Everyday Politics and the Leadership of Health Policy Implementation.

This article aims to prompt reflection about the everyday politics of health systems, their importance to health policy implementation, and what sort of leadership, provided by whom, is required to address them. It is founded on insights drawn from empirical and theoretical literature, combined with practical experience developed through relevant research and teaching. Ultimately it argues that the everyday politics of the health system represent the multiple actors, interests, and choices that frontline leaders routinely address and that influence the collective action taken through the system in pursuit of public value. Leadership to address these everyday politics entails the practice of power and support for collective sense-making. Nurturing these political leadership skills through new forms of leadership development is therefore a vital component of health system development

Consortium for Health Policy & Systems Analysis in Africa

All CHEPSAA’s African members have produced reports that provide an overview of the HPSR+A capacity needs and assets in their organizations and its wider context. They each include recommendations about how to develop capacity. The assessment reports are from Ghana, South Africa, Tanzania, Kenya and Nigeria, and there are also comparative assessments with guidance on how to approach the needs assessment. CHEPSAA (the Consortium for Health Policy & Systems Analysis in Africa) works to develop the emerging field of health policy and systems research and analysis (HPSR+A) in Africa through harnessing synergies among a consortium of African and European universities

Does identity shape leadership and management practice? Experiences of PHC facility managers in Cape Town, South Africa.

In South Africa, as elsewhere, Primary Health Care (PHC) facilities are managed by professional nurses. Little is known about the dimensions and challenges of their job, or what influences their managerial practice. Drawing on leadership and organizational theory, this study explored what the job of being a PHC manager entails, and what factors influence their managerial practice. We specifically considered whether the appointment of professional nurses as facility managers leads to an identity transition, from nurse to manager. The overall intention was to generate ideas about how to support leadership development among PHC facility managers. Adopting case study methodology, the primary researcher facilitated in-depth discussions (about their personal history and managerial experiences) with eight participating facility managers from one geographical area. Other data were collected through in-depth interviews with key informants, document review and researcher field notes/journaling. Analysis involved data triangulation, respondent and peer review and cross-case analysis. The experiences show that the PHC facility manager's job is dominated by a range of tasks and procedures focused on clinical service management, but is expected to encompass action to address the population and public health needs of the surrounding community. Managing with and through others, and in a complex system, requiring self-management, are critical aspects of the job. A range of personal, professional and contextual factors influence managerial practice, including professional identity. The current largely facility-focused management practice reflects the strong nursing identity of managers and broader organizational influences. However, three of the eight managers appear to self-identify an emerging leadership identity and demonstrate related managerial practices. Nonetheless, there is currently limited support for an identity transition towards leadership in this context. Better support for leadership development could include talent-spotting and nurturing, induction and peer-mentoring for newly appointed facility managers, ongoing peer-support once in post and continuous reflective practice

Influence of organisational culture on the implementation of health sector reforms in low- and middle-income countries: a qualitative interpretive review.

BACKGROUND: Health systems, particularly in low- and middle-income countries, are commonly plagued by poor access, poor performance, inefficient use and inequitable distribution of resources. To improve health system efficiency, equity and effectiveness, the World Development Report of 1993 proposed a first wave of health sector reforms, which has been followed by further waves. Various authors, however, suggest that the early reforms did not lead to the anticipated improvements. They offer, as one plausible explanation for this gap, the limited consideration given to the influence over implementation of the software aspects of the health system, such as organisational culture - which has not previously been fully investigated. OBJECTIVE: To identify, interpret and synthesise existing literature for evidence on organisational culture and how it influences implementation of health sector reforms in low- and middle-income countries. METHODS: We conducted a systematic search of eight databases: PubMed; Africa-Wide Information, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Econlit, PsycINFO, SocINDEX with full text, Emerald and Scopus. Eight papers were identified. We analysed and synthesised these papers using thematic synthesis. RESULTS: This review indicates the potential influence of dimensions of organisational culture such as power distance, uncertainty avoidance, and in-group and institutional collectivism over the implementation of health sector reforms. This influence is mediated through organisational practices such as communication and feedback, management styles, commitment and participation in decision-making. CONCLUSION: This interpretive review highlights the dearth of empirical literature around organisational culture and therefore its findings can only be tentative. There is a need for health policymakers and health system researchers to conduct further analysis of organisational culture and change within the health system

Exploring how different modes of governance act across health system levels to influence primary healthcare facility managers' use of information in decisionmaking: experience from Cape Town, South Africa

BACKGROUND: Governance, which includes decision-making at all levels of the health system, and information have been identified as key, interacting levers of health system strengthening. However there is an extensive literature detailing the challenges of supporting health managers to use formal information from health information systems (HISs) in their decision-making. While health information needs differ across levels of the health system there has been surprisingly little empirical work considering what information is actually used by primary healthcare facility managers in managing, and making decisions about, service delivery. This paper, therefore, specifically examines experience from Cape Town, South Africa, asking the question: How is primary healthcare facility managers’ use of information for decision-making influenced by governance across levels of the health system? The research is novel in that it both explores what information these facility managers actually use in decision-making, and considers how wider governance processes influence this information use. METHODS: An academic researcher and four facility managers worked as co-researchers in a multi-case study in which three areas of management were served as the cases. There were iterative cycles of data collection and collaborative analysis with individual and peer reflective learning over a period of three years. RESULTS: Central governance shaped what information and knowledge was valued – and, therefore, generated and used at lower system levels. The central level valued formal health information generated in the district-based HIS which therefore attracted management attention across the levels of the health system in terms of design, funding and implementation. This information was useful in the top-down practices of planning and management of the public health system. However, in facilities at the frontline of service delivery, there was a strong requirement for local, disaggregated information and experiential knowledge to make locally-appropriate and responsive decisions, and to perform the people management tasks required. Despite central level influences, modes of governance operating at the subdistrict level had influence over what information was valued, generated and used locally. CONCLUSIONS: Strengthening local level managers’ ability to create enabling environments is an important leverage point in supporting informed local decision-making, and, in turn, translating national policies and priorities, including equity goals, into appropriate service delivery practices.ISIScopu

Workplace-based learning for health system leaders: practical strategies for training institutions and governments

RESYST members Jane Doherty and Lucy Gilson have published a report following a three-day consultative workshop in Cape Town. The workshop brought together 35 leadership training experts from a range of institutions to enhance the capacity and capabilities of the people and systems engaged in leadership development. "Fast-changing and unpredictable health systems require creative, intelligent and resilient leaders" The norm in leadership training is formal, residential training programmes which face a number of limitations and can be disruptive to service delivery. The participants brainstormed how training institutions and governments can better support public health sector leaders to realise their leadership potential through enabling learning in the workplace. The report addresses several questions including: - What are the key challenges faced by leaders trying to operate effectively in the public health sectors of their own countries? - What type of leadership does the public health sector need? - What tools and approaches can best to support workplace-based learning? -How can we make workplace-based training sustainable? The informal report is intended to generate excitement for designing and supporting workplace-based learning in low- and middle-income country settings. It also includes detailed sections outlining experiences, strategies, critical reflections and recommended techniques that were discussed during the workshop. The report also recommends useful resources for further development

What Is Resilience and How Can It Be Nurtured? A Systematic Review of Empirical Literature on Organizational Resilience.

BACKGROUND: Recent health system shocks such as the Ebola outbreak of 2014-2016 and the global financial crisis of 2008 have generated global health interest in the concept of resilience. The concept is however not new, and has been applied to other sectors for a longer period of time. We conducted a review of empirical literature from both the health and other sectors to synthesize evidence on organizational resilience. METHODS: We systematically searched for literature in PubMed, Econlit, EBSCOHOST databases, google, and Google Scholar and manually searched the reference lists of selected papers. We identified 34 papers that met our inclusion criteria. We analysed data from the selected papers by thematic review. RESULTS: Resilience was generally taken to mean a system's ability to continue to meet its objectives in the face of challenges. The concepts of resilience that were used in the selected papers emphasized not just a system's capacity to withstand shocks, but also to adapt and transform. The resilience of organizations was influenced by the following factors: Material resources, preparedness and planning, information management, collateral pathways and redundancy, governance processes, leadership practices, organizational culture, human capital, social networks and collaboration. CONCLUSION: A common theme across the selected papers is the recognition of resilience as an emergent property of complex adaptive systems. Resilience is both a function of planning for and preparing for future crisis (planned resilience), and adapting to chronic stresses and acute shocks (adaptive resilience). Beyond resilience to acute shocks, the resilience of health systems to routine and chronic stress (everyday resilience) is also key. Health system software is as, if not more important, as its hardware in nurturing health system resilience

Advancing the application of systems thinking in health: South African examples of a leadership of sensemaking for primary health care

BACKGROUND: New forms of leadership are required to bring about the fundamental health system changes demanded by primary health care (PHC). Using theory about complex adaptive systems and policy implementation, this paper considers how actors' sensemaking and the exercise of discretionary power currently combine to challenge PHC re-orientation in the South African health system; and provides examples of leadership practices that promote sensemaking and power use in support of PHC. METHODS: The paper draws on observational, interview, and reflective data collected as part of the District Innovation and Action Learning for Health Systems Development (DIALHS) project being implemented in Cape Town, South Africa. Undertaken collaboratively between health managers and RESEARCHERS, the project is implemented through cycles of action-learning, including systematic reflection and synthesis. It includes a particular focus on how local health managers can better support front line facility managers in strengthening PHC. RESULTS: The results illuminate how the collective understandings of staff working at the primary level - of their working environment and changes within it - act as a barrier to centrally-led initiatives to strengthen PHC. Staff often fail to take ownership of such initiatives and experience them as disempowering. Local area managers, located between the centre and the service frontline, have a vital role to play in providing a leadership of sensemaking to mediate these challenges. Founded on personal values, such leadership entails, for example, efforts to nurture PHC-aligned values and mind-sets among staff; build relationships and support the development of shared meanings about change; instil a culture of collective inquiry and mutual accountability; and role-model management practices, including using language to signal meaning. CONCLUSIONS: PHC will only become a lived reality within the South African health system when frontline staff are able to make sense of policy intentions and incorporate them into their everyday routines and practices. This requires a leadership of sensemaking that enables front line staff to exercise their collective discretionary power in strengthening PHC. We hope this theoretically-framed analysis of one set of experiences stimulates wider thinking about the leadership needed to sustain primary health care in other settings.The DIAHLS project is funded by the Atlantic Philanthropies. This paper was prepared with support from the Collaboration for Health Systems, Analysis and Innovation’ and is part of the Thematic Series entitled: “Advancing the application of systems thinking in health”. The Series was coordinated by the Alliance for Health Policy and Systems research, World Health Organization. The publication of the Series and the associated capacity building and dissemination activities were carried out with the aid of a grant from the International Development Research Centre, Ottawa, Canada.Web of Scienc