Browsing by Author "Marchal, Bruno"

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    A qualitative study of the dissemination and diffusion of innovations: bottom up experiences of senior managers in three health districts in South Africa
    (2019-03-29) Orgill, Marsha; Gilson, Lucy; Chitha, Wezile; Michel, Janet; Erasmus, Ermin; Marchal, Bruno; Harris, Bronwyn
    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.
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    Bottom-up innovation for health management capacity development: a qualitative case study in a South African health district
    (2021-03-24) Orgill, Marsha; Marchal, Bruno; Shung-King, Maylene; Sikuza, Lwazikazi; Gilson, Lucy
    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.
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    Strengthening district management as a key lever in health system strengthening: bottom up innovation in two district health systems in South Africa
    (2025) Orgill, Marsha; Gilson, Lucy; Marchal, Bruno
    It is widely recognised that the District Health System (DHS) is an effective vehicle for institutionalising Primary Health Care (PHC) - and establishing an effective DHS to improve access to health services has been an explicit South African government goal since 2003. Whilst there has been progress towards this goal, there have also been challenges. These include a persistent management skills' deficit at district level, in the context of an already under resourced health system. To address this challenge, the competencies of managers and the capabilities of management teams must be strengthened. Against this background, this PhD sought to understand how, why and in which contexts the capacity development of managers can be nurtured within the South African DHS, applying a bottom-up perspective considering district-level experience. More specifically, I sought to understand the processes, tactics and strategies within the DHS that trigger mechanisms to effect change in management capacity and support system strengthening. A South African national policy process offered the opportunity for this research. In 2012 - 2017, the National Department of Health piloted reforms toward National Health Insurance (NHI) in eleven health district pilot sites across the country, focusing on strengthening and re-engineering PHC. As part of this reform, the Minister of Health called for district management and leadership to be strengthened. The overarching methodology of the PhD was realist evaluation, and a case study design was used. An initial context mapping process allowed understanding the broader context of reform and supported the development of programme theories in each of two case study sites. The programme theories were then tested and refined through empirical research in each site. Through the cross-case analysis, I then refined my Middle Range Theory - the final product of a realist evaluation. Key findings include that senior DHS managers drew on their tacit knowledge, understanding of local context, formal training, and systems thinking and sensemaking skills to design innovations to develop the competencies and capabilities of managers and the capacity of structures in the district health system. From a bottom-up perspective, capacity development in health districts was an emergent process, that was led by district managers. It combined the natural diffusion of ideas and intentional efforts to delegate and disseminate a range of tasks and activities toward nurturing systemic capacity in the district. They worked only with existing resources. The managers used their positional authority and sensegiving skills (using carrots, sticks and sermons), to motivate staff and to develop individual, team and structural capacity. At the same time, prioritising management strengthening as part of nationally-led reforms stimulated systemic capacity development at the district level. Key lessons are that: management capacity development should be integrated within routine health system functioning; formal training should be complemented by workplace-based learning; training should enable managers to lead systemic capacity development, team development and broader system strengthening; and large-scale processes of health system strengthening must prioritise system capacity development within the DHS. Overall, this PhD contributes to the evidence base on how to nurture management and systemic capacity development within the district health system in less well-resourced contexts.