Advancing the application of systems thinking in health: realist evaluation of the Leadership Development Programme for district manager decision-making in Ghana
Advancing the application of systems thinking in health: realist evaluation of the Leadership Development Programme for district manager decision-making in Ghana
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DOI：
10.1186/1478-4505-12-29
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发表时间：
2014-06-16
影响因子：
4
通讯作者：
Agyepong, Irene Akua
中科院分区：
文献类型：
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作者：
Kwamie, Aku;van Dijk, Han;Agyepong, Irene Akua
背景：虽然人们普遍认为强有力的地区管理者决策改善了卫生系统，但对加强能力干预措施的设计和实施如何发挥作用的了解有限。加纳卫生局通过了领导力发展方案(LDP)作为一项干预措施，以支持地区工作队内部管理和领导力的发展。本文试图解决当自民党被引入加纳的地区卫生系统时，它是如何以及为什么起作用的，以及它是否支持地区团队的系统思维。方法：我们进行了一项现实主义评估，以调查干预的结果、背景和机制。基于我们先前工作中提出的两个工作假设，我们对加纳大阿克拉地区的一个农村地区进行了解释性案例研究。数据收集包括参与者观察，文件回顾，以及在干预之前、期间和之后对地区经理的半结构化访谈。从对背景的深入分析和观察到的短期和中期结果向后工作，我们绘制了因果环图来解释背景、结果和机制之间的相互作用。结果：LDP对地区经理和团队来说是一次宝贵的经验，因为新方法支持团队合作、倡议建设和改进的优先顺序。然而，自民党没有在地区团队中制度化，也没有带来更多的系统思维。这与自民党内部高度不确定的背景以及制度的等级权威有关，这引发了自民党组织控制的根本目标。结论：当试图维持复杂的干预措施时，考虑组织背景是重要的，因为它似乎会影响短期和中期结果之间的差距。更明确地关注系统思维原则，使地区管理者能够更好地应对其背景，可能会加强自民党未来的制度化。
Background: Although there is widespread agreement that strong district manager decision-making improves health systems, understanding about how the design and implementation of capacity-strengthening interventions work is limited. The Ghana Health Service has adopted the Leadership Development Programme (LDP) as one intervention to support the development of management and leadership within district teams. This paper seeks to address how and why the LDP 'works' when it is introduced into a district health system in Ghana, and whether or not it supports systems thinking in district teams.Methods: We undertook a realist evaluation to investigate the outcomes, contexts, and mechanisms of the intervention. Building on two working hypotheses developed from our earlier work, we developed an explanatory case study of one rural district in the Greater Accra Region of Ghana. Data collection included participant observation, document review, and semi-structured interviews with district managers prior to, during, and after the intervention. Working backwards from an in-depth analysis of the context and observed short-and medium-term outcomes, we drew a causal loop diagram to explain interactions between contexts, outcomes, and mechanisms.Results: The LDP was a valuable experience for district managers and teams were able to attain short-term outcomes because the novel approach supported teamwork, initiative-building, and improved prioritisation. However, the LDP was not institutionalised in district teams and did not lead to increased systems thinking. This was related to the context of high uncertainty within the district, and hierarchical authority of the system, which triggered the LDP's underlying goal of organisational control.Conclusions: Consideration of organisational context is important when trying to sustain complex interventions, as it seems to influence the gap between short-and medium-term outcomes. More explicit focus on systems thinking principles that enable district managers to better cope with their contexts may strengthen the institutionalisation of the LDP in the future.