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Open Access 01-12-2021 | Research article

Bottom-up innovation for health management capacity development: a qualitative case study in a South African health district

Authors: Marsha Orgill, Bruno Marchal, Maylene Shung-King, Lwazikazi Sikuza, Lucy Gilson

Published in: BMC Public Health | Issue 1/2021

Abstract

Background

As part of health system strengthening in South Africa (2012–2017) a new district health manager, taking a bottom-up approach, developed a suite of innovations to improve the processes of monthly district management team meetings, and the practices of managers and NGO partners attending them. Understanding capacity as a property of the health system rather than only of individuals, the research explored the mechanisms triggered in context to produce outputs, including the initial sensemaking by the district manager, the subsequent sensegiving and sensemaking in the team and how these homegrown innovations interacted with existing social processes and norms within the system.

Methods

We conducted a realist evaluation, adopting the case study design, over a two-year period (2013–2015) in the district of focus. The initial programme theory was developed from 10 senior manager interviews and a literature review. To understand the processes and mechanisms triggered in the local context and identify outputs, we conducted 15 interviews with managers in the management team and seven with non-state actors. These were supplemented by researcher notes based on time spent in the district. Thematic analysis was conducted using the Context-Mechanism-Outcome configuration alongside theoretical constructs.

Results

The new district manager drew on systems thinking, tacit and experiential knowledge to design bottom-up innovations. Capacity was triggered through micro-practices of sensemaking and sensegiving which included using sticks (positional authority, enforcement of policies, over-coding), intentionally providing justifications for change and setting the scene (a new agenda, distributed leadership). These micro-practices in themselves, and by managers engaging with them, triggered a generative process of buy-in and motivation which influenced managers and partners to participate in new practices within a routine meeting.

Conclusion

District managers are well placed to design local capacity development innovations and must draw on systems thinking, tacit and experiential knowledge to enable relevant ‘bottom-up’ capacity development in district health systems. By drawing on soft skills and the policy resources (hardware) of the system they can influence motivation and buy-in to improve management practices. From a systems perspective, we argue that capacity development can be conceived of as part of the daily activity of managing within routine spaces.

Available only for authorised users

In the larger project, we selected 3 of the 11 NHI pilot sites based on the following criteria: (1) a district that was actively receiving information from other levels of government and/or was implementing some of the innovations, (2) access to the site, meaning district managers were prepared to give us access to staff and (3) rural/urban mix to capture variation in experiences of implementation possibly linked to geography (f40

et al., 2019).

As part of another innovation in the district some hospital managers were being replaced in their current job due to new job requirements, they were not removed from the payroll or from the district.

These were not new formal posts on the organogram but rather a description of the duties they were expected to fulfil.

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Title: Bottom-up innovation for health management capacity development: a qualitative case study in a South African health district
Authors: Marsha Orgill
Bruno Marchal
Maylene Shung-King
Lwazikazi Sikuza
Lucy Gilson
Publication date: 01-12-2021
Publisher: BioMed Central
Published in: BMC Public Health / Issue 1/2021
Electronic ISSN: 1471-2458
DOI: https://doi.org/10.1186/s12889-021-10546-w

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Bottom-up innovation for health management capacity development: a qualitative case study in a South African health district

Abstract

Background

Methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

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