Evaluating Systems-Thinking for District Managers: Ghana

Author(s) Aku Kwamie1, Han van Dijk2, Irene Agyepong3.
Affiliation(s) Health Policy, Planning and Management, University of Ghana, School of Public Health, Accra, Ghana, Anthropology and Sociology of Development, Wageningen University, Utrecht, Netherlands, Health Policy, Planning and Management, University of Ghana, School of Public Health, Accra, Ghana.
Country - ies of focus Ghana
Relevant to the conference tracks Health Workforce
Summary This presentation examines a management and leadership capacity strengthening intervention for district health managers in the Greater Accra Region of Ghana. It is based on the continuous quality improvement philosophy. In particular, the study's interest was in whether the intervention supports the development of systems-thinking in district managers in order to enhance their decision-making in implementing policies and organizing service delivery at district level. We undertook a realist evaluation in order to understand the mechanisms of the how the intervention worked given the context in which the intervention was introduced.
Background Across district health systems in low and middle income countries, district managers have the integrative role of interfacing between national-level policy formulation, and ensuring policy implementation at facility level. In aiming to strengthen health systems to better deliver services, weaknesses in district-level management and leadership capacities are often cited as bottlenecks to achieving health outcomes. Leadership and management are critical, complex functions of any health system. While there is widespread agreement on the need to strengthen these capacities for more effective health systems and better decision-making, there is limited understanding as to how such capacity strengthening interventions work. This is particularly true at the district level. To date, studies on management and leadership capacity strengthening in low and middle income country health systems have focused on skills acquisition and few have focused on the mechanisms of how such interventions work. There is a need to better understand the dynamics of district health system leadership and management in order to better strengthen them.
Objectives District managerial decision-making takes place in complex contexts, and thus capacity strengthening approaches must recognize systems theory and complexity. Continuous quality improvement is a management philosophy which supports both management processes and structures. Continuous quality improvement philosophy is based on the assumption that problems within the organization are not clinically, nor administratively rooted, but rather are systemic, and arise out of a structural inability to perform as intended. The systems-thinking perspectives of continuous quality improvement require an ability to analytically integrate the relationships, linkages and interactions at play among actors within the system which influence the capacity to perform. However, continuous quality improvement has two paradoxical goals inherent within it: while it focuses on controls, uniformity and standards, it is also focused on creativity, learning and organizational cultural change. The goal which dominates any continuous quality improvement process will depend on the degree of contextual uncertainty in the system into which it is introduced.
Continuous quality improvement has as its prime objective the establishment of quality as a key priority in management practice, to shift management’s role to one of creating a system able to produce quality outcomes, and to empower staff to make decisions. Previous work in Ghana has indicated the potential for implementing continuous quality improvement within the health system. Thus the objectives of this paper are to understand: (a) how and why a leadership and management intervention based on continuous quality improvement influences district manager decision-making; (b) whether the intervention leads to increased systems-thinking in district managers; and (c) by which mechanism the observed outcomes of the intervention are brought about.
Methodology We undertook a realist evaluation to investigate the mechanisms of the intervention, and the contexts in which the mechanisms are triggered. Realist evaluation moves towards a more generative perspective on “how did the intervention work, for whom, and in which contexts”, thereby integrating theories of causality with the actors and structures involved in a given system. Beginning with two working hypotheses to be tested, we built an explanatory case study of one rural district in the Greater Accra Region of Ghana where the intervention was introduced. The first theory hypothesized systems-thinking as the means for organizational change (through a mechanism of control). The second theory hypothesized systems-thinking as the ends of organizational change (through a mechanism of learning). Data collection included participant observation, document review and semi-structured interviews with district managers prior to, during, and after the intervention. District managers were defined as (i) members of the district health management team, including the district director of health services, (ii) members of the district hospital management team, and (iii) members of the three sub-district health teams. These managers were selected because, within the district, they represent the top-management for decision-making for organization and delivery of services. Interviews were also conducted with members of the regional facilitation team. The intervention consisted of a six-month cycle, where district teams made up of managers and staff came together in the capital city Accra three times on a bi-monthly schedule for face-to-face two-day workshops with the facilitation team. Face-to-face workshops were interspersed by monthly coaching visits; facilitators attended teams in their facilities with their broader staff to ensure that practices that had been taught to the core teams had been dispersed organization-wide. Working backwards from the observed immediate outcomes of the intervention, and examining the intermediate outcomes since the end of the intervention, we systematically built a causal map linking the outcomes and contexts to potential mechanisms of the intervention.
Results District managers had little prior training in management, and most learnt their management roles on the job. District managers faced serious time constraints due to ‘crash programmes’, the concurrent scheduling of training workshops and meetings programmed by various vertical programme units from the regional level. There was little evidence of integration of the intervention practices amongst the teams. The lack of institutionalization was influenced by the time constraints of routine work, and was further compromised by a change of leadership at regional, district and sub-district levels. We found four mechanisms at play which accounted for these observations: first, the novelty of the intervention itself provided an increased sense of urgency among teams. District managers were open to engaging with the process, and the imposition of deadlines heightened the perception of needing to achieve results, as compared to when the same work is required to achieve routine targets. Secondly, the intervention helped district managers to develop their initiative and reduce excuse-making. It was acknowledged that some problems faced by teams were ‘beyond’ district managers, and as such, initiative-taking was encouraged on a ‘small-scale’ basis mainly. Linked to this, the third mechanism was learning how to better prioritize. Through better prioritization, district managers felt better able to manage crash programmes, and as such viewed themselves as becoming more efficient in their work. Fourthly, supporting teamwork through teaching district managers on how to acknowledge and inspire their staff was important in contributing to the sense of improved work climate. Despite these positive developments, the intervention did not bring about systems-thinking in district managers. This correlated with the context of high resource uncertainty, partly determined by the highly centralized decision-making around both human and financial resources. Coupled to the top-down manner in which the intervention was introduced to district teams, this context further triggered the intervention’s underlying focus on organizational control, as opposed to organizational learning. Critically, organizational culture in this case remained unchanged.
Conclusion Our findings indicate that the top-down nature in which the intervention was introduced emphasized the primary goal of organizational control. This explains the lack of evidence of organizational learning and creativity. These findings uphold earlier work which describes the rigidity and lack of responsiveness in command-and-control structures observed in several African health systems as contributing partly to the challenge of quality of care in service delivery. Factors which reduce effectiveness of continuous quality improvements, namely vertical introduction, lacking systemic perspectives, and tool-driven processes were apparent in this case. In considering how the intervention might have been implemented differently, we see five ways which could have potentially altered the causal path: 1) had the facilitation team been peers instead of superiors (i.e., had facilitators been other district managers previously exposed to the intervention rather than regional managers) this may have weakened the hierarchical authority, thereby reducing the top-down nature of the intervention’s introduction; 2) had districts volunteered to receive the intervention instead of being randomly selected; and 3) had ongoing mentorship and coaching been built into the process through systematic follow-up, this may have supported institutionalization of the intervention practices; 4) had the time-frame of the intervention been lengthened beyond six months, this may have had deeper-lasting effects in becoming routine in daily management practices; and 5) had organizational learning been an explicit goal of the intervention (also supported by longer time-frames), with reflection processes built in as a major part of the intervention, this may have provided greater opportunity for more systems-thinking to develop in district managers.
As the health sector considers scaling-up the intervention to other districts, these findings will provide inputs into this process. This is particularly critical given the context of the health sector, which can be the more important dimension of complexity, as opposed to the intervention itself. Continuous quality improvement interventions interact with the contexts in which they are introduced, thus determining the types of outcomes possible. Such considerations must be kept in mind. Already, two members of the research team are affiliated with the Ghana Health Service and have ongoing policy dialogues with key actors in the Service.

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