TY - JOUR
T1 - Organizational change and everyday health system resilience
T2 - lessons from Cape Town, South Africa
AU - Gilson, Lucy
AU - Ellokor, Soraya
AU - Lehmann, Uta
AU - Brady, Leanne
N1 - Funding Information:
We thank the heath staff and managers of Area South for their continued dedication and commitment to the people of Cape Town - and their support for this work. We thank our colleagues in the Resilient and Responsive Health Systems, RESYST, Consortium for their support and engagement. This research is an output of RESYST, which was funded by the UK Aid from the Department for International Development ( DFID ) for the benefit of developing countries. However, the views expressed and information contained in it are not necessarily those of or endorsed by DFID, which can accept no responsibility for such views or information or for any reliance placed on them.
Funding Information:
In S-sd there was a ‘culture of acceptance of top down imperatives’ (SE interview, July 02, 2018). In contrast, in MP-sd, there were emerging signs of the organizational re-culturing needed to support PHC improvement - including trust between managers and staff and more pro-active decision-making (MP-sd senior manager interviews, 2017). However, the ‘dominance of bureaucratic management and accountability processes’ that demand compliance with service delivery targets was still an obstacle to maintaining new ways of working in the sub-district (Cleary et al., 2018: ii73).Service delivery challenges were also discussed in 9/16 AMCM meetings alongside service, budget and staffing data (minutes analysis, May2017-Nov2018), with the aim of developing the collective mindset that ‘service change is possible’ (SE Interview July 22, 2018). Three dedicated AMCM discussions (Aug–Sept 2017, April 2018; insert link to online file A) focused on service expansion. The researcher diary identified some challenges in the way these discussions were structured (see also Box 3), and that facility managers had not clearly engaged their own staff about the issues; but, over time, managers became more active in the meetings. For example, in September 2017 one small group considered geriatric service provision challenges: ‘[the] discussion throws up quite a few ideas; and the suggestion that ‘we need to talk more with each other’; it was a good discussion’ (researcher diary, September 27, 2107). In April 2018, moreover, the managers compared the difficult, but successful, roll-out of PNC with the failure to provide geriatric care and identified steps to strengthen future service expansion (AMCM minutes). Finally, repeated discussion within the AMCM and Think Tank of PHC facility staffing challenges (minutes' analysis) informed the location of new pharmacy posts - and by April 2018 improvements in pharmacy support were noted (researcher diary).AMCM service delivery discussions were followed-up in SE's one-on-one meetings with other senior managers, who in turn followed up with PHC facility managers and doctors. A dedicated manager was also assigned to support facility managers in preparing for IC assessments in 2017. In 2018, S&M visits focused on encouraging staff in larger facilities to think how to improve towards IC standards, although SE was concerned that an audit, rather than supportive, supervision style was applied (interviews, July 04, 2018, August 21, 2019).The final element of response to service delivery stressors was, again, the Area manager's own leadership. She repeatedly raised the challenges of expanding and strengthening service provision and the need for more resources with the CityHealth Director and colleagues. MP-sd, in particular, fell short of the City-wide staffing norms for providing comprehensive services (researcher diary, September 27, 2017). The CityHealth Director also engaged up the system to press the case for more resources. From January 2018 all CityHealth Areas received additional annual capital budgets for minor upgrades/equipment to support IC implementation (representing a more than 40-fold increase in the Area budget). Other once-only budgetary increases were also received, including from reallocating unspent budgets from elsewhere in the Social Services Cluster.The IC programme may also have supported PHC improvement. SE judged that it had encouraged Area-wide review and reflection, including peer support (interview, July 04, 2018). However, it imposed considerable stress on PHC facility managers and had required direct support from the Area level. She was also concerned about its potential to generate 'maladapted emergence' (SE interview, July 04, 2018). Its audit and compliance approach, for example, might have demotivated staff - especially because some established targets simply could not be achieved. It also encouraged compliance above improvement (e.g. leading equipment to be moved between facilities during the audit process, to meet standards). In resilience capacity terms, then, it is possible that the IC process may have directed learned resourcefulness towards managing short-term needs, as well as crowded out the creative ingenuity and other cognitive capacities required to enable sustained service transformation over the long term.Although the particular role of sensemaking in producing or inhibiting change, and in enabling new ways of organizing, is acknowledged in wider literature (Maitlis and Christianson, 2014), there are few reported health system experiences. Jordan et al. (2009), for example, consider the role of impromptu conversations in supporting sensemaking and encouraging self-organization among agents within US primary care. They suggest that the work of organizational change is not about designing new structures but about introducing new themes into organizational conversations. Confirming the Area South experience, they argue that local managers can enable such conversations by creating time and space where they can unfold, as well as supporting conversations that allow people to manage uncertainty and re-shape relationships. Such conversations may, then, support the collective mindfulness thought to fuel organizational resilience (Williams et al., 2017).We thank the heath staff and managers of Area South for their continued dedication and commitment to the people of Cape Town - and their support for this work. We thank our colleagues in the Resilient and Responsive Health Systems, RESYST, Consortium for their support and engagement. This research is an output of RESYST, which was funded by the UK Aid from the Department for International Development (DFID) for the benefit of developing countries. However, the views expressed and information contained in it are not necessarily those of or endorsed by DFID, which can accept no responsibility for such views or information or for any reliance placed on them.
Publisher Copyright:
© 2020 Elsevier Ltd
PY - 2020/12
Y1 - 2020/12
N2 - This paper reports a study from Cape Town, South Africa, that tested an existing framework of everyday health system resilience (EHSR) in examining how a local health system responded to the chronic stress of large-scale organizational change. Over two years (2017–18), through cycles of action-learning involving local managers and researchers, the authorial team tracked the stress experienced, the response strategies implemented and their consequences. The paper considers how a set of micro-governance interventions and mid-level leadership practices supported responses to stress whilst nurturing organizational resilience capacities. Data collection involved observation, in-depth interviews and analysis of meeting minutes and secondary data. Data analysis included iterative synthesis and validation processes. The paper offers five sets of insights that add to the limited empirical health system resilience literature: 1) resilience is a process not an end-state; 2) resilience strategies are deployed in combination rather than linearly, after each other; 3) three sets of organizational resilience capacities work together to support collective problem-solving and action entailed in EHSR; 4) these capacities can be nurtured by mid-level managers’ leadership practices and simple adaptations of routine organizational processes, such as meetings; 5) central level actions must nurture EHSR by enabling the leadership practices and micro-governance processes entailed in everyday decision-making.
AB - This paper reports a study from Cape Town, South Africa, that tested an existing framework of everyday health system resilience (EHSR) in examining how a local health system responded to the chronic stress of large-scale organizational change. Over two years (2017–18), through cycles of action-learning involving local managers and researchers, the authorial team tracked the stress experienced, the response strategies implemented and their consequences. The paper considers how a set of micro-governance interventions and mid-level leadership practices supported responses to stress whilst nurturing organizational resilience capacities. Data collection involved observation, in-depth interviews and analysis of meeting minutes and secondary data. Data analysis included iterative synthesis and validation processes. The paper offers five sets of insights that add to the limited empirical health system resilience literature: 1) resilience is a process not an end-state; 2) resilience strategies are deployed in combination rather than linearly, after each other; 3) three sets of organizational resilience capacities work together to support collective problem-solving and action entailed in EHSR; 4) these capacities can be nurtured by mid-level managers’ leadership practices and simple adaptations of routine organizational processes, such as meetings; 5) central level actions must nurture EHSR by enabling the leadership practices and micro-governance processes entailed in everyday decision-making.
UR - http://www.scopus.com/inward/record.url?scp=85092477183&partnerID=8YFLogxK
U2 - 10.1016/j.socscimed.2020.113407
DO - 10.1016/j.socscimed.2020.113407
M3 - Article
C2 - 33068870
AN - SCOPUS:85092477183
SN - 0277-9536
VL - 266
JO - Social Science and Medicine
JF - Social Science and Medicine
M1 - 113407
ER -
