Enabling relational leadership in primary healthcare settings: lessons from the DIALHS collaboration

Investigating socio-ecological factors influencing implementation of tuberculosis infection prevention and control in rural Papua New Guinea

BACKGROUND

Tuberculosis (TB) is a highly transmissible infectious disease killing millions of people yearly, particularly in low-income countries. TB is most likely to be transmitted in healthcare settings with poor infection control practices. Implementing TB infection prevention and control (TB-IPC) is pivotal to preventing TB transmission in healthcare settings. This study investigated diverse stakeholders' perspectives relating to barriers and strategies for TB-IPC in rural hospitals in Papua New Guinea.

METHODS

Multiple qualitative case studies were conducted with 32 key stakeholders with experience in TB services. Data collection drew on three primary sources to triangulate data: semi-structured interviews, document reviews and field notes. The data were analyzed using hybrid deductive-inductive thematic analysis.

RESULTS

Our results reveal that key stakeholders perceive multiple interdependent factors that affect TB-IPC practice. The key emerging themes include strategic planning for and prioritizing TB-IPC guidelines; governance, leadership and accountability at the provincial level; community attitudes towards TB control; institutional capacity to deliver TB care, healthcare workers' safety, and long-term partnership and integration of TB-IPC programmes into the broad IPC programme.

CONCLUSIONS

The evidence suggests that a multi-perspective approach is crucial for TB-IPC guidelines in healthcare institutions. Interventions focusing on addressing health systems strengthening may improve the implementation of TB-IPC guidelines.

How capacity building of district health managers has been designed, delivered and evaluated in sub-Saharan Africa: a scoping review and best fit framework analysis

OBJECTIVES

We aimed to understand how capacity building programmes (CBPs) of district health managers (DHMs) have been designed, delivered and evaluated in sub-Saharan Africa. We focused on identifying the underlying assumptions behind leadership and management CBPs at the district level.

DESIGN

Scoping review.

DATA SOURCES

We searched five electronic databases (MEDLINE, Health Systems Evidence, Wiley Online Library, Cochrane Library and Google Scholar) on 6 April 2021 and 13 October 2022. We also searched for grey literature and used citation tracking.

ELIGIBILITY CRITERIA

We included all primary studies (1) reporting leadership or management capacity building of DHMs, (2) in sub-Saharan Africa, (3) written in English or French and (4) published between 1 January 1987 and 13 October 2022.

DATA EXTRACTION AND SYNTHESIS

Three independent reviewers extracted data from included articles. We used the best fit framework synthesis approach to identify an a priori framework that guided data coding, analysis and synthesis. We also conducted an inductive analysis of data that could not be coded against the a priori framework.

RESULTS

We identified 2523 papers and ultimately included 44 papers after screening and assessment for eligibility. Key findings included (1) a scarcity of explicit theories underlying CBPs, (2) a diversity of learning approaches with increasing use of the action learning approach, (3) a diversity of content with a focus on management rather than leadership functions and (4) a diversity of evaluation methods with limited use of theory-driven designs to evaluate leadership and management capacity building interventions.

CONCLUSION

This review highlights the need for explicit and well-articulated programme theories for leadership and management development interventions and the need for strengthening their evaluation using theory-driven designs that fit the complexity of health systems.

180° view on general practitioners' leadership skills: practice-level comparisons of leader and staff assessments using data from the cluster-randomised controlled IMPROVEjob study

OBJECTIVES

Strong primary care leaders are needed to assure high quality services for patient populations. This study analysed general practitioners' (GP) leadership skills comparing practice-level self and staff assessments based on the full range of leadership model and the leader-member exchange (LMX).

SETTING

The questionnaire survey was conducted among German general practice leaders and their staff participating in the IMPROVEjob trial.

PARTICIPANTS

The study population comprised 60 German general practices with 366 participants: 84 GP practice leaders and 282 employees (28 physicians and 254 practice assistants).

PRIMARY AND SECONDARY OUTCOME MEASURES

Leadership skills of the practice leaders were measured using the Integrative Leadership Questionnaire (German Fragebogen für integrative Führung) and the LMX-7 questionnaire. Leaders rated themselves and practice staff rated their leaders. The data was analysed by paired mean comparisons on the practice level.

RESULTS

For most leadership dimensions, practice leaders rated themselves higher than their employees rated them. Differences were found for transformational leadership (p<0.001, d=0.41), especially for the dimensions 'innovation' (p<0.001, d=0.69) and 'individuality focus' (p<0.001, d=0.50). For transactional leadership, the dimension 'goal setting' differed significantly (p<0.01, d=0.30) but not the other dimensions. Scores for negative leadership were low and showed no differences between leaders and employees. Interestingly, employed physicians' rated their practice leaders higher on the two transformational ('performance development', 'providing a vision') and all transactional dimensions. The LMX-7 scale showed high quality relationships between leaders and employees.

CONCLUSIONS

This 180° analysis of GPs' leadership skills with self and employee ratings indicated good relationships. There is a potential to improve leadership regarding goal-setting, innovation and focusing on individual team members. These results allow for the development of targeted interventions.

TRIAL REGISTRATION NUMBER

German Clinical Trials Register, DRKS00012677. Registered 16 October 2019.

Capacity building of district health management teams in the era of provincial health administration reform in the Democratic Republic of Congo: a realist evaluation protocol

INTRODUCTION

In 2006, the Congolese Ministry of Health developed a health system strengthening strategy focusing on health district development. This strategy called for reforming the provincial health administration in order to better support the health district development through leadership and management capacity building of district health management teams. The implementation is currently underway, yet, more evidence on how, for whom and under what conditions this capacity building works is needed. The proposed research aims to address this gap using a realist evaluation approach.

METHODS AND ANALYSIS

We will follow the cycle of the realist evaluation. First, we will elicit the initial programme theory through a scoping review (completed in December 2022, using MEDLINE, Health Systems Evidence, Wiley Online Library, Cochrane Library, Google Scholar and grey literature), a review of health policy documents (completed in March 2023), and interviews with key stakeholders (by June 2023). Second, we will empirically test the initial programme theory using a multiple-embedded case study design in two provincial health administrations and four health districts (by March 2024). Data will be collected through document reviews, in-depth interviews, non-participant observations, a questionnaire, routine data from the health information management system and a context mapping tool. We will analyse data using the Intervention-Context-Actor-Mechanism-Outcome configuration heuristic. Last, we will refine the initial programme theory based on the results of the empirical studies and develop recommendations for policymakers (by June 2024).

ETHICS AND DISSEMINATION

The Institutional Review Board of the Institute of Tropical Medicine and the Medical Ethics Committee of the University of Lubumbashi approved this study. We will also seek approvals from provincial-level and district-level health authorities before data collection in their jurisdictions. We will disseminate the study findings through the publication of articles in peer-reviewed academic journals, policy briefs for national policymakers and presentations at national and international conferences.

Successes, weaknesses, and recommendations to strengthen primary health care: a scoping review

BACKGROUND

Primary health care (PHC) is a roadmap for achieving universal health coverage (UHC). There were several fragmented and inconclusive pieces of evidence needed to be synthesized. Hence, we synthesized evidence to fully understand the successes, weaknesses, effective strategies, and barriers of PHC.

METHODS

We followed the PRISMA extension for scoping reviews checklist. Qualitative, quantitative, or mixed-approach studies were included. The result synthesis is in a realistic approach with identifying which strategies and challenges existed at which country, in what context and why it happens.

RESULTS

A total of 10,556 articles were found. Of these, 134 articles were included for the final synthesis. Most studies (86 articles) were quantitative followed by qualitative (26 articles), and others (16 review and 6 mixed methods). Countries sought varying degrees of success and weakness. Strengths of PHC include less costly community health workers services, increased health care coverage and improved health outcomes. Declined continuity of care, less comprehensive in specialized care settings and ineffective reform were weaknesses in some countries. There were effective strategies: leadership, financial system, 'Diagonal investment', adequate health workforce, expanding PHC institutions, after-hour services, telephone appointment, contracting with non-governmental partners, a 'Scheduling Model', a strong referral system and measurement tools. On the other hand, high health care cost, client's bad perception of health care, inadequate health workers, language problem and lack of quality of circle were barriers.

CONCLUSIONS

There was heterogeneous progress towards PHC vision. A country with a higher UHC effective service coverage index does not reflect its effectiveness in all aspects of PHC. Continuing monitoring and evaluation of PHC system, subsidies to the poor, and training and recruiting an adequate health workforce will keep PHC progress on track. The results of this review can be used as a guide for future research in selecting exploratory and outcome parameters.

Realising radical potential: building community power in primary health care through Participatory Action Research

BACKGROUND

While community participation is an established pro-equity approach in Primary Health Care (PHC), it can take many forms, and the central category of power is under-theorised. The objectives were to (a) conduct theory-informed analysis of community power-building in PHC in a setting of structural deprivation and (b) develop practical guidance to support participation as a sustainable PHC component.

METHODS

Stakeholders representing rural communities, government departments and non-governmental organisations engaged through a participatory action research (PAR) process in a rural sub-district in South Africa. Three reiterative cycles of evidence generation, analysis, action, and reflection were progressed. Local health concerns were raised and framed by community stakeholders, who generated new data and evidence with researchers. Dialogue was then initiated between communities and the authorities, with local action plans coproduced, implemented, and monitored. Throughout, efforts were made to shift and share power, and to adapt the process to improve practical, local relevance. We analysed participant and researcher reflections, project documents, and other project data using power-building and power-limiting frameworks.

RESULTS

Co-constructing evidence among community stakeholders in safe spaces for dialogue and cooperative action-learning built collective capabilities. The authorities embraced the platform as a space to safely engage with communities and the process was taken up in the district health system. Responding to COVID-19, the process was collectively re-designed to include a training package for community health workers (CHWs) in rapid PAR. New skills and competencies, new community and facility-based alliances and explicit recognition of CHW roles, value, and contribution at higher levels of the system were reported following the adaptations. The process was subsequently scaled across the sub-district.

CONCLUSIONS

Community power-building in rural PHC was multidimensional, non-linear, and deeply relational. Collective mindsets and capabilities for joint action and learning were built through a pragmatic, cooperative, adaptive process, creating spaces where people could produce and use evidence to make decisions. Impacts were seen in demand for implementation outside the study setting. We offer a practice framework to expand community power in PHC: (1) prioritising community capability-building, (2) navigating social and institutional contexts, and (3) developing and sustaining authentic learning spaces.

An antidote to what's ailing healthcare workers: a new (old) way of relational leadership

PURPOSE

The purpose of the study's mixed-methods evaluation was to examine the ways in which a relational leadership development intervention enhanced participants' abilities to apply relationship-oriented skills on their teams.

DESIGN/METHODOLOGY/APPROACH

The authors evaluated five program cohorts from 2018-2021, involving 127 interprofessional participants. The study's convergent mixed-method approach analyzed post-course surveys for descriptive statistics and interpreted six-month post-course interviews using qualitative conventional content analysis.

FINDINGS

All intervention features were rated as at least moderately impactful by at least 83% of participants. The sense of community, as well as psychological safety and trust created, were rated as impactful features of the course by at least 94% of participants. At six months post-intervention, participants identified benefits of greater self-awareness, deeper understanding of others and increased confidence in supporting others, building relationships and making positive changes on their teams.

ORIGINALITY/VALUE

Relational leadership interventions may support participant skills for building connections, supporting others and optimizing teamwork. The high rate of skill application at six months post-course suggests that relational leadership development can be effective and sustainable in healthcare. As the COVID-19 pandemic and systemic crises continue to impact the psychological well-being of healthcare colleagues, relational leadership holds promise to address employee burnout, turnover and isolation on interprofessional care teams.

Leadership Development: Exploring Relational Leadership Implications in Healthcare Organizations

(1) Background: Relational Leadership Theory (RLT) has been gaining rising attention for the past 20 years with studies investigating multiple implications and practices of relationships within organizations. Yet, less attention has been given in healthcare settings. By virtue of the emerging need to move beyond exploring the quality of relationships and to move towards the exploitation of relational dynamics that influence leadership development in healthcare organizations, this study explores both the dyad relationships and the context in which those occur. With recent attention directed to the implementation of human-centered practices and the creation of effective networks to bring desired results, RLT is called on to advance this agenda within healthcare organizations. (2) Material and Methods: Research articles that examined leadership theories over the past thirty years were selected from computerized databases and manual searches. (3) Results: It is argued that the way and context in which relationships are formed between leaders and members is a social process that, in turn, shapes the effectiveness of the management of those organizations. Leadership is not rank-it is the relationship with the relational dynamics that play in the same context, creating evolutionary organizational processes. (4) Conclusions: This paper challenges leadership theory one step further. Exploring an organization through relational leadership theory is much like wearing the lens of 'cause and effect' in leadership behavioral studies. Therefore, this study contributes to this direction with a robust co-examination of relational dynamics that take place in the healthcare sector, showcasing a broader framework in which relational leadership is germinated and influences its outcomes.

Understanding intra- and interprofessional team and teamwork processes by exploring facility-based neonatal care in kenyan hospitals

BACKGROUND

Within intensive care settings such as neonatal intensive care units, effective intra- and interprofessional teamwork has been linked to a significant reduction of errors and overall improvement in the quality of care. In Kenya, previous studies suggest that coordination of care among healthcare teams providing newborn care is poor. Initiatives aimed at improving intra- and interprofessional teamwork in healthcare settings largely draw on studies conducted in high-income countries, with those from resource-constrained low and middle countries, particularly in the context of newborn care lacking. In this study, we explored the nature of intra- and interprofessional teamwork among health care providers in newborn units (NBUs) of three hospitals in Kenya, and the professional and contextual dynamics that shaped their interactions.

METHODS

This exploratory qualitative study was conducted in three hospitals in Nairobi and Muranga Counties in Kenya. We adopted an ethnographic approach, utilizing both in-depth interviews (17) and non-participant observation of routine care provision in NBUs (250 observation hours). The study participants included: nurses, nursing students, doctors, and trainee doctors. All the data were thematically coded in NVIVO 12.

RESULTS

The nature of intra- and interprofessional teamwork among healthcare providers in the study newborn units is primarily shaped by broader contextual factors and varying institutional contexts. As a result, several team types emerged, loosely categorized as the 'core' team which involves providers physically present in the unit most times during the work shift; the emergency team and the temporary ad-hoc teams which involved the 'core' team, support staff students and mothers. The emergence of these team types influenced relationships among providers. Overall, institutionalized routines and rituals shaped team relations and overall functioning.

CONCLUSIONS

Poor coordination and the sub-optimal nature of intra-and interprofessional teamwork in NBUs are attributed to broader contextual challenges that include low staff to patient ratios and institutionalized routines and rituals that influenced team norming, relationships, and team leadership. Therefore, mechanisms to improve coordination and collaboration among healthcare teams in these settings need to consider contextual dynamics including institutional cultures while also targeting improvement of team-level processes including leadership development and widening spaces for more interaction and better communication.

How to work with intangible software in public health systems: some experiences from India

This commentary focuses on "intangible software", defined as the range of ideas, norms, values and issues of power or trust that affect the performance of health systems. While the need to work with intangible software within health systems is increasingly being recognized, the practical hows of doing so have been given less attention. In this commentary, we, a team of researchers and implementers from India, have tried to deliberate on these hows through a practice lens. We engage with four questions of current relevance to intangible software in the field of health policy and systems research (HPSR): (1) Is it possible to rewire intangible software in health systems? (2) What approaches have been attempted in the Indian public health system to rewire intangibles? (3) Have such approaches been evaluated? (4) What practical lessons can we offer from our experience on rewiring intangibles? From our perspective, approaches to rewiring intangible software recognize that people in health systems are capable of visioning, thinking, adapting to and leading change. These approaches attempt to challenge the often-unchallenged power hierarchies in health systems by allowing people to engage deeply with widely accepted norms and routinized actions. In this commentary, we have reported on such approaches from India under six categories: approaches intended to enable visioning and leading; approaches targeted at engaging with evidence better; approaches intended to help health workers navigate contextual complexities; approaches intended to build the cultural competence; approaches that recognize and reward performance; and approaches targeted at enabling collaborative work and breaking power hierarchies. Our collective experiences suggest that intangible software interventions work best when they are codesigned with various stakeholders, are contextually adapted in an iterative manner and are implemented in conjunction with structural improvements. Also, such interventions require long-term investments. Based on our experiences, we highlight the need for the following: (1) fostering more dialogue on this category of interventions among all stakeholders for cross-learning; (2) evaluating and publishing evidence on such interventions in nonconventional ways, with a focus on participatory learning; and (3) building ecosystems that allow experiential learnings on such interventions to be shared.

Coaching to develop leadership for healthcare managers: a mixed-method systematic review protocol

BACKGROUND

An increasing number of interventions have focused on leadership development for healthcare managers, among which coaching is a common strategy. The purpose of the present systematic review is to synthesize evidence on the effect of coaching in developing leadership of healthcare managers.

METHODS AND ANALYSIS

A literature search will be conducted in six English databases (MEDLINE (Ovid), CINAHL, Embase, Cochrane library, Nursing & Allied Health Premium, and Scopus) and four Chinese databases (Wanfang, CNKI, SinoMed, and VIP) from inception to April 1st, 2022. The titles, abstracts, and full texts of the studies will be screened by two independent researchers to determine their eligibility. The RoB 2, ROBINS-I, CASP, and MMAT will be applied to assess the quality of randomized trials, non-randomized studies, qualitative studies, and mixed-method studies, respectively. We will then extract the study characteristics, participant characteristics, and study outcomes of the reviewed papers. The Aims, Ingredients, Mechanism, and Delivery framework will be used to extract the components of coaching strategies. For quantitative data, a meta-analysis will be performed if sufficient data are available; otherwise, we will conduct a narrative synthesis. Thematic synthesis methods will be used for qualitative data analysis.

DISCUSSION

By conducting this systematic review, we expect to synthesize evidence regarding the components of coaching for leadership development among healthcare managers; the influence of coaching on leadership development among managers at the individual, unit-wide, or organizational level; and how managers view coaching as a leadership development strategy.

TRIAL REGISTRATION

PROSPERO registration number: CRD42020194290 .

An innovative leadership development initiative to support building everyday resilience in health systems

Effective management and leadership are essential for everyday health system resilience, but actors charged with these roles are often underprepared and undersupported to perform them. Particular challenges have been observed in interpersonal and relational aspects of health managers’ work, including communication skills, emotional competence and supportive oversight. Within the Resilient and Responsive Health Systems (RESYST) consortium in Kenya, we worked with two county health and hospital management teams to adapt a package of leadership development interventions aimed at building these skills. This article provides insights into: (1) the content and co-development of a participatory intervention combining two core elements: a complex health system taught course, and an adapted communications and emotional competence process training; and (2) the findings from a formative evaluation of this intervention which included observations of the training, individual interviews with participating managers and discussions in regular meetings with managers. Following the training, managers reported greater recognition of the importance of health system software (values, belief systems and relationships), and improved self-awareness and team communication. Managers appeared to build valued skills in active listening, giving constructive feedback, ‘stepping back’ from automatic reactions to challenging emotional situations and taking responsibility to communicate with emotional competence. The training also created spaces for managers to share experiences, reflect upon and nurture social competences. We draw on our findings and the literature to propose a theory of change regarding the potential of our leadership development intervention to nurture everyday health system resilience through strengthening cognitive, behavioural and contextual capacities. We recommend further development and evaluation of novel approaches such as those shared in this article to support leadership development and management in complex, hierarchical systems.

Team-based primary health care for non-communicable diseases: complexities in South India

Chronic non-communicable diseases (NCDs), such as diabetes and cardiovascular diseases, have reached epidemic proportions worldwide. Health systems, especially those in low- and middle-income countries, such as India, struggle to deliver quality chronic care. A reorganization of healthcare service delivery is needed to strengthen care for chronic conditions. In this study, we evaluated the implementation of a package of tailored interventions to reorganize care, which were identified following a detailed analysis of gaps in delivering quality NCD care at the primary care level in India. Interventions included a redesign of the workflow at primary care clinics, a redistribution of tasks, the introduction of patient information records and the involvement of community health workers in the follow-up of patients with NCDs. An experimental case study design was chosen to study the implementation of the quality improvement measures. Three public primary care facilities in rural South India were selected. Qualitative methods were used to gain an in-depth understanding of the implementation process and outcomes of implementation. Observations, field notes and semi-structured interviews with staff at these facilities (n = 15) were thematically analysed to identify contextual factors that influenced implementation. Only one of the primary health centres implemented all components of the intervention by the end of 9 months. The main barriers to implementation were hierarchical arrangements that inhibited team-based care, the amount of time required for counselling and staff transfers. Team cohesion, additional staff and staff motivation seem to have facilitated implementation. This quality improvement research highlights the importance of building relational leadership to enable team-based care at primary care clinics in India. Redesigned organization of care and task redistribution is important solutions to deliver quality chronic care. However, implementing these will require capacity building of local primary care teams.

Interventions to strengthen the leadership capabilities of health professionals in Sub-Saharan Africa: a scoping review

Leadership is a critical component of a health system and may be particularly important in Sub-Saharan Africa, where clinicians take on significant management responsibilities. However, there has been little investment in strengthening leadership in this context, and evidence is limited on what leadership capabilities are most important or how effective different leadership development models are. This scoping review design used Arksey and O’Malley’s approach of identifying the question and relevant studies, selection, charting of data, summarizing of results and consultation. A comprehensive search strategy was used that included published and unpublished primary studies and reviews. Seven databases were searched, and papers written in English and French between 1979 and 2019 were included. Potential sources were screened against inclusion and exclusion criteria. Data were grouped into common categories and summarized in tables; categories included conceptual approach to leadership; design of intervention; evaluation method; evidence of effectiveness; and implementation lessons. The findings were then analysed in the context of the review question and objectives. Twenty-eight studies were included in the review out of a total of 495 that were initially identified. The studies covered 23 of the 46 countries in Sub-Saharan Africa. The leadership development programmes (LDPs) described were diverse in their design. No consistency was found in the conceptual approaches they adopted. The evaluation methods were also heterogeneous and often of poor quality. The review showed how rapidly leadership has emerged as a topic of interest in health care in Sub-Saharan Africa. Further research on this subject is needed, in particular in strengthening the conceptual and competency frameworks for leadership in this context, which would also inform better evaluation. Our findings support the need for LDPs to be accredited, better integrated into existing systems and to put greater emphasis on institutionalization and financial sustainability from their early development.

To bend without breaking: a qualitative study on leadership by doctors in Sierra Leone

Strong leadership capabilities are essential for effective health services, yet definitions of leadership remain contested. Despite the acknowledged contextual specificity of leadership styles, most leadership theories draw heavily from Western conceptualizations. This cultural bias may attenuate the effectiveness of programmes intended to transform healthcare practice in Sub-Saharan Africa, where few empirical studies on health leadership have been conducted. This paper examines how effective leadership by doctors was perceived by stakeholders in one particular context, Sierra Leone. Drawing together extensive experience of in-country healthcare provision with a series of in-depth interviews with 27 Sierra Leonean doctors, we extended a grounded-theory approach to come to grips with the reach and relevance of contemporary leadership models in capturing the local experiences and relevance of leadership. We found that participants conceptualized leadership according to established leadership models, such as transformational and relational theories. However, participants also pointed to distinctive challenges attendant to healthcare provision in Sierra Leone that required specific leadership capabilities. Context-specific factors included health system breakdown, politicization in the health sector and lack of accountability, placing importance on skills such as persistence, role modelling and taking initiative. Participants also described pressure to behave in ways they deemed antithetical to their personal and professional values and also necessary in order to continue a career in the public sector. The challenge of navigating such ethical dilemmas was a defining feature of leadership in Sierra Leone. Our research demonstrates that while international leadership models were relevant in this context, there is strong emphasis on contingent or situational leadership theories. We further contribute to policy and practice by informing design of leadership development programmes and the establishment of a more enabling environment for medical leadership by governments and international donors.

Using social network analysis to examine inter-governmental relations in the implementation of the Ideal Clinic Realisation and Maintenance programme in two South African provinces

BACKGROUND

Within the context of universal health coverage (UHC), South Africa has embarked on a series of health sector reforms. The implementation of the Ideal Clinic Realisation and Maintenance (ICRM) programme is a major UHC reform. Cooperative governance is enshrined in South Africa's Constitution, with health a concurrent competency of national and provincial government. Hence, effective inter-governmental relations (IGR) are essential for the ICRM programme implementation.

AIM

The aim of the study was to measure the cohesion of IGR, specifically consultation, support and information sharing, across national, provincial and local government health departments in the ICRM programme implementation.

MATERIALS AND METHODS

Using Provan and Milward's theory on network effectiveness, this study was a whole network design social network analysis (SNA). The study was conducted in two districts in Gauteng (GP) and Mpumalanga (MP) provinces of South Africa. Following informed consent, we used both an interview schedule and a network matrix to collect the social network data from health policy actors in national, provincial and local government. We used UCINET version 6.619 to analyse the SNA data for the overall network cohesion and cohesion within and between the government spheres.

RESULTS

The social network analysis revealed non-cohesive relationships between the different spheres of government. In both provinces, there was poor consultation in the ICRM programme implementation, illustrated by the low densities of seeking advice (GP = 15.6%; MP = 24.4%) and providing advice (GP = 14.1%; MP = 25.1%). The most cohesive relationships existed within the National Department of Health (density = 66.7%), suggesting that national policy actors sought advice from one another, rather than from the provincial health departments. A density of 2.1% in GP, and 12.5% in MP illustrated the latter.

CONCLUSION

The non-cohesive relationships amongst policy actors across government spheres should be addressed in order to realise the benefits of cooperative governance in implementing the ICRM programme.

First do no harm: practitioners' ability to 'diagnose' system weaknesses and improve safety is a critical initial step in improving care quality

Healthcare systems across the world and especially those in low-resource settings (LRS) are under pressure and one of the first priorities must be to prevent any harm done while trying to deliver care. Health care workers, especially department leaders, need the diagnostic abilities to identify local safety concerns and design actions that benefit their patients. We draw on concepts from the safety sciences that are less well-known than mainstream quality improvement techniques in LRS. We use these to illustrate how to analyse the complex interactions between resources and tools, the organisation of tasks and the norms that may govern behaviours, together with the strengths and vulnerabilities of systems. All interact to influence care and outcomes. To employ these techniques leaders will need to focus on the best attainable standards of care, build trust and shift away from the blame culture that undermines improvement. Health worker education should include development of the technical and relational skills needed to perform these system diagnostic roles. Some safety challenges need leadership from professional associations to provide important resources, peer support and mentorship to sustain safety work.

How to do no harm: empowering local leaders to make care safer in low-resource settings

In a companion paper, we showed how local hospital leaders could assess systems and identify key safety concerns and targets for system improvement. In the present paper, we consider how these leaders might implement practical, low-cost interventions to improve safety. Our focus is on making immediate safety improvements both to directly improve patient care and as a foundation for advancing care in the longer-term. We describe a 'portfolio' approach to safety improvement in four broad categories: prioritising critical processes, such as checking drug doses; strengthening the overall system of care, for example, by introducing multiprofessional handovers; control of known risks, such as only using continuous positive airway pressure when appropriate conditions are met; and enhancing detection and response to hazardous situations, such as introducing brief team meetings to identify and respond to immediate threats and challenges. Local clinical leaders and managers face numerous challenges in delivering safe care but, if given sufficient support, they are nevertheless in a position to bring about major improvements. Skills in improving safety and quality should be recognised as equivalent to any other form of (sub)specialty training and as an essential element of any senior clinical or management role. National professional organisations need to promote appropriate education and provide coaching, mentorship and support to local leaders.

Shocks, stress and everyday health system resilience: experiences from the Kenyan coast

Health systems are faced with a wide variety of challenges. As complex adaptive systems, they respond differently and sometimes in unexpected ways to these challenges. We set out to examine the challenges experienced by the health system at a sub-national level in Kenya, a country that has recently undergone rapid devolution, using an 'everyday resilience' lens. We focussed on chronic stressors, rather than acute shocks in examining the responses and organizational capacities underpinning those responses, with a view to contributing to the understanding of health system resilience. We drew on learning and experiences gained through working with managers using a learning site approach over the years. We also collected in-depth qualitative data through informal observations, reflective meetings and in-depth interviews with middle-level managers (sub-county and hospital) and peripheral facility managers (n = 29). We analysed the data using a framework approach. Health managers reported a wide range of health system stressors related to resource scarcity, lack of clarity in roles and political interference, reduced autonomy and human resource management. The health managers adopted absorptive, adaptive and transformative strategies but with mixed effects on system functioning. Everyday resilience seemed to emerge from strategies enacted by managers drawing on a varying combination of organizational capacities depending on the stressor and context.

Organizational change and everyday health system resilience: Lessons from Cape Town, South Africa

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.

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Resilience to chronic stress will prepare health systems to face acute shocks.

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Collective problem-solving and sensemaking enable everyday resilience.

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Distributed leadership, feeling safe and reflective practice are key processes.

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New forms of health system strengthening are needed to nurture resilience.

Learning sites for health system governance in Kenya and South Africa: reflecting on our experience

Background

Health system governance is widely recognised as critical to well-performing health systems in low- and middle-income countries. However, in 2008, the Alliance for Health Policy and Systems Research identified governance as a neglected health systems research issue. Given the demands of such research, the Alliance recommended applying qualitative approaches and institutional analysis as well as implementing cross-country research programmes in engagement with policy-makers and managers. This Commentary reports on a 7-year programme of work that addressed these recommendations by establishing, in partnership with health managers, three district-level learning sites that supported real-time learning about the micro-practices of governance – that is, managers’ and health workers’ everyday practices of decision-making.

Paper focus

The paper’s specific focus is methodological and it seeks to prompt wider discussion about the long-term and engaged nature of learning-site work for governance research. It was developed through processes of systematic reflection within and across the learning sites. In the paper, we describe the learning sites and our research approach, and highlight the set of wider activities that spun out of the research partnership, which both supported the research and enabled it to reach wider audiences. We also separately present the views of managers and researchers about the value of this work and reflect carefully on four critiques of the overall approach, drawing on wider co-production literature.

Conclusions

Ultimately, the key lessons we draw from these experiences are that learning sites offer particular opportunities not only to understand the everyday realities of health system governance but also to support emergent system change led by health managers; the wider impacts of this type of research are enabled by working up the system as well as by infusing research findings into teaching and other activities, and this requires supportive organisational environments, some long-term research funding, recognising the professional and personal risks involved, and sustaining activities over time by paying attention to relationships; and working in multiple settings deepens learning for both researchers and managers. We hope the paper stimulates further reflection about research on health system governance and about co-production as a research approach.

Action research and health system strengthening: the case of the health sector support programme in Mauritania, West Africa

Background

Access to qualitative and equitable healthcare is a major challenge in Mauritania. In order to support the country’s efforts, a health sector strengthening programme was set up with participatory action research at its core. Reinforcing a health system requires a customised and comprehensive approach to face the complexity inherent to health systems. Yet, limited knowledge is available on how policies could enhance the performance of the system and how multi-stakeholder efforts could give rise to changes in health policy. We aimed to analyse the ongoing participatory action research and, more specifically, see in how far action research as an embedded research approach could contribute to strengthening health systems.

Methods

We adopted a single-case study design, based on two subunits of analysis, i.e., two selected districts. Qualitative data were collected by analysing country and programme documents, conducting 12 semi-structured interviews and performing participatory observations. Interviewees were selected based on their current position and participation in the programme. The data analysis was designed to address the objectives of the study, but evolved according to emerging insights and through triangulation and identification of emergent and/or recurrent themes along the process.

Results

An evaluation of the progress made in the two districts indicates that continuous capacity-building and empowerment efforts through a participative approach have been key elements to enhance dialogue between, and ownership of, the actors at the local health system level. However, the strong hierarchical structure of the Mauritanian health system and its low level of decentralisation constituted substantial barriers to innovation. Other constraints were sociocultural and organisational in nature. Poor work ethics due to a weak environmental support system played an important role. While aiming for an alignment between the flexible iterative approach of action research and the prevailing national linear planning process is quite challenging, effects on policy formulation and implementation were not observed. An adequate time frame, the engagement of proactive leaders, maintenance of a sustained dialogue and a pragmatic, flexible approach could further facilitate the process of change.

Conclusion

Our study showcases that the action research approach used in Mauritania can usher local and national actors towards change within the health system strengthening programme when certain conditions are met. An inclusive, participatory approach generates dynamics of engagement that can facilitate ownership and strengthen capacity. Continuous evaluation is needed to measure how these processes can further develop and presume a possible effect at policy level.

Unravelling the role of leadership in motivation of health workers in a Moroccan public hospital: a realist evaluation

OBJECTIVES

This study aimed at opening the black box of the relationship between leadership and motivation of health workers by focusing on a high-performance hospital in Morocco.

DESIGN

We adopted the realist evaluation approach and used the case study design to test the initial programme theory we formulated on the basis of a scoping review on complex leadership. We used the Intervention-Context-Actors-Mechanism-Outcome Configuration as a heuristic tool to identify plausible causal configurations.

SETTINGS

Since 2000, the Ministry of Health in Morocco initiated many reforms in the frame of the governmental deconcentration process called 'advanced regionalisation'. The implementation of these reforms is hampered by inadequate human resource management capacities of local health system managers. Yet, the National 'Concours Qualité', a national quality assurance programme implemented since 2007, demonstrated that there are many islands of excellence. We explore how leadership may play a role in explaining these islands of excellence.

PARTICIPANTS

We carried out a document review, 18 individual interviews and 3 group discussions (with doctors, administrators and nurses), and non-participant observations during a 2-week field visit in January-February 2018.

RESULTS

We confirmed that effective leaders adopt an appropriate mix of transactional, transformational and distributed leadership styles that fits the mission, goals, organisational culture and nature of tasks of the organisation and the individual characteristics of the personnel when organisational culture is conducive. Leadership effectiveness is conditioned by the degree of responsiveness to the basic psychological needs of autonomy, competence and relatedness, perceived organisational support and perceived supervisor support. Transactional and overcontrolling leadership behaviour decreased the satisfaction of the need for autonomy and mutual respect. By distributing leadership responsibilities, complex leaders create an enabling environment for collective efficacy and creative problem solving.

CONCLUSIONS

We found indications that in the Moroccan context, well-performing hospitals could be characterised by a good fit between leadership styles, organisational characteristics and individual staff attributes.

Leadership development in health information management (HIM): literature review

PURPOSE

The health information management (HIM) profession lacks clarity around leadership and leadership development. To date, little empirical research exists on this topic, and it is unclear if broader approaches for healthcare leadership are suitable. This paper aims to explore which the leadership styles are relevant to the HIM profession. The findings were also used to inform a discussion on how HIM professionals could develop these leadership styles.

DESIGN/METHODOLOGY/APPROACH

Through a systematic scoping literature review, deductive thematic analysis was undertaken to extrapolate common themes around this style of leadership based on transversal competency domains that reflect twenty-first century skills (i.e. critical thinking and innovation, interpersonal, intrapersonal and global citizenship) (Bernard, Watch and Ryan, 2016; UNESCO, 2015 ). This approach enabled the findings to be discussed from a leadership development perspective.

FINDINGS

Analysis of the literature revealed that a relational leadership style through a team-based approach is required. Literature studies on how to develop leadership competencies were not found.

RESEARCH LIMITATIONS/IMPLICATIONS

Future policy and research implications include the need for research on transversal competencies to determine if they can shape HIM leadership development.

PRACTICAL IMPLICATIONS

This leadership style and competencies proposed are relevant across many occupations and may have broader applications for leadership research, education and development.

ORIGINALITY/VALUE

This paper defines the style of leadership required in the HIM profession and identifies a succinct set of contemporary competencies to inform the development of this type of leadership.

Rethinking collaboration: developing a learning platform to address under-five mortality in Mpumalanga province, South Africa

Following 50 years of apartheid, South Africa introduced visionary health policy committing to the right to health as part of a primary health care (PHC) approach. Implementation is seriously challenged, however, in an often-dysfunctional health system with scarce resources and a complex burden of avoidable mortality persists. Our aim was to develop a process generating evidence of practical relevance on implementation processes among people excluded from access to health systems. Informed by health policy and systems research, we developed a collaborative learning platform in which we worked as co-researchers with health authorities in a rural province. This article reports on the process and insights brought by health systems stakeholders. Evidence gaps on under-five mortality were identified with a provincial Directorate after which we collected quantitative and qualitative data. We applied verbal autopsy to quantify levels, causes and circumstances of deaths and participatory action research to gain community perspectives on the problem and priorities for action. We then re-convened health systems stakeholders to analyse and interpret these data through which several systems issues were identified as contributory to under-five deaths: staff availability and performance; service organization and infrastructure; multiple parallel initiatives; and capacity to address social determinants. Recommendations were developed ranging from immediate low- and no-cost re-organization of services to those where responses from higher levels of the system or outside were required. The process was viewed as acceptable and relevant for an overburdened system operating 'in the dark' in the absence of local data. Institutional infrastructure for evidence-based decision-making does not exist in many health systems. We developed a process connecting research evidence on rural health priorities with the means for action and enabled new partnerships between communities, authorities and researchers. Further development is planned to understand potential in deliberative processes for rural PHC.

Strengthening health system leadership for better governance: what does it take?

This editorial provides an overview of the six papers included in this special supplement on health leadership in Africa. Together the papers provide evidence of leadership in public hospital settings and of initiatives to strengthen leadership development. On the one hand, they demonstrate both that current leadership practices often impact negatively on staff motivation and patient care, and that contextual factors underpin poor leadership. On the other hand, they provide some evidence of the positive potential of new forms of participatory leadership, together with ideas about what forms of leadership development intervention can nurture new forms of leadership. Finally, the papers prompt reflection on the research needed to support the implementation of such interventions.