Abstract
Performance of local health services managers at district level is crucial to ensure that health services are of good quality and cater to the health needs of the population in the area. In many low- and middle-income countries, health services managers are poorly equipped with public health management capacities needed for planning and managing their local health system. In the south Indian Tumkur district, a consortium of five non-governmental organizations partnered with the state government to organize a capacity-building program for health managers. The program consisted of a mix of periodic contact classes, mentoring and assignments and was spread over 30 months. In this paper, we develop a theoretical framework in the form of a refined program theory to understand how such a capacity-building program could bring about organizational change. A well-formulated program theory enables an understanding of how interventions could bring about improvements and an evaluation of the intervention. In the refined program theory of the intervention, we identified various factors at individual, institutional, and environmental levels that could interact with the hypothesized mechanisms of organizational change, such as staff’s perceived self-efficacy and commitment to their organizations. Based on this program theory, we formulated context–mechanism–outcome configurations that can be used to evaluate the intervention and, more specifically, to understand what worked, for whom and under what conditions. We discuss the application of program theory development in conducting a realist evaluation. Realist evaluation embraces principles of systems thinking by providing a method for understanding how elements of the system interact with one another in producing a given outcome.
Highlights
The local health system at the district level is an important organizational unit for management of health services
The first point of contact between people and healthcare professionals is a network of Primary Health Centers (PHC), which depend on a hospital at the sub-district level for secondary care
Our analysis shows that the program implementers felt that the objectives of the capacity-building program aligned with the new resources coming through the National Rural Health Mission (NRHM) and NRHM’s efforts at district level decentralization
Summary
The local health system at the district level is an important organizational unit for management of health services. In India and many other low- and middle-income countries (LMICs), doctors are usually in charge of the management of local health systems. It should ensure that the health care provided is organized and managed in such a way that it is physically and financially accessible, equitable, of good quality, and responsive to local needs [1]. Many district health systems in LMICs do not have the capacity to allocate their financial resources equitably and manage their technical resources optimally [2]. The health workforce is unequally distributed leading to skill mix problems [3]. This affects the quality of the healthcare provided and the health status of the people. In the absence of a well-functioning local health system, disease-control programs are hampered in achieving their goals, in spite of their good design
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