The dissemination and diffusion of innovations: what helps managers to lead change in the district health system?
A key challenge of top-down policy formulation is that those on the ground - in health districts, health facilities and communities - are typically excluded from the process. They often do not have full information on the policy’s rationale and/or full details on how to implement it. This can result in the policy implementation or know-do gap.
It is therefore important for policy formulators to effectively disseminate information on the rationale, content and system requirements of new policy to frontline implementers, especially those who must lead and manage the change. Managers on the ground must be able to make sense of the change for themselves and translate new policies for their staff, although some information will also spread through natural diffusion.
Fortunately, there are lenses to help us think about the dissemination and diffusion of new policies and programmes. Diffusion and dissemination exist on a continuum: dissemination strategies are formal, planned efforts to persuade target groups to adopt an innovation (often centralised and occurring through vertical hierarchies) whereas in pure diffusion, the spread of innovations is unplanned, informal, decentralised, and largely mediated by peers (Greenhalgh et al. 2003).
In this blog I summarise findings from a paper in which I sought to garner key lessons about what dissemination strategies (or lack thereof) make life easier or more difficult for senior managers in health districts to adopt reforms. I looked at the period 2012 – early 2014 when the national government introduced new innovations into the National Health Insurance pilot districts in South Africa. I interviewed 37 senior managers in three health districts and found:
- Reform champions can play a role in disseminating information. A roadshow by the Minister of Health helped managers to make sense of the rationale for reforms, including the need for change and an integrated PHC platform. Face-to-face time with the Minister also made managers feel valued.
- When ideas underpinning new reforms aligned well with existing ideas and programmes in the district, it was easier to diffuse reforms into the district.
- When articulating the innovations to stakeholders, it helped to show how they linked to existing policies in the health system; demonstrating continuity between practices.
- Managers need early information about which new actors (donors, NGO partners etc.) will be arriving in their districts to support change. They also valued pre-scheduled visits from national government to align with the routine district activities already planned.
- To lead change, managers need full information on the how, why and what to do of individual innovations, as well as lessons on how it had worked in other contexts. This helps them to understand the innovations and disseminate information to their staff.
- Dissemination and diffusion is not a once-off activity. Managers successfully employed some of the new reforms to support the implementation of other reforms later introduced in the same district. For example, a new team of district clinical specialists helped to develop an induction programme for a group of private general practitioners contracting into the public sector.
- NHI coordinators, who served as project managers, helped to anchor the reforms in the district, as they explicitly liaised up, down and across the health system. The NHI coordinators valued being accepted as part of the district management team.
- It is helpful if some members of the innovation team have a history in the district, supporting them to capitalize on existing networks, which enables further dissemination.
- It is helpful to link new members of the management team with others who have institutional memory to help them navigate the system. For example a new NHI coordinator attended meetings with someone who had long been in charge of PHC in the district to help with his confidence.
- When support teams from national government assist in managing change, it helps if they are open minded to the local context shaping the reform to support local needs, can make decisions quickly and are responsive to requests for information.
- Managers know what the basic needs in their districts are, so provide them with some space to also fix existing local problems through harnessing these new resources.
- Chronic systemic challenges make it hard to implement change, especially in contexts with vacancies and a history of poor performance, but new innovations like NHI piloting also bring funding and renewed interest which can improve life in the district.
Senior managers in the district health system are critical boundary spanners between top-down reforms and local implementation. Those who work at the top must think strategically about how to be most helpful when disseminating information about reforms and think through mechanisms that enable managers to influence their staff to adopt reforms. Senior managers hold a critical space between national policies and lower levels of government.
Marsha Orgill, Division of Health Policy and Systems, School of Public Health and Family Medicine, University of Cape Town