Beyond adoption: A new framework for theorising and evaluating Non-adoption, Abandonment and challenges to Scale-up, Spread and Sustainability (NASSS) of health and care technologies

© 2017 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.Background: Many promising technological innovations in health and social care are characterized by nonadoption or abandonment by individuals or by failed attempts to scale up locally, spread distantly, or sustain the innovation long term at the organization or system level. Objective: Our objective was to produce an evidence-based, theory-informed, and pragmatic framework to help predict and evaluate the success of a technology-supported health or social care program. Methods: The study had 2 parallel components: (1) secondary research (hermeneutic systematic review) to identify key domains, and (2) empirical case studies of technology implementation to explore, test, and refine these domains. We studied 6 technology-supported programs—video outpatient consultations, global positioning system tracking for cognitive impairment, pendant alarm services, remote biomarker monitoring for heart failure, care organizing software, and integrated case management via data sharing—using longitudinal ethnography and action research for up to 3 years across more than 20 organizations. Data were collected at micro level (individual technology users), meso level (organizational processes and systems), and macro level (national policy and wider context). Analysis and synthesis was aided by sociotechnically informed theories of individual, organizational, and system change. The draft framework was shared with colleagues who were introducing or evaluating other technology-supported health or care programs and refined in response to feedback. Results: The literature review identified 28 previous technology implementation frameworks, of which 14 had taken a dynamic systems approach (including 2 integrative reviews of previous work). Our empirical dataset consisted of over 400 hours of ethnographic observation, 165 semistructured interviews, and 200 documents. The final nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) framework included questions in 7 domains: the condition or illness, the technology, the value proposition, the adopter system (comprising professional staff, patient, and lay caregivers), the organization(s), the wider (institutional and societal) context, and the interaction and mutual adaptation between all these domains over time. Our empirical case studies raised a variety of challenges across all 7 domains, each classified as simple (straightforward, predictable, few components), complicated (multiple interacting components or issues), or complex (dynamic, unpredictable, not easily disaggregated into constituent components). Programs characterized by complicatedness proved difficult but not impossible to implement. Those characterized by complexity in multiple NASSS domains rarely, if ever, became mainstreamed. The framework showed promise when applied (both prospectively and retrospectively) to other programs.Peer reviewe

Workforce planning and development in times of delivery system transformation

Background As implementation of the US Affordable Care Act (ACA) advances, many domestic health systems are considering major changes in how the healthcare workforce is organized. The purpose of this study is to explore the dynamic processes and interactions by which workforce planning and development (WFPD) is evolving in this new environment. Methods Informed by the theory of loosely coupled systems (LCS), we use a case study design to examine how workforce changes are being managed in Kaiser Permanente and Montefiore Health System. We conducted site visits with in-depth interviews with 8 to 10 stakeholders in each organization. Results Both systems demonstrate a concern for the impact of change on their workforce and have made commitments to avoid outsourcing and layoffs. Central workforce planning mechanisms have been replaced with strategies to integrate various stakeholders and units in alignment with strategic growth plans. Features of this new approach include early and continuous engagement of labor in innovation; the development of intermediary sense-making structures to garner resources, facilitate plans, and build consensus; and a whole system perspective, rather than a focus on single professions. We also identify seven principles underlying the WFPD processes in these two cases that can aid in development of a new and more adaptive workforce strategy in healthcare. Conclusions Since passage of the ACA, healthcare systems are becoming larger and more complex. Insights from these case studies suggest that while organizational history and structure determined different areas of emphasis, our results indicate that large-scale system transformations in healthcare can be managed in ways that enhance the skills and capacities of the workforce. Our findings merit attention, not just by healthcare administrators and union leaders, but by policymakers and scholars interested in making WFPD policies at a state and national level more responsive

Assessment of the influence of sustainable development goals declaration on health financing reforms for universal health coverage in Uganda : A stakeholders’ perspective

Thesis (PhD (Health Systems))--University of Pretoria, 2023.Background Achieving universal health coverage (UHC) requires health financing reforms (HFR) in many countries. Health Financing Reforms are inherently political. The sustainable development goals (SDG) declaration provides a global political commitment that can potentially influence HFR for UHC at national level. However, how the declaration has influenced HFR discourse at the national level and how ministries of health and other stakeholders are using the declaration to influence reforms towards UHC were yet to be explored. Therefore, this thesis explored how SDG declaration has influenced health financing reforms for UHC in Uganda and proposed a framework for examining such complex processes needing multidisciplinary lens of health systems financing, health policy analysis and policy transfers. Aims and objectives This thesis aimed at exploring the influence of the SDG declaration on health financing reforms in Uganda, and to develop a theory of change for desired health financing reforms for UHC. The study objectives were: - i. Exploring changes in health system financing towards UHC in Uganda between financial years 2000/2001 and 2019/2020. ii. Examining how the SDG declaration has influenced health financing reforms for UHC in Uganda. iii. Identifying factors that have facilitated or inhibited SDGs declaration in influencing health financing reforms for UHC in Uganda iv. Developing a theory of change on how the SDG declaration influence health financing reforms for UHC. Methods This was an exploratory and explanatory qualitative study using a case study approach, with Uganda being the case. Detailed literature reviews were conducted and in doing literature reviews, document review guides were used for data collection. Key informant interviews (KIIs) with purposely selected respondents were also conducted to enrich the findings from the literature reviews and to refine the theory of change. Relevant theories, frameworks, and concepts especially Kutzin’s health financing conceptual framework, Dolowitz and Marsh policy transfer theory and concepts from health policy analyses guided data collection and analysis. Results Uganda has had a variation in the focus of health financing policy objectives over the four strategic plan periods running between 2000/2001 and 2019/2020 financial years, from equity and mobilizing more funding to financial risk protection and UHC. The variation in policy intentions over the four strategic plan periods were informed by low level of national health sector funding, global level discussions on SDGs and UHC, and financing reform discourse focusing on establishing a National Health Insurance Fund (NHIF). However, policy objectives were not followed by the necessary structural changes in the organization of the health financing functions and thus the health financing organization architecture have not changed much over the years. Some reforms such as the abolition of user fees in public health facilities, development of National Minimum Health Care Package (NMHCP) as the benefits package, Sector Wide Approach (SWAp), movement towards performance-based financing were noticeable. The policy objective statements, and the reforms were generally aligned to World Health Organization (WHO) policy principles of reforms that advance UHC. However, given the limited structural changes in health system financing there have been very subtle progress in terms of improvement in financial risk protection. Furthermore, there have been limited studies on global to national policy transfers especially in the health sector and particular on health financing reforms. Majority of studies on health financing reforms in Uganda have focused on the technical aspects using rather rigid health financing conceptual frameworks for analysis that do not cover aspects of policy transfers. On how the SDG declaration is influencing health financing reforms in Uganda, the declaration has raised and sustained the issue of health financing high on the national agenda and provided a framework for development of policies such as national UHC roadmap and health financing strategy 2016. The declaration has also energized the process of developing National Health Insurance Fund (NHIF), with a number of stakeholders who are not traditionally involved in health financing discussion showing interest. Civil Society and Professional Associations are using the SDG declaration as a tool for engagement with other stakeholders as they seek support for health financing reforms towards UHC with a focus on NHIF. Factors favouring the SDG declaration to influence health financing reforms in Uganda include the high media attention and the reporting requirement on countries. These ensure there is continuous discussion on health financing in relation to SDGs. Having a specific indicator on UHC and therefore health financing in the declaration has also ensured the SDG declaration continues to influence the health financing discourse at the national level. Other factors include strong partnership between MOH and other stakeholders, and development partners’ support. However, the push for reforms in health financing for UHC based on the SDG declaration is tempered by factors such as limited fiscal space for health as reforms require funding, lack of relevant recent evidence grounded in country data and complexity of the health financing issues which are not well understood by the general population and other key stakeholder groups. Conclusion The SDG declaration has influenced health financing reforms in Uganda with national policy intentions aligning with proven global policy principles. However, much needs to be done to go beyond aligning policy principles to proven global reform principles to ensuring there is commensurate changes in health financing system architecture and functions. Previous reforms can provide lessons for better adaptation of the global health financing reform principles that advance UHC. In addition, use of theory-driven frameworks such as the theory of change (TOC) can provide a more comprehensive set of information to support reform drivers to design appropriate strategies for engaging stakeholders for buy-in and development of context appropriate policies.School of Health Systems and Public Health (SHSPH)PhD (Health Systems)Unrestricte

"We had to manage what we had on hand, in whatever way we could": Adaptive responses in policy for decentralised drug-resistant tuberculosis care in South Africa

Karina Kielmann - ORCID: 0000-0001-5519-1658 https://orcid.org/0000-0001-5519-1658Replaced AM with VoR 2021-02-19.In 2011, the South African National TB Programme launched a policy of decentralized management of drug-resistant tuberculosis (DR-TB) in order to expand the capacity of facilities to treat patients with DR-TB, minimize delays to access care and improve patient outcomes. This policy directive was implemented to varying degrees within a rapidly evolving diagnostic and treatment landscape for DR-TB, placing new demands on already-stressed health systems. The variable readiness of district-level systems to implement the policy prompted questions not only about differences in health systems resources but also front-line actors’ capacity to implement change in resource-constrained facilities. Using a grounded theory approach, we analysed data from indepth interviews and small group discussions conducted between 2016 and 2018 with managers (n = 9), co-ordinators (n = 15), doctors (n = 7) and nurses (n = 18) providing DR-TB care. Data were collected over two phases in district-level decentralized sites of three South African provinces. While health systems readiness assessments conventionally map the availability of ‘hardware’, i.e. resources and skills to deliver an intervention, a notable absence of systems ‘hardware’ meant that systems ‘software’, i.e. health care workers (HCWs) agency, behaviours and interactions provided the basis of locally relevant strategies for decentralized DR-TB care. ‘Software readiness’ was manifest in four areas of DR-TB care: re-organization of service delivery, redressal of resource shortages, creation of treatment adherence support systems and extension of care parameters for vulnerable patients. These strategies demonstrate adaptive capacity and everyday resilience among HCW to withstand the demands of policy change and innovation in stressed systems. Our work suggests that a useful extension of health systems ‘readiness’ assessments would include definition and evaluation of HCW ‘software’ and adaptive capacities in the face of systems hardware gaps.The work presented in this paper was supported by the Joint Health Systems Research Initiative, jointly supported by the Department for International Development (DFID), the Economic and Social Research Council (ESRC), the Medical Research Council (MRC) and the Wellcome Trust (Grant# MR/N015924/1). This UK funded award is part of the EDCTP2 programme supported by the European Union. Ethical approval for the project was obtained through the University of Cape Town Human Research Ethics Committee (HREC REF 350/2016). HC is supported by a Wellcome Trust Fellowship. The authors wish to thank and acknowledge Dr. Norbert Ndjeka (SA NDOH), the provinces of the W Cape, E Cape, KZN for all their input and assistance.https://doi.org/10.1093/heapol/czaa14736pubpub

Dialectics of Efficient Change Management in the Regional Social Systems

The research has placed emphasis on the role of the social infrastructure sectors, providing social services, which facilitate human potential development in a modern state. Theoretical positions of the scientist considering the nature of social benefits and necessity of the government support for the social sphere has been summarized in the article. The state of the Russian social infrastructure sectors has been considered and the analysis of their performance compared to these of the social infrastructure sectors in other countries has been conducted in the research work. Taking into consideration the performance ratings of the effectiveness of the national education systems, the countries around the world concerning the effectiveness of the health system, the countries around the world concerning the social development level in 2014, the authors have proposed the conceptual approach that makes it possible to consider the correlation and interrelation of the level of the government financing of the social sphere and the dynamics of the contribution of social infrastructure sectors in the development of the human capital, ensuring the gross domestic product increase. The necessity of making innovative changes in the socio-economic systems of the social infrastructure sectors, to improve their performance, taking into account the results obtained, in the first place, in health care, has been wellgrounded and theoretical approaches to the changes management in the socio-economic systems has been studied in the article. The theoretical approaches to the changes management in the socio-economic systems have been studied by the authors. Based on the conducted studies and the formed theoretical basis for improving the level of changes management in open socio-economic systems, for the purpose of development of the theoretical and methodological approaches to changes management as applied to health care sphere, optimization model of management of health care organizations by way of ranking of manageable and unmanageable changes has been proposed. The possibility of using management optimization by way of ranking of manageable and unmanageable changes in the health care management at different levels has been confirmed with high-performance indicators at the micro-, meso- and macro levels in the sector, by the example of implementation of the national project “Health” and innovative organizational changes facilitating the return to work of patients of the working age, which are involved in the gross domestic product formation in the city of Yekaterinburg.The article has been prepared with the support of the Russian Science Foundation grant No. 14-18-00456 “Support of geoecosocioeconomic approach to development of strategic nature resources capacity of the low-studied northern territories within the investment project “Arctic — Central Asia”

On people, data and systems : perspectives on routine health data processing and its digitalization in Tanzania

Background: Facility-based routine health information is captured in health management information systems by health care providers and is the main data source for health system planning and outcome monitoring in Tanzania and other low- and middle-income countries. While this system is fully digitalized in high-income countries, it is still partly paper-based in others. These use i) facility registers, ii) daily tally sheets and iii) monthly summary forms, which are later entered into the District Health Information System-2 software. These hybrid systems are prone to errors related to i) data entry, ii) calculation and iii) data transfer, with negative implications for data completeness and availability. The unavailability of data and lack of trust in its quality may lead to low data use for resource forecasting and planning, especially at subnational and facility levels. Through automatization of data processing, digital technology may be able to address these challenges, making it especially attractive in settings with high disease burdens and few resources. One example of a promising digital solution for low-resource settings is Smart Paper Technology, which produces automated electronic registers and summary reports by scanning bar-coded forms from individual service encounters. Implementation research, however, suggests a complex interplay between the implementation environment and the introduction and sustained institutionalization of technology. The aim of this thesis was to understand the social practices involved in generating and processing routine maternal and newborn health data, using paper-based and digital tools within the health management information system in Tanzania. Smart Paper Technology and the current health management information system with its different digital components are used for evaluation. Study I had the objective of understanding health care providers’ and facility/district managers’ perceptions of Smart Paper Technology and to assess time spent on documentation with the new system. A time-motion study, before and after the introduction of the technology, was applied together with eight focus group discussions with 18 health care providers from three health facilities and 11 in-depth interviews with healthcare managers from one district authority. Quantitative data was analyzed using descriptive statistics and bivariable modelling. Reflexive thematic analysis was used to analyze qualitative data. Findings illustrate challenges to Smart Paper Technology implementation related to pre-existing health system bottlenecks, e.g. lack of human resources, supervision and transport, but also a difference in values assigned to the new system by health care providers and their managers. Health care providers found Smart Paper Technology useful and applicable to their context with perceived benefits for documentation and clinical care. These experiences were confirmed by quantitative data, showing no significant difference between time spent on overall documentation pre- and post-introduction of Smart Paper Technology (27 vs 26 %, adjusted p 0.763) but an increase in time spent on clinical tasks (26.9 vs 37.1%, adjusted p 0.001). Health care managers, in contrast, found it difficult to identify benefits from the new technology for their own work related to national reporting, due to access problems with the digital dashboard and questionable quality of Smart Paper Technology data. They therefore continued to focus managerial efforts on the existing health management information system. Study II’s objective was to assess the quality of Smart Paper Technology data for maternal care services related to i) completeness and timeliness and ii) internal consistency. A cross-sectional survey over 12 months was performed in 13 health facilities using data from the Smart Paper Technology system and District Health Information System-2. Descriptive statistics were produced based on indicators derived from the World Health Organization’s Data Quality Review Toolkit. Results show that data quality of the Smart Paper Technology system was not superior to that of the pre-existing health management information system overall. This may be linked to the effects of duplicate data entry on health care provider performance and consequently on data completeness. Smart Paper Technology performed slightly better in some aspects of internal consistency: Fewer health facilities produced only one or two outliers with Smart Paper Technology in each month of the study period (antenatal care=4, care during labour = 6, postnatal care =4) than with the District Health Information System-2 (antenatal care= 7, care during labour= 9, postnatal care= 6). Smart Paper Technology also yielded higher consistency for the documented postpartum use of oxytocin in relation to the number of documented deliveries with 62% of facilities showing a less than 10% difference between these indicators as opposed to 38% for the District Health Information System-2. However, the pre-existing system demonstrated better data quality in all other quality dimensions, i.e. data completeness, timeliness and consistency of data trends over the study period. Study III: The objective was to improve understanding about the processes involved in health care providers’ data use; which type of information is used together with health management information system data and for what purposes. A constructivist grounded theory-based ethnographic approach was applied, consisting of i) 14 in-depth interviews with health care providers from maternity wards in two hospitals, as well as ii) 48 hours of observation in the maternity wards and ii) two focus group discussions with 11 health care providers from the same hospitals. Findings illustrate how health care providers appropriated numeric data from the official health management information system and narrative data that they had produced for clinical documentation to safeguard social relationships with superiors, patients and the community they served. While they identified themselves as data collectors and not users of the health management information system, they applied narrative clinical documentation systems to service improvement and to protect themselves against litigation or managerial reprimands. Study IV’s objective was to generate knowledge on experiences and perceptions of health care policymakers in Tanzania related to data, data systems and the implementation of digital technology to support health information management. 16 in-depth interviews with healthcare managers from national and subnational levels were conducted and analyzed using reflexive thematic analysis. Results suggest that the health management information system in Tanzania is governed using institutional and discretionary power. Institutional power was mainly used at the national level to conceptualize data collection and processing systems and the scale-up of digitalization. Discretionary power was mainly used for implementation at subnational level. The use of different power practices was influenced by available funding and health care managers’ perception that health care providers, the primary data collectors, lack motivation to perform and are unpredictable in their actions regarding the continuous production of good data quality. Conclusions: Acceptance or rejection of digital technology was influenced to a considerable extent by social practices at all levels of the health system. These included actors’ perceived benefits of maintaining existing social practices. These practices, which are part of an organization’s culture related to data and data processes, require attention during the conceptualization and implementation of health information systems. Numeric and contextual information is used concomitantly at various levels of Tanzania’s health management information system. The health management information system in Tanzania forms a complex adaptive system with inherently high levels of unpredictability, non-linearity, self-organization and adaptation over time. Health care managers’ power practices in the conceptualization and implementation of policies reflect this complexity. Contextual factors affect digital technology integration and have consequences for data quality and use of digital AND paper-based health management information systems. Context may therefore be even more important than the format and technology of data collection and processing

Multicultural Organizational Development: A Resource for Health Equity

Discusses ways to develop the multicultural capacity of health organizations, based on theories from the behavioral sciences that have been applied to organizational management

What we have learned about policy-research linkage from providing a rapid response facility for international healthcare comparisons to the Department of Health in England

In this paper we reflect on our experience of providing a rapid response facility for international healthcare policy comparisons to the English Department of Health. We examine the challenges of developing sustained relationships with policy officials while providing an 'on-demand' service in an environment with high turnover of policies and staff. It may be easier for policy makers to draw on researchers in such a setting than for researchers to foster 'linkage and exchange' relationships with policy makers. Under the facility, knowledge transfer has mostly been from researchers to policy officials, affording us little insight into the policy process or the impact of our work

Clinical governance and nursing : a sociological analysis

The primary focus for this Thesis is an account of the degree to which nurses and other stakeholders in one National Health Service hospital Trust have responded to the ‘clinical governance’ initiative, the effects on quality improvement and professional regulation and the practical accomplishment of legitimacy. ‘Clinical governance’ involves demonstrating that quality assurance is routine practice within every healthcare organization. A case study was undertaken, using broadly ethnographic methods. The qualitative data were obtained by documentary analysis, non-participant observation of meetings and day-to-day ward activity and semi-structured interviews. In terms of the analysis of documents and observation of meetings, new institutionalism theory was found to be useful as a framework for understanding the political and ceremonial conformity that marked the clinical governance process. Errors and inconsistencies were found in formal documentation and the Trusts’ reporting systems were fraught with problems. Nevertheless, during the same period the Trust obtained national recognition for having appropriate structures and systems in place in relation to clinical governance. A grounded theory approach was adopted in the analysis of the semi-structured interviews. Emerging themes from interview data were identified under the main categories of: ‘Making Sense,’ ‘Knowledge Construction,’ ‘Somebody Else’s Job’ and ‘Real Work.’ It was concluded that at a practice level, clinical governance was poorly understood and that the corporate organizational goals were ambiguous and seen as unrealistic on a day-to-day basis. The study concludes that what is happening is not a ‘failure’ but an unintended consequence that has resulted from an inadequate understanding of how organizations work. It is suggested that the organization has conformed to the appropriate standards in order to survive legitimately, but the ultimate impact of clinical governance on the quality of care in practice is inconsistent.EThOS - Electronic Theses Online ServiceGBUnited Kingdo