In this section, we describe the general context of the district, the innovations to strengthen management practices, key outputs achieved in the eighteen-month period November 2013 to April 2015 and finally, present a discussion of the mechanisms (resources and reasoning) triggered in context that generated outputs. The results are summarised in table format in Appendix 2.
A. Context and actors
The health district was under-performing relative to the rest of the country regarding health outcomes and still suffered from human and infrastructural under-resourcing as a result of the legacies of apartheid (pre democracy in 1994) in South Africa (77). The district is considered rural, it is hard to attract staff and at times there are poor working relationships between the district and the Provincial government.
In November 2013 a new DM with twenty-nine years’ experience in the South African health system (public and private sector) arrived to lead the district. The new DM worked with a core district management team (DMT) who met every Monday morning. There was also an extended DMT (including the core managers as well as hospital, programmatic and sub district managers and other invited guests, in total twenty-four managers at that time) who met once a month to report, plan and prioritise for the district. There were critical vacancies in the DMT, and three hospital CEOs who had to leave their hospital posts[1] were sent to work within the district office with no specific portfolio. The DM reflected that stability was needed, and challenges were made more complex by being an NHI pilot district expected to implement several new service delivery reforms;
“I think the preparation for NHI relies heavily on innovation and in order to innovate properly, you need a stable system. This is an extremely unstable system, so you have got to innovate and stabilise at the same time, which I think adds a lot to the complexity of what we do (The new DM, 09/09/2014).
The extended monthly DMT meeting needed to change, as it was a space mainly used for complaining. The use of information by hospital and sub-district managers for problem diagnosis, decision making, and accountability needed to be improved;
“I think that there were lots of meetings, or there are lots of meetings that happen, but not lots of structured meetings. Not lots of minutes and not lots of agendas, so you cannot go to a meeting and you sit there the whole day and you don’t have something tangible to show …. We get a lot of whining sessions, but they actually don’t help at all …. That is more the approach than to listen, because you can spend ninety percent of your time listening to or whining, and then only ten percent looking at solutions, whereas we would like to reverse that … It is about looking at the indicators and asking: “Why we are doing well or why we are doing badly? … It has worked before and it is kind of standard practice in functional systems. I am sure it will work” (The new DM, 19/02/2014).
The information manager (IM) was carrying the burden of information preparation and presentation for the meeting. He had a sense that managers were afraid of working with numbers resulting in a general culture of avoidance and deferring queries back to her;
“… because even things that they can do themselves, they will also say: “No give it to [the] information person.” … They would make it a big deal when it comes to compilation of other reports. Anything that is computer related, they associate it with anything that relates to numbers. They will just give it to someone to add it in … they don’t want to use numbers” (Manager 1, 09/09/2013).
The IM already had a huge workload to manage, including managing all the aggregate information, quality checking data and being responsive to information requests in the district. Additional data capturers had been sent as the district was an NHI pilot site, but they did not have the skills to do the work required. In the past, sometimes reports had been generated, but problems raised in them by managers were either not acted upon, or those in authority did not have power to act on them, reducing motivation to produce new reports.
There were also many NGO partners operating in the district, but it was not clear whether partners were well aligned with the service delivery priorities in the district health plan (DHP). The new DM felt there was neither a shared vision among all partners, nor an established decision-making platform where decisions could be taken consultatively with stakeholders.
B. The innovation for management capacity development
The ‘bricolage’ of inter-connected innovations introduced in the extended DMT monthly management meetings to improve collective capabilities (managerial practices) were:
(1a) The introduction of a new agenda that focused on the core functions of the district, addressing the system building blocks (the agenda included ‘services’, ‘corporate governance’ and ‘quality’, with time allocated for each item) and the introduction of a routine procedure to support decision making, whereby managers had to produce reports, covering core indicators for reading, distributed before the meeting. See Additional File 3 for key agenda items.
(1b) An explicit effort to institutionalise the engagement with and application of information by all managers, backed up by the DM’s purposeful enforcement of the national District Health Management and Information Systems (DHMIS) policy. Linked to this, the DM also established the routine procedure that managers must first investigate problems by collecting information on the ground before bringing them to the monthly meeting, and be ready to discuss solutions and progress (or lack thereof).
(1c) The routine procedure that NGO partners in the district would attend the extended district management meeting in order to support coordination and accountability, as well as discuss their activities directly with the DM.
(1d) Defining job descriptions for the ex-hospital CEOs newly posted to the district office and describing their purpose in the team, alongside attempts to fill critical management vacancies in the team.
C. Emergent outputs
By 2015, 18 months after the new DM’s appointment, senior managers and district partners who attended the monthly meetings confirmed that the innovations resulted in an emerging set of improved management practices over time – contributing to emergent capacity.
Output 1a: A new extended DMT agenda with a structured format was being routinely applied, managers had to present on core system issues and meetings were being time-managed.
"Yes, we present but we are being given a chance, we are being informed earlier on that you are expected to present in such-and-such a DMT because of the time schedule and there are a lot of them here. So, it doesn’t become possible for us all to report. For instance, there’s a lot of, the NHLS, there’s pharmaceutical, there’s the information officer who gives a summary report for the activities that happened in the districts. Then we input or respond; when you haven’t done well, you indicate what causes the deviations from targets and how are you going to improve on those things. And if we don’t present the actual status ourselves, it appears". (Manager 7, 02/10/ 2015).
Managers were preparing and sending reports to the new DM who then decided which reports had to be circulated to all to read in preparation for the meeting,
“so what we are trying to do now is have a structured agenda, not a reactive agenda, a structured agenda where you have reports that you prepare and then the line management people that attend have to interact with those reports” (The new DM, 19/02/2014).
Nonetheless, getting managers to engage with information in the reports was not easy. Toward the end of 2014 at least fifteen managers were submitting reports to the DM, who then decided what would be discussed in the meeting. The hospital managers and sub-district managers as line managers were expected to read the reports to empower themselves. The DM identified two challenges to his vision, he was not fully satisfied with the make-up of the reports and not all managers had read the reports as needed before coming to meetings;
“because progressively we are going to start making decisions based on that and if they don’t read those reports … …. we are now at the point where we are kind of saying read your emails, read your reports etcetera” (The new DM, 19/09/2014)
Output 1b: The application of information for decision making was now part of managers’ performance contracts as per the Health Management and Information Systems (HMIS) Policy. There was an improved use of information to diagnose problems, monitor progress, and to support forward planning in the extended DMT meetings by sub-district managers. The IM and another manager in the DMT confirmed that, in 2015, service delivery information was being presented and discussed in the meeting and that managers had to account for targets. This process remained in place after our final evaluation period,
“we continued with what [the new DM] has started. We look into the indicators and the performance of the district, the subdistrict and the hospital CEOs, they do make some presentations so that we are able to identify gaps and formalise some strategies to work around the gaps - we’re still continuing” (Manager 6, 17/05/ 2015).
While problems were still brought to meetings, there was a proactive effort to identify solutions in the meeting;
"So now at least people, even though not everybody, but some are able to say, okay, we have got a challenge of transport – how about if management could talk with [the] municipality so that we can join vehicles together when they are going to ward A, maybe we got to ward A, all of them. Starting from that integrated planning there" (Manager 8, 24/03/2015).
"I have to get assistance from the people who are actually doing the immunisations, what was the problem? Were there vaccines that were not available, for instance; or was there something that made them not be able to come to the facility?" (Manager 7, 02/10/2015).
Output 1d: Improved capability to relate and partner with others
The large NGOs in the district met with the new DM personally to report on their district activities and subsequently, a growing number of NGOs attended DMT meetings to present and discuss their progress. NGOs also participated in developing the DHP to ensure shared planning and vision.
“Yes, I was part of that stakeholders [mapping] meeting and we all [NGO partners] presented the work that we are doing, the challenges and the successes that we have had. And on a monthly basis we used to give him our progress reports in the DMT meetings” (NGO partner 1, 18/05/2015).
"…. they [NGOs] are actually invited to make inputs [into the DHP] and also to look at the priorities of the district when they are going to be doing that. So their plans must actually be part of what the district plan is" (Manager 4, 1/10/2015).
Formal invitations to partners had also become routinised.
"Ja [yes], I think mainly it’s [NGO partner 1 & 2] who are attending those district management meetings, though it’s continuously growing in terms of who is attending those meetings" (Manager 4, 1/10/2015).
An NGO partner who had been part of the DMT meetings before 2013 (when the new DM arrived) noted that, as partners had to present on their activities when attending, it improved accountability amongst NGOs (NGO partner 2a, 2/10/2015).
Output 1e: The new DM filled at least two key senior management posts that had been critical vacancies, an HIV/AIDS, STI and TB (HAST) manager and a quality assurance manager. Also, the hospital CEOs who had been redirected to the district office were given clear job roles[2] linked to their competencies and the needs of the DMT.
D. Mechanisms for change
1. Initial sensemaking by the DM
The arrival and initial sensemaking by the DM were both a trigger and a mechanism in improving management practices in the DMT meeting.
“Look, when I first got here, we went through quite a long process of saying: “What is the ideal organogram that is needed at district level? What are the ideal processes needed at district level to ensure that we are able to have a strong management team that can take us into the NHI?” Therefore, I think it does depend a lot on what people we’ve got. I think there needs to be a standardisation of processes, because the way I am doing things, it is pretty similar to the way they do it in the [previous Province he worked in], but chatting to my colleagues from other provinces, it is not the same and I think there needs to be a standardisation of the management processes. There should be some space in between for us to express our individuality and so on, but essentially there needs to be an improvement in the standardisation” (The new DM, 09/09/2013).
The new DM drew on his personal resources, including tacit knowledge and experience in the public and private health system in another Province to design the bricolage of innovations. He did not believe that more resources would by themselves improve district performance and instead judged that inefficiencies in the public sector could be dealt with through systems improvements. The new DM explained where the idea for the structured agenda came from:
“my little thing to keep me focused, there is a thing called the district management accountability framework, which over the …. five years, .. … that I was a manager in [Province X] we progressively developed a series of things that need to be in place for a health system to be functional. So, we documented you know, the governance, management, leadership … as I was saying, those things are the pillars of …what is it … [the] WHO building blocks, but having lived through the … development of it, I understand it in a particular way. It is ... management, governance, leadership, it is service delivery, it is critical support functions, and it is quality. Now … and below that, I can see the headings … and that is the agenda for the DMT (The new DM, 09/09/2013).
“So, I think the vision comes from … a lot of the vision comes from what I have seen in reality in [Province X]. A lot of the vision [also] comes from what I have seen in reality in the private sector” (The new DM, 9/09/2014).
1a. Introducing a new agenda in the extended DMT meeting: sensemaking and sensegiving as reciprocal processes
The DM ‘disciplined’ the DMT meeting space as part of sensegiving to others– as shown in Table 2 ““discipline comes from a meticulous organisation of gestures, words and objects that permits optimal use of space, bodies, and thought” (64). He employed tacit and experiential knowledge of meetings and agendas to structure proceedings in the space, the information managers summarised the comparative data and time was allocated for managers in the meetings to speak to their performance, reinforcing accountability.
The DM translated and framed the need for a new agenda by drawing on familiar organisational-cultural codes of the health system, including discourses such as ‘core business of health’, ‘patient care related’, ‘indicators’ and ‘PHC’ and ‘performance’– the careful crafting of ‘normative sermons’.
" You know, when he came there was much more focus around the core business in meetings, than to simply discuss how much money we have spent around HR, around that, and so on. Remember, we are having this business of being the Department of Health, so everything must be patient care-related. Now once you talk the performance indicators, you talk PHC, hospital indicators, that’s fundamental – because we can say our department is existing not because of various other things but because of the performance. I would say in relation to that I'm still very much pleased " (Manager 2, 25/03/2015).
For one manager, working closely alongside the DM (proximity to change) enabled an understanding of the need for change;
"Maybe one will be saying because I was really always close to this office and having that advantage of knowing why there is this initiative, why we should change – I would say starting from you say the nature of our agenda items in the DMT … (Manager 2, 25/03/2015).
The DM over-coded, drawing on familiar organisational socio- cultural codes as a ‘stick’, noting that the ‘auditor general’ (a powerful character in the bureaucracy) can check up on the use of information and the focus on performance in meetings by looking at the agenda; effectively using hardware of the systems as a stick linked to accountability.
"the DMT meetings might have been held every month but if in the minutes and the agenda, there’s no ….. agenda items around the information or data management, then you cannot say you are discussing your performance – because it’s not showing in the agenda and minutes. So that’s what [the new DM] emphasised all the time" (Manager 1, 09/09/2013).
The new approach to meetings encouraged active participation by senior managers, whilst simultaneously facilitating their buy-in to the new practices through the process of ‘doing’. Managers appreciated that they were not ‘falling asleep’ any longer because of long drawn out processes. Increased participation provided more ingredients for sensemaking and sensegiving, which triggered motivation and self-efficacy of managers.
"Yes, because before the subdistrict managers were presenting, the CEOs were presenting – so when the last one is presenting you are no more listening, it’s already four o’clock, so you are tired. So the way he did it – it’s for the information manager to present comparing the subdistricts, not for subdistricts for [sub district A] to present, then one for sub-district B to present because at the end you won’t be able to see how do they work comparing them, and where to give assistance. The way he did it is for the information manager to present and show us which subdistricts doesn’t perform well in what. That has really helped us. Like they are also doing it today in preparation of the DMT on Thursday" (Manager 8, 24/03/2015).
These actions were complemented by the preparation and pre-reading of reports which reinforced the use of information which combined with the requirement to present problems with potential solutions, fed into a more structured agenda.
1b. Embedding the use of information for problem diagnosis and problem solving, sensegiving and sensemaking as a social process
The DM used his positional authority and employed over-coding, drawing on the professional codes of the bureaucracy [public policy], to create shared meaning around information use for decision making. The National Health Management and Information Systems policy (policy hardware) also served as a ‘stick’. The new DM enforced it to justify why managers must use information and monitor performance in their daily practise. Information use also formed part of their performance contracts as per the policy. He married this with a sermon approach, taking the time, together with the Information Manager (IM), to personally visit managers at facilities, but also reinforcing that they ‘must’ comply with government policy.
"They [the managers] were fine because we were also emphasising to them that it’s not any person’s choice, because it’s a policy issue which, though we were trained on it, but in terms of implementation, you were not implementing it as expected, but now that [was coming from] from the district manager" when [the new DM] went around (Manager 1, 09/09/2013).
Including the IM as part of his visits was symbolic in ‘setting the scene’ as the IM legitimated discussions, was always highly motivated for change despite not having had the authority to enforce improved information practices and knew the content of the HMIS in detail. To improve information use and accountability in the DMT meeting, the new DM drew on his positional authority and introduced a requirement that the sub district manager ‘sign-off’ data from the facilities before sending to the district office.
“They [sub-district managers] are more responsive, especially when it comes to the variances that we are showing them, because they are the only people that should tell us the reason as to why is it like this” (Manager 1, 09/09/2013).
The planning manager, identified as exceptional by the DM, was tasked with reviewing all the data from facilities to identify any obvious discrepancies. The DM then employed ‘sticks’ to reinforce the importance of data by writing letters to each facility manager or sub-district manager, saying either 1) your data was late, 2) your data was not complete, 3) your data is not believable in the following areas.
“So, she is now … she has given me the second month’s letter, and it is almost identical to the first month’s letter” (The new DM, 19/09/2014).
The information management changes, however, had not yet impacted at the facility level at the time of this study.
Sensemaking and sensegiving for information use was also reinforced by the working environment Some managers had been permanently appointed to their positions during the tenure of the new DM. The IM felt ‘being permanent’ supported responsiveness and accountability in the meeting, as when managers are in acting positions it was easier for them to say they are ‘only acting’ which fed into a lack of accountability.
Since NHI piloting began, additional resources for performance monitoring were introduced by the National government and the Provincial government, including templates for monitoring and evaluation and sets of preparatory activities for meetings. All managers in the DMT had been given computers and 3G data cards. The IM was hopeful that the new technology would enable better practices by the managers. She felt she needed to be released from the dependence of managers on her for information:
“Yes, because in those pivot tables [shown on the computers], all the indicators for various programmes, they are there. So the managers even [can] now compare quarters to look at the performance of sub‑district A versus [B] sub-district … to see areas that are alarming and as well as for them to be able to act up on the data that they see and it’s also assisting me as information manager, even if I am not there (Manager 1, 09/09/2013).
However, there were still challenges to using information for decision making, including a lack of trust in the data from some managers in the DMT, who therefore did not always believe in it for decision making. The DM tried to curtail these reservations by using an example of a project where data had successfully been collected and verified to illustrate that it is possible to change practice and get good data.
The new DM primarily used his positional authority (systems hardware) and told managers they must present proposed solutions based on insights from the ‘ground’ in the meeting – however he did try and justify the change through explanation,
"Ja, people were focussing on challenges. Really their focus was specific to challenges. Like they are doing now, [they] don’t have vehicles to reach area 1, so at the end what he was saying is when you have got a challenge, come up with a proposed solution, it mustn’t be just a challenge being thrown because you need to think what is it that can help you to change" (Manager 8, 24/03/2015).
But wasn’t always easy process to get people to focus on solutions. Doctors’ accommodation repeatedly came up as an issue, with a seeming lack of solution;
“So, people started getting a little bit edgy. They said what is the point of telling this guy that we have got a problem, because he actually can’t do anything about it, you know and it is that kind of a … situation” (new DM, 19/09/2014)
When a problem was resolved the team were asked to share lessons in order to generate collective learning and thus contribute to the collective capabilities of the team.
1c.Sensegiving to NGOS: crafting and managing key relationships to attract resources and support (Baser and Morgan, 2008)
In 2013, the new DM used his positional authority to host a stakeholder meeting for NGOs to present to him what they were doing in the district, what progress they were making and to remind them of their role as supporters in the district. They were told they would be invited to the extended DMT monthly meetings to present on their work to ensure objectives and progress would be aligned to district goals – effectively reinforcing ‘the disciplining of the space’. His actions were supported by many managers in the DMT;
“They [NGOS] don’t have priorities; it’s the district that has priorities – they are here to support the district to achieve the set targets on those specific priorities” (Manager 5, 1/10/2015).
For supportive NGOs he leveraged on existing shared meanings and, with some, a history of working together, for example an NGO sharing office space in the district office facilitated relationship building. He thus tapped into the intrinsic motivation of some, as they felt he gave them a ‘voice’ in these processes and that he was working hard at working together.
“Everybody had a voice. Everybody had a voice, all the partners had a voice. We felt part of the plan, and so we were prepared or we managed to own the plan" (NGO partner 1, 18/05/2015).
"as a partner we have to compromise". "As a partner we have to be flexible all the time because we are here to respond to the needs of the DoH. So if you are not doing that then the relationship between yourself and the DoH might turn a little bit sour; so you have to ensure that you’re flexible all the time" (NGO partner 1, 18/05/2015).
“no he was not a difficult person because he had the best interests of the department at heart” (NGO Partner 2b, 18/06/2020).
He told NGO partners who did not want to create a shared vision that he would report directly to their funders, using sensegiving ‘sticks’ to influence participation.
“we are actually more explicit to them, and said if you don’t talk to us, then we write to your funder, saying that you are not helping us, then they can send the money somewhere else, because everybody comes and they think the answer is training” (The new DM, 19/09/2014).
Some managers were wary of including NGOs in DMT meetings, who hold them accountable in the media. However, the new DM successfully justified the need for inclusion using his experiential knowledge;
“Really, it started working. He invited partners, even the partner that we didn’t like it a lot, Partner XXXX, so we felt that these are the people that normally write negatively about the department of health – then why are they here now? But the way he explained it ... because they were part of the meeting and they know what is happening, they have inputted in relation into what is supposed to be changed. … It really worked; I think it really worked because otherwise we didn’t like the idea, but we saw that it as fruitful” (Manager 8, 23/05/2015).
As part of his plan the new DM had originally requested one of the large NGO partners to steward all the NGOs in the district. However, this did not work - the new DM noted that not all NGOs were pulling in the same direction or knew what they were doing toward district goals, “they must be guided as to what the needs of the district are” (The new DM, 19/09/2014).
The DM then drew on his planning manager to take coordination forward; employing distributed leadership toward the overall goal;
“[the planning manager] ensures that we plan with our partners; we do reviews with our partners" (Manager 6, 17/06/2020).
The district NGO coordinator felt somewhat left out of these new processes, as he was not a senior manager and thus did not attend extended DMT meetings. In his daily role he coordinated Community Based Organisation organisations rather than large NGOs.
The DM also used familiar professional codes and discourse to translate to NGOs that they had to participate in the development of the District Health Plan. This also helped to create shared meaning on the importance of shared vision and accountability in the district;
"Firstly, [the new DM] told us that what he needs is a consolidated plan for the DoH and for the partners as well. As partners we have our own operational plans that talk to the objectives and the targets that have been set up by our funders, and there are certain indicators that we need to focus on. Same applies to the DoH because they have got some indicators that they need to focus on, so [the new DM] said with all your plans that you have, they need to be integrated into our master-plan so that we can have one plan that we are going to support and implement as OR Tambo district. So we found that very valuable because with all the plans that we had, we had an opportunity to express our concerns and maybe the needs that we might have as partners for the kind of support that we are expecting from the DoH" (NGO partner 1, 18/05/2015).
Other mechanisms in context that facilitated sensemaking and sensegiving included the formal establishment of a large NGO specifically placed in the district to provide technical support directly linked to being an NHI pilot site, and the arrival of donor-funded projects which intentionally and actively sought to build working relationships between themselves and members of the management team (eg. a UNICEF project).
An NGO partner noted that strong partnerships are built on good relationships,
“Make good relationships with people, be flexible and try and understand other’s opinions. Don’t be a know it all - acknowledge we learn from them and then learn from us. Be yourself and present yourself as you are” (NGO Partner 2b, 18/06/2020).
While the arrangements had improved, persistent ongoing challenges for partner NGOs in the district included no power and a lack of recourse to hold staff accountable in the sub-districts they supported where, for example, staff showed lack of urgency.
1d. The number and distribution of managers in the team: negotiation as sensegiving
Using his positional authority, the DM negotiated within his resource envelope rather than pushing the Provincial government for more money to fill a critical vacancy (quality assurance manager) in the DMT;
“I have weighed up the benefit of one post above the other one, and said I am giving you [the Provincial government] the money for a quality assurance manager, … I have got a TB manager that resigned, and I said TB and HIV should actually be under the same deputy director. So, I am taking that TB money and that is quality assurance money” (The new DM, 19/09/2014).
This approach of ranking management posts according to importance was contested, as some senior managers felt that posts at the same level cannot be ranked (e.g. occupational health and safety against an HIV manager). But, using his positional authority, the new DM told managers to do the ranking. He used an exercise in which managers were asked to rank themselves from one to ten, in order to create shared meaning. Using his implicit knowledge he tried to create sense for others and diffuse meanings around the change – to subjectively influence and convince recipients to adopt change (64). Whilst acknowledging the reluctance of managers to do the ranking and his own discomfort in ranking posts as he believed were all important, he noted that due to shortages of money it had to be done.
“But you … as a leader and manager, you have to make tough decisions” (The new DM, 19/09/2014).
He noted some said he did not push the Province hard enough for more resources, but he drew on his knowledge resources to arrive at a decision;
“I come from a different school of thought, but I mean to be fair, there are people that say I don’t argue enough for more resources and that is based on … I attended a course on efficiency and so on and he [the lecturer] said the worst thing that you can do for a dysfunctional system is to throw money into it ….. it makes it more dysfunctional. So, I have been … when Province says I am not giving you money, I say okay” (The new DM, 19/09/2014).
.For the Hospital CEOs who were deployed to the DMT with no portfolio he considered their skill set, then wrote each one a role description and assigned them a portfolio of work where they could use their skills, thus purposefully enhancing the collective capabilities of managers within the DMT. The DM drew on a common cultural code in the workplace of having a ‘role description’ to facilitate a sense of collective purpose.
"He couldn’t get formal job description because job descriptions comes from the provincial office ..[but] … he looked at those who were additional to the establishment and then from there he managed to allocate them in areas where he was seeing that there are gaps … so from there you will be able now to come with what you are supposed to be doing" (Manager 8, 24/03/2015).
Footnote:
[1] 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.
[2] These were not new formal posts on the organogram but rather a description of the duties they were expected to fulfil.