Advancing the application of systems thinking in health: a realist evaluation of a capacity building programme for district managers in Tumkur, India
Advancing the application of systems thinking in health: a realist evaluation of a capacity building programme for district managers in Tumkur, India
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DOI：
10.1186/1478-4505-12-42
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发表时间：
2014-08-26
影响因子：
4
通讯作者：
Criel, Bart
中科院分区：
文献类型：
--
作者：
Prashanth, Nuggehalli Srinivas;Marchal, Bruno;Criel, Bart
背景资料：卫生系统的干预措施，如卫生工作者的能力建设，在各区实施，以提高保健组织的业绩。然而，这种干预措施往往在某些情况下有效，而在另一些情况下无效。地方卫生系统可以看作是复杂的适应系统，根据当地条件和一些个人、机构和环境因素，对能力建设干预措施的投入作出不同的反应。我们的目的是展示如何现实主义的评估方法先进的复杂系统的思维在医疗保健评价的方法来理解组织的变化在当地的卫生系统在印度南部的Tumkur区。我们收集了关于talukas的几个输入、过程和结果指标的数据（区的行政附属单位），并探讨个人，机构，和背景因素在使用定性数据的结果作出贡献结果：Tumkur地区的talukas对干预的反应不同。他们的反应可以通过几个个人，机构和环境因素之间的相互作用来解释。在一个拥有忠诚的工作人员和积极的变革意愿的taluka中，干预措施通过与权力下放过程中的现有机会保持一致来提高绩效。然而，对该组织的承诺既不重要，也不充分。另外两个talukas的忠诚员工无法实现他们改善组织绩效的意图。在另一个taluka，领导层能够弥补缺乏commitment.Conclusions：地方卫生系统的能力建设可以通过调整或反对内部（个人和组织）和外部（政策和社会政治环境）属性的组织之间的现有关系。在设计和实施阶段，干预计划者需要确定这种触发调整的机会。地方卫生系统的内部结构可能各不相同，因此，能力建设方案需要考虑到通过不同途径进行变革的可能性。通过制定和测试假设，进行批判性比较，发现经验模式，并监测其范围和程度的过程中，现实主义的评价能够全面评估卫生系统的全系统变化。
Background: Health systems interventions, such as capacity-building of health workers, are implemented across districts in order to improve performance of healthcare organisations. However, such interventions often work in some settings and not in others. Local health systems could be visualised as complex adaptive systems that respond variously to inputs of capacity building interventions, depending on their local conditions and several individual, institutional, and environmental factors. We aim at demonstrating how the realist evaluation approach advances complex systems thinking in healthcare evaluation by applying the approach to understand organisational change within local health systems in the Tumkur district of southern India.Methods: We collected data on several input, process, and outcome measures of performance of the talukas (administrative sub-units of the district) and explore the interplay between the individual, institutional, and contextual factors in contributing to the outcomes using qualitative data (interview transcripts and observation notes) and quantitative measures of commitment, self-efficacy, and supervision style.Results: The talukas of Tumkur district responded differently to the intervention. Their responses can be explained by the interactions between several individual, institutional, and environmental factors. In a taluka with committed staff and a positive intention to make changes, the intervention worked through aligning with existing opportunities from the decentralisation process to improve performance. However, commitment towards the organisation was neither crucial nor sufficient. Committed staff in two other talukas were unable to actualise their intentions to improve organisational performance. In yet another taluka, the leadership was able to compensate for the lack of commitment.Conclusions: Capacity building of local health systems could work through aligning or countering existing relationships between internal (individual and organisational) and external (policy and socio-political environment) attributes of the organisation. At the design and implementation stage, intervention planners need to identify opportunities for such triggering alignments. Local health systems may differ in their internal configuration and hence capacity building programmes need to accommodate possibilities for change through different pathways. By a process of formulating and testing hypotheses, making critical comparisons, discovering empirical patterns, and monitoring their scope and extent, a realist evaluation enables a comprehensive assessment of system-wide change in health systems.