A qualitative study of the dissemination and diffusion of innovations: bottom up experiences of senior managers in three health districts in South Africa.

BACKGROUND: In 2012 the South African National Department of Health (SA NDoH) set out, using a top down process, to implement several innovations in eleven health districts in order to test reforms to strengthen the district health system. The process of disseminating innovations began in 2012 and senior health managers in districts were expected to drive implementation. The research explored, from a bottom up perspective, how efforts by the National government to disseminate and diffuse innovations were experienced by district level senior managers and why some dissemination efforts were more enabling than others. METHODS: A multiple case study design comprising three cases was conducted. Data collection in 2012 - early 2014 included 38 interviews with provincial and district level managers as well as non- participant observation of meetings. The Greenhalgh et al. (Milbank Q 82(4):581-629, 2004) diffusion of innovations model was used to interpret dissemination and diffusion in the districts. RESULTS: Managers valued the national Minister of Health's role as a champion in disseminating innovations via a road show and his personal participation in an induction programme for new hospital managers. The identification of a site coordinator in each pilot site was valued as this coordinator served as a central point of connection between networks up the hierarchy and horizontally in the district. Managers leveraged their own existing social networks in the districts and created synergies between new ideas and existing working practices to enable adoption by their staff. Managers also wanted to be part of processes that decide what should be strengthened in their districts and want clarity on: (1) the benefits of new innovations (2) total funding they will receive (3) their specific role in implementation and (4) the range of stakeholders involved. CONCLUSION: Those driving reform processes from 'the top' must remember to develop well planned dissemination strategies that give lower-level managers relevant information and, as part of those strategies, provide ongoing opportunities for bottom up input into key decisions and processes. Managers in districts must be recognised as leaders of change, not only as implementers who are at the receiving end of dissemination strategies from those at the top. They are integral intermediaries between those at the at the coal face and national policies, managing long chains of dissemination and natural (often unpredictable) diffusion.

The everyday practice of supporting health system development: learning from how an externally-led intervention was implemented in Mozambique.

Health system strengthening (HSS) has often been undertaken by global health actors working through vertical programmes. However, experience has shown the challenges of this approach, and the need to recognize health systems as open complex adaptive systems-which in turn has implications for the design and implementation approach of more 'horizontal' HSS interventions. From 2009 to 2016, the Doris Duke Charitable Foundation supported the African Health Initiative, establishing Population Health Implementation and Training partnerships in five African countries (Ghana, Mozambique, Rwanda, Tanzania and Zambia). Each partnership was designed as a large-scale, long-term, complex health system strengthening intervention, at a primary care or district level-and in each country the intervention was adapted to suit that specific health systems context. In Mozambique, the Population Health Implementation and Training partnership sought to strengthen integrated health systems management at district and provincial levels (through a variety of capacity-development intervention activities, including in-service training and mentoring); to improve the quality of routine data and develop appropriate tools to facilitate decision-making for provincial and district managers; and to build capacity to design and conduct innovative operations research in order to guide integration and system-strengthening efforts. The success of this intervention, as assessed by outcome measures, has been reported elsewhere. In this paper, the implementation practice of this horizontal HSS intervention is assessed, focusing on the key features of how implementation occurred and the implementation approach. A case study focusing on HSS implementation practice was conducted by external researchers from 2014 to 2017. The importance of an accompanying implementation research approach is emphasized-especially for HSS interventions where the 'complex adaptive system' (complex and constantly changing context) forces constant adaptations to the intervention design and approach.

Organisational culture and trust as influences over the implementation of equity-oriented policy in two South African case study hospitals.

BACKGROUND: This paper uses the concepts of organisational culture and organisational trust to explore the implementation of equity-oriented policies - the Uniform Patient Fee Schedule (UPFS) and Patients' Rights Charter (PRC) - in two South African district hospitals. It contributes to the small literatures on organisational culture and trust in low- and middle-income country health systems, and broader work on health systems' people-centeredness and "software". METHODS: The research entailed semi-structured interviews (Hospital A n = 115, Hospital B n = 80) with provincial, regional, district and hospital managers, as well as clinical and non-clinical hospital staff, hospital board members, and patients; observations of policy implementation, organisational functioning, staff interactions and patient-provider interactions; and structured surveys operationalising the Competing Values Framework for measuring organisational culture (Hospital A n = 155, Hospital B n = 77) and Organisational Trust Inventory (Hospital A n = 185, Hospital B n = 92) for assessing staff-manager trust. RESULTS: Regarding the UPFS, the hospitals' implementation approaches were similar in that both primarily understood it to be about revenue generation, granting fee exemptions was not a major focus, and considerable activity, facility management support, and provincial support was mobilised behind the UPFS. The hospitals' PRC paths diverged quite significantly, as Hospital A was more explicit in communicating and implementing the PRC, while the policy also enjoyed stronger managerial support in Hospital A than Hospital B. Beneath these experiences lie differences in how people's values, decisions and relationships influence health system functioning and in how the nature of policies, culture, trust and power dynamics can combine to create enabling or disabling micro-level implementation environments. CONCLUSIONS: Achieving equity in practice requires managers to take account of "unseen" but important factors such as organisational culture and trust, which are key aspects of the organisational context that can profoundly influence policies. In addition to implementation "hardware" such as putting in place necessary staff and resources, it emphasises "software" implementation tasks such as relationship management and the negotiation of values, where equity-oriented policies might be interpreted as challenging health workers' status and values, and paying careful attention to how policies are practically framed and translated into practice, to ensure key equity aspects are not neglected.

Strengthening post-graduate educational capacity for health policy and systems research and analysis: the strategy of the Consortium for Health Policy and Systems Analysis in Africa.

BACKGROUND: The last 5-10 years have seen significant international momentum build around the field of health policy and systems research and analysis (HPSR + A). Strengthening post-graduate teaching is seen as central to the further development of this field in low- and middle-income countries. However, thus far, there has been little reflection on and documentation of what is taught in this field, how teaching is carried out, educators' challenges and what future teaching might look like. METHODS: Contributing to such reflection and documentation, this paper reports on a situation analysis and inventory of HPSR + A post-graduate teaching conducted among the 11 African and European partners of the Consortium for Health Policy and Systems Analysis in Africa (CHEPSAA), a capacity development collaboration. A first questionnaire completed by the partners collected information on organisational teaching contexts, while a second collected information on 104 individual courses (more in-depth information was subsequently collected on 17 of the courses). The questionnaires yielded a mix of qualitative and quantitative data, which were analysed through counts, cross-tabulations, and the inductive grouping of material into themes. In addition, this paper draws information from internal reports on CHEPSAA's activities, as well as its external evaluation. RESULTS: The analysis highlighted the fluid boundaries of HPSR + A and the range and variability of the courses addressing the field, the important, though not exclusive, role of schools of public health in teaching relevant material, large variations in the time investments required to complete courses, the diversity of student target audiences, the limited availability of distance and non-classroom learning activities, and the continued importance of old-fashioned teaching styles and activities. CONCLUSIONS: This paper argues that in order to improve post-graduate teaching and continue to build the field of HPSR + A, key questions need to be addressed around educational practice issues such as the time allocated for HPSR + A courses, teaching activities, and assessments, whether HPSR + A should be taught as a cross-cutting theme in post-graduate degrees or an area of specialisation, and the organisation of teaching given the multi-disciplinary nature of the field. It ends by describing some of CHEPSAA's key post-graduate teaching development activities and how these activities have addressed the key questions.

The use of street-level bureaucracy theory in health policy analysis in low- and middle-income countries: a meta-ethnographic synthesis.

This article presents a synthesis of studies that explicitly use the theory of street-level bureaucracy to illuminate health policy implementation in low- and middle-income countries. Street-level bureaucrats are frontline workers in bureaucracies, e.g. nurses, who regularly interact directly with citizens in discharging their policy implementation duties and who have some discretion over which services are offered, how services are offered and the benefits and sanctions allocated to citizens. This synthesis seeks to achieve the dual objectives of, first, reflecting on how street-level bureaucracy theory has been used in the literature and, second, providing an example of the application of the synthesis methodology of meta-ethnography to the health policy analysis literature. The article begins by outlining meta-ethnography and providing more information on the papers on which the synthesis is based. This is followed by a detailed account of how the synthesis was achieved and by an articulation of the synthesis. It then concludes with thoughts and questions on the value and relevance of the synthesis, the experience of conducting the synthesis and the partial way in which street-level bureaucracy theory has been used in the literature examined.

A new methodology for assessing health policy and systems research and analysis capacity in African universities.

BACKGROUND: The importance of health policy and systems research and analysis (HPSR+A) has been increasingly recognised, but it is still unclear how most effectively to strengthen the capacity of the different organisations involved in this field. Universities are particularly crucial but the expansive literature on capacity development has little to offer the unique needs of HPSR+A activity within universities, and often overlooks the pivotal contribution of capacity assessments to capacity strengthening. METHODS: The Consortium for Health Policy and Systems Analysis in Africa 2011-2015 designed and implemented a new framework for capacity assessment for HPSR+A within universities. The methodology is reported in detail. RESULTS: Our reflections on developing and conducting the assessment generated four lessons for colleagues in the field. Notably, there are currently no published capacity assessment methodologies for HPSR+A that focus solely on universities - we report a first for the field to initiate the dialogue and exchange of experiences with others. Second, in HPSR+A, the unit of assessment can be a challenge, because HPSR+A groups within universities tend to overlap between academic departments and are embedded in different networks. Third, capacity assessment experience can itself be capacity strengthening, even when taking into account that doing such assessments require capacity. CONCLUSIONS: From our experience, we propose that future systematic assessments of HPSR+A capacity need to focus on both capacity assets and needs and assess capacity at individual, organisational, and systems levels, whilst taking into account the networked nature of HPSR+A activity. A genuine partnership process between evaluators and those participating in an assessment can improve the quality of assessment and uptake of results in capacity strengthening.

Appealing to altruism: an alternative strategy to address the health workforce crisis in developing countries?

BACKGROUND: Recruitment and retention of health workers is a major concern. Policy initiatives emphasize financial incentives, despite mixed evidence of their effectiveness. Qualitative studies suggest that nurses especially may be more driven by altruistic motivations, but quantitative research has overlooked such values. This paper adds to the literature through characterizing the nature and determinants of nurses' altruism, based on a cross-country quantitative study. METHODS: An experimental 'dictator game' was undertaken with 1064 final year nursing students in Kenya, South Africa and Thailand between April 2007 and July 2008. This presents participants with a real financial endowment to split between themselves and another student, a patient or a poor person. Giving a greater share of this financial endowment to the other person is interpreted as reflecting greater altruism. RESULTS: Nursing students gave over 30% of their initial endowment to others (compared with 10% in similar experiments undertaken in other samples). Respondents in all three countries showed greater generosity to patients and the poor than to fellow students. CONCLUSIONS: Consideration needs to be given to how to appeal to altruistic values as an alternative strategy to encourage nurses to enter the profession and remain, such as designing recruitment strategies to increase recruitment of altruistic individuals who are more likely to remain in the profession.

Using stakeholder analysis to support moves towards universal coverage: lessons from the SHIELD project.

Stakeholder analysis is widely recommended as a tool for gathering insights on policy actor interests in, positions on, and power to influence, health policy issues. Such information is recognized to be critical in developing viable health policy proposals, and is particularly important for new health care financing proposals that aim to secure universal coverage (UC). However, there remain surprisingly few published accounts of the use of stakeholder analysis in health policy development generally, and health financing specifically, and even fewer that draw lessons from experience about how to do and how to use such analysis. This paper, therefore, aims to support those developing or researching UC reforms to think both about how to conduct stakeholder analysis, and how to use it to support evidence-informed pro-poor health policy development. It presents practical lessons and ideas drawn from experience of doing stakeholder analysis around UC reforms in South Africa and Tanzania, combined with insights from other relevant material. The paper has two parts. The first presents lessons of experience for conducting a stakeholder analysis, and the second, ideas about how to use the analysis to support policy design and the development of actor and broader political management strategies. Comparison of experience across South Africa and Tanzania shows that there are some commonalities concerning which stakeholders have general interests in UC reform. However, differences in context and in reform proposals generate differences in the particular interests of stakeholders and their likely positioning on reform proposals, as well as in their relative balance of power. It is, therefore, difficult to draw cross-national policy comparisons around these specific issues. Nonetheless, the paper shows that cross-national policy learning is possible around the approach to analysis, the factors influencing judgements and the implications for, and possible approaches to, management of policy processes. Such learning does not entail generalization about which UC reform package offers most gain in any setting, but rather about how to manage the reform process within a particular context.

How to start thinking about investigating power in the organizational settings of policy implementation.

Power, a concept at the heart of the health policy process, is surprisingly rarely explicitly considered in the health policy implementation literature for low and middle income countries. In an attempt to support empirical research on power, this paper outlines some of the key insights on power from implementation theory. It then describes examples of power that might be seen in health policy implementation settings, such as hospitals, clinics and the local bureaucracies in which these are embedded, and concludes with suggestions for ways of investigating power and ensuring sound judgments are made about its existence and its influence over policy implementation.