Abstract
BackgroundHealth 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.MethodsWe 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.ResultsThe 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.ConclusionsCapacity 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.Electronic supplementary materialThe online version of this article (doi:10.1186/1478-4505-12-42) contains supplementary material, which is available to authorized users.
Highlights
A capacity-building intervention that targets district health management teams is complex given that its implementation involves various actors with different objectives, roles, and power
We aim to demonstrate how the realist evaluation approach helps in advancing complex systems thinking in healthcare evaluation
Health worker performance is closely related to their management capacity, but not limited to capacity alone; performance of health staff is determined by a variety of factors related to motivation, organisational dynamics and culture, and environmental factors including socio-economic and political factors [5,6,7]
Summary
A capacity-building intervention that targets district health management teams is complex given that its implementation involves various actors with different objectives, roles, and power. Health worker performance is closely related to their management capacity, but not limited to capacity alone; performance of health staff is determined by a variety of factors related to motivation, organisational dynamics and culture, and environmental factors including socio-economic and political factors [5,6,7] These determinants of performance are constantly changing. From a complex adaptive systems perspective, capacity and performance could be viewed as emergent characteristics of a district health system that has many constantly self-adjusting and inter-dependent components [8] Health systems interventions, such as capacity-building of health workers, are implemented across districts in order to improve performance of healthcare organisations.
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