready to discuss solutions and progress (or lack thereof).
-
(1c) The routine procedure that NGO partners in the district would attend the extended district management meeting in order to support coordination and accountability, as well as discuss their activities directly with the DM.
-
(1d) Defining job descriptions for the ex-hospital CEOs newly posted to the district office describing their purpose in the team; as well as attempts to fill critical management vacancies in the team.
Outputs
Output 1a
Already by the end of 2014, at least 15 managers were preparing and submitting reports to the DM, who then decided both what would be discussed in the meeting and which reports would be circulated in preparation."Yes, we present but we are being given a chance, we are being informed earlier on that you are expected to present in such-and-such a DMT because of the time schedule and there are a lot of them here. So, it doesn’t become possible for us all to report. For instance, there’s a lot of, the NHLS, there’s pharmaceutical, there’s the information officer who gives a summary report for the activities that happened in the districts. Then we input or respond; when you haven’t done well, you indicate what causes the deviations from targets and how are you going to improve on those things. And if we don’t present the actual status ourselves, it appears". (Manager 7, 02/10/ 2015).
The hospital managers and sub-district managers as line managers were expected to read the reports to empower themselves. Nonetheless, getting managers to engage with information in the reports was not easy. The DM identified two challenges: he was not fully satisfied with the make-up of the reports and not all managers had read the reports as needed before coming to meetings;“so what we are trying to do now is have a structured agenda, not a reactive agenda, a structured agenda where you have reports that you prepare and then the line management people that attend have to interact with those reports” (The new DM, 19/02/2014).
“because progressively we are going to start making decisions based on that and if they don’t read those reports … …. we are now at the point where we are kind of saying read your emails, read your reports etcetera” (The new DM, 19/09/2014)
Output 1b
While problems were still brought to meetings, there was a proactive effort to identify solutions in the meeting:“We continued with what [the new DM] has started. We look into the indicators and the performance of the district, the subdistrict and the hospital CEOs, they do make some presentations so that we are able to identify gaps and formalise some strategies to work around the gaps - we’re still continuing.” (Manager 6, 17/05/ 2015).
"So now, at least people, even though not everybody, but some are able to say, okay, we have got a challenge of transport – how about if management could talk with [the] municipality so that we can join vehicles together when they are going to ward A, maybe we got to ward A, all of them. Starting from that integrated planning there." (Manager 8, 24/03/2015).
"I have to get assistance from the people who are actually doing the immunisations, what was the problem? Were there vaccines that were not available, for instance; or was there something that made them not be able to come to the facility?" (Manager 7, 02/10/2015).
Output 1c
“Yes, I was part of that stakeholders [mapping] meeting and we all [NGO partners] presented the work that we are doing, the challenges and the successes that we have had. And on a monthly basis we used to give him our progress reports in the DMT meetings” (NGO partner 1, 18/05/2015).
Formal invitations to partners had also become routinised." …. they [NGOs] are actually invited to make inputs [into the DHP] and also to look at the priorities of the district when they are going to be doing that. So their plans must actually be part of what the district plan is" (Manager 4, 1/10/2015).
An NGO partner who had been part of the DMT meetings before 2013 (when the new DM arrived) noted that as partners had to present on their activities when attending the meetings, accountability amongst NGOs improved (NGO partner 2a, 2/10/2015)."Ja [yes], I think mainly it’s [NGO partner 1 & 2] who are attending those district management meetings, though it’s continuously growing in terms of who is attending those meetings." (Manager 4, 1/10/2015).
Output 1d
Mechanisms for change
Initial sensemaking by the DM
The new DM drew on his personal resources, including tacit knowledge and experience in the public and private health system in another province to design the suite of inter-connected innovations. He did not believe that more resources would by themselves improve district performance and instead judged that inefficiencies in the public sector could be dealt with through system improvements. The new DM explained where the idea for the structured agenda came from:“Look, when I first got here, we went through quite a long process of saying: “What is the ideal organogram that is needed at district level? What are the ideal processes needed at district level to ensure that we are able to have a strong management team that can take us into the NHI?” Therefore, I think it does depend a lot on what people we’ve got. I think there needs to be a standardisation of processes, because the way I am doing things, it is pretty similar to the way they do it in the [previous Province he worked in], but chatting to my colleagues from other provinces, it is not the same and I think there needs to be a standardisation of the management processes. There should be some space in between for us to express our individuality and so on, but essentially there needs to be an improvement in the standardisation” (The new DM, 09/09/2013).
“My little thing to keep me focused, there is a thing called the district management accountability framework, which over the …. five years, … that I was a manager in [Province X], we progressively developed a series of things that need to be in place for a health system to be functional. So, we documented you know, the governance, management, leadership … as I was saying, those things are the pillars of … what is it … [the] WHO building blocks, but having lived through the … development of it, I understand it in a particular way. It is ... management, governance, leadership, it is service delivery, it is critical support functions, and it is quality. Now … and below that, I can see the headings … and that is the agenda for the DMT (The new DM, 09/09/2013).
“So, I think the vision comes from … a lot of the vision comes from what I have seen in reality in [Province X]. A lot of the vision [also] comes from what I have seen in reality in the private sector” (The new DM, 9/09/2014).
Introducing a new agenda in the extended DMT meeting: sensemaking and sensegiving as reciprocal processes
For one manager, working closely alongside the DM (proximity to change) enabled an understanding of the need for change:"You know, when he came, there was much more focus around the core business in meetings, than to simply discuss how much money we have spent around HR, around that, and so on. Remember, we are having this business of being the Department of Health, so everything must be patient care-related. Now once you talk the performance indicators, you talk PHC, hospital indicators, that’s fundamental – because we can say our department is existing not because of various other things but because of the performance. I would say in relation to that I'm still very much pleased " (Manager 2, 25/03/2015).
The DM over-coded, drawing on familiar organisational socio-cultural codes as a ‘stick’, noting that the ‘auditor general’ (a powerful figure in the bureaucracy) can check up on the use of information and the focus on performance in meetings by looking at the agenda, effectively using hardware of the system as a stick linked to accountability."Maybe one will be saying because I was really always close to this office and having that advantage of knowing why there is this initiative, why we should change – I would say starting from you say the nature of our agenda items in the DMT.” (Manager 2, 25/03/2015).
The new approach to meetings encouraged active participation by senior managers, whilst simultaneously facilitating their buy-in to the new practices through the process of ‘doing’. Managers appreciated that they were no longer tired in meetings because of long drawn-out processes. Increased participation provided more ingredients for sensemaking and sensegiving, which triggered the motivation and self-efficacy of managers."The DMT meetings might have been held every month, but if in the minutes and the agenda, there’s no … .. agenda items around the information or data management, then you cannot say you are discussing your performance – because it’s not showing in the agenda and minutes. So, that’s what [the new DM] emphasised all the time." (Manager 1, 09/09/2013).
These actions were complemented by the preparation and pre-reading of reports, which reinforced the use of information and, together with the requirement to present problems with potential solutions, fed into a more structured agenda."Yes, because before the subdistrict managers were presenting, the CEOs were presenting – so when the last one is presenting, you are no more listening. It’s already four o’clock, so you are tired. So the way he did it – it’s for the information manager to present comparing the subdistricts, not for subdistricts, for [sub-district A] to present, then one for sub-district B to present, because at the end, you won’t be able to see how do they work comparing them, and where to give assistance. The way he did it is for the information manager to present and show us which subdistricts doesn’t perform well in what. That has really helped us. Like they are also doing it today in preparation of the DMT on Thursday." (Manager 8, 24/03/2015).
Embedding the use of information for problem diagnosis and problem solving: sensegiving and sensemaking as a social process
"They [the managers] were fine because we were also emphasising to them that it’s not any person’s choice, because it’s a policy issue which, though we were trained on it, but in terms of implementation, you were not implementing it as expected. But now, that [was coming from] from the district manager" when [the new DM] went around.” (Manager 1, 09/09/2013)
The planning manager, identified as exceptional by the DM, was tasked with reviewing all the data from facilities to identify any obvious discrepancies. The DM then employed ‘sticks’ to reinforce the importance of data by writing letters to each facility manager or sub-district manager, saying either 1) your data was late, 2) your data was not complete, 3) your data is not believable in the following areas (…).“They [sub-district managers] are more responsive, especially when it comes to the variances that we are showing them, because they are the only people that should tell us the reason as to why it is like this.” (Manager 1, 09/09/2013).
“So, she is now … she has given me the second month’s letter, and it is almost identical to the first month’s letter.” (The new DM, 19/09/2014).
However, there were still challenges to using information for decision making in the DMT, including some managers’ lack of trust in the data. The DM tried to address these reservations by using an example of a project where data had successfully been collected and verified to illustrate that it is possible to change practice and get good data.“Yes, because in those pivot tables [shown on the computers], all the indicators for various programmes, they are there. So the managers even [can] now compare quarters to look at the performance of sub-district A versus [B] sub-district … to see areas that are alarming and as well as for them to be able to act up on the data that they see and it’s also assisting me as information manager, even if I am not there. (Manager 1, 09/09/2013).
However, it was not always easy to make people focus on solutions. Doctors’ accommodation was one intractable problem that seemingly had no solution:"Ja, people were focussing on challenges. Really their focus was specific to challenges. Like they are doing now, [they] don’t have vehicles to reach area 1, so at the end what he was saying is “when you have got a challenge, come up with a proposed solution”. It mustn’t be just a challenge being thrown because you need to think what is it that can help you to change." (Manager 8, 24/03/2015).
When a problem was resolved, the team were asked to share lessons in order to generate collective learning and thus contribute to the collective capabilities of the team.“So, people started getting a little bit edgy. They said “what is the point of telling this guy that we have got a problem, because he actually can’t do anything about it”, you know and it is that kind of a … situation” (new DM, 19/09/2014)
Sensegiving to NGOS: crafting and managing key relationships to attract resources and support
For the NGOs who supported these actions, the new DM tapped into shared meanings and, in some cases, a history of working relationships (for example, generated by sharing office space with the NGO). They felt he was working hard at working together and that he gave them a voice in these processes. He, thus, also tapped into their intrinsic motivation. In this research we interviewed four staff members from two supportive NGOs:“They [NGOS] don’t have priorities; it’s the district that has priorities – they are here to support the district to achieve the set targets on those specific priorities.” (Manager 5, 1/10/2015).
“Everybody had a voice. Everybody had a voice, all the partners had a voice. We felt part of the plan, and so we were prepared or we managed to own the plan." (NGO partner 1, 18/05/2015).
"As a partner we have to compromise. ( … ) As a partner we have to be flexible all the time, because we are here to respond to the needs of the DoH. So, if you are not doing that, then the relationship between yourself and the DoH might turn a little bit sour; so you have to ensure that you’re flexible all the time." (NGO partner 1, 18/05/2015).
The DM told NGO partners who did not want to create a shared vision that he would report directly to their funders, using sensegiving ‘sticks’ to influence participation.“No, he was not a difficult person because he had the best interests of the department at heart” (NGO Partner 2b, 18/06/2015).
Some managers were wary of including NGOs in DMT meetings, given negative experiences of media reporting prompted by NGOs. However, the new DM successfully justified the need for inclusion using his experiential knowledge:“We are actually more explicit to them, and said “if you don’t talk to us, then we write to your funder, saying that you are not helping us, then they can send the money somewhere else”, because everybody comes and they think the answer is training.” (The new DM, 19/09/2014).
As part of his plan, the new DM originally requested one of the large NGO partners to steward all the NGOs in the district as “they must be guided as to what the needs of the district are” (The new DM, 19/09/2014). But as this approach did not work because not all NGOs were pulling in the same direction, he then drew on his planning manager, who had a long history working in the district and long-standing relationships, to take coordination forward. The DM thus employed distributed leadership toward the overall goal.“Really, it started working. He invited partners, even the partner that we didn’t like a lot, Partner XXXX. So, we felt that these are the people that normally write negatively about the department of health – then why are they here now? But the way he explained it ... because they were part of the meeting and they know what is happening, they have inputted in relation into what is supposed to be changed. … It really worked; I think it really worked, because otherwise we didn’t like the idea, but we saw that as fruitful.” (Manager 8, 23/05/2015).
However, the district NGO coordinator felt somewhat left out of these new processes, as he was not a senior manager and did not attend extended DMT meetings. He also primarily coordinated Community Based Organisation Organisations (CBOs), rather than large NGOs - smaller organisations receiving subsidies from the Provincial government and monitored by the district office.“[The planning manager] ensures that we plan with our partners; we do reviews with our partners." (Manager 6, 17/05/2015).
Other mechanisms in context that facilitated sensemaking and sensegiving included the ongoing work of a large NGO specifically placed in the district to provide technical support to the district as an NHI pilot site. Some donor-funded projects also intentionally and actively sought to build working relationships between themselves and members of the management team (e.g. a UNICEF project)."Firstly, [the new DM] told us that what he needs is a consolidated plan for the DoH and for the partners as well. As partners, we have our own operational plans that talk to the objectives and the targets that have been set up by our funders, and there are certain indicators that we need to focus on. Same applies to the DoH, because they have got some indicators that they need to focus on. So, [the new DM] said “with all your plans that you have, they need to be integrated into our master-plan so that we can have one plan that we are going to support and implement as district [X]. So we found that very valuable because with all the plans that we had, we had an opportunity to express our concerns and maybe the needs that we might have as partners for the kind of support that we are expecting from the DoH." (NGO partner 1, 18/05/2015).
Despite the improvements experienced, persistent ongoing challenges for partner NGOs in the district included their limited power to hold staff in the sub-districts they supported accountable, where, for example, staff showed lack of urgency.“Make good relationships with people, be flexible and try and understand the other’s opinions. Don’t be a know it all - acknowledge we learn from them and then learn from us. Be yourself and present yourself as you are.” (NGO Partner 2b, 18/06/2015).
The number and distribution of managers in the team: negotiation as sensegiving
“I have weighed up the benefit of one post above the other one, and said I am giving you [the Provincial government] the money for a quality assurance manager, … I have got a TB manager that resigned, and I said TB and HIV should actually be under the same deputy director. So, I am taking that TB money and that is quality assurance money.” (The new DM, 19/09/2014).
“But you … as a leader and manager, you have to make tough decisions” (The new DM, 19/09/2014).
“I come from a different school of thought, but I mean to be fair, there are people that say I don’t argue enough for more resources and that is based on … I attended a course on efficiency and so on and he [the lecturer] said the worst thing that you can do for a dysfunctional system is to throw money into it … It makes it more dysfunctional. So, I have been … when Province says I am not giving you money, I say okay.” (The new DM, 19/09/2014).
"He couldn’t get formal job descriptions because job descriptions come from the provincial office ..[but] … he looked at those who were additional to the establishment and then from there, he managed to allocate them in areas where he was seeing that there are gaps … So, from there, you will be able now to come with what you are supposed to be doing." (Manager 8, 24/03/2015).
Did practices continue over time?
In 2015, the new DM also confirmed that the Planning Manager continued to ensure that planning and review processes continued with partners. Similarly, the Hospital CEOs deployed to the DMT without portfolio continued to work within clear role descriptions to ensure they functioned as an effective part of the team:Yes, it does because that’s what we are continuing even with …. , we continued with what [the previous DM] has started. We look into the indicators and the performance of the district, the subdistrict and the hospital CEOs, they do make some presentations so that we are able to identify gaps and formalise some strategies to work around the gaps - we’re still continuing. (Manager 6, 17/05/2015).
Nonetheless, the new DM was not naïve about the broader contextual challenges faced in leading the district in 2015, including key leadership vacancies in the hospitals (and in the district more broadly) and challenges related to clinical governance in some hospitals:"Then I am able to allocate them to those areas. So, they’re kind of busy there, because once you don’t utilise one, he becomes demotivated and feels as if he’s worthless. But now, we are utilising them fully." (Manager 6, 17/05/2015).
"So, there are those kind of weaknesses that affect the progress and stability in the district" (Manager 6, 17/05/2015).
More positively, the new DM mentioned that a new key NHI liaison official had been appointed at the Provincial government, which helped them stay on top of NHI processes in the district."So, another weakness is you see there’s a lot of staff turnover in the whole district, especially clinical people, professionals, the nurses. Because you will appoint a hospital manager; while you’re appointing this one, the other one says I'm resigning, I'm going. So it’s those kind of things that are threats now – I've done the weakness, the threats" (Manager 6, 17/05/2015).