Health Sector Organisations Research Articles

Readiness of Chief Executives for transformational change across Health, Councils and Third sector in Scotland to lead public service reform: A Grounded Theory Approach

Introduction: The Chrisitie Commission Report (2011) set out a proposition and key recommendations for the public services in Scotland to embark on a journey of transformational change, and to improve the outcomes for the people of Scotland. The scale and scope of the reform is very large and transcends, Health, Councils and Third Sector. This research is timely and investigated the readiness of chief executives of organizations from each of the 3 sectors to achieve Christie’s Transformational agenda. Methods: A constructivist grounded theory method was used (Charmaz 2000). This involved detailed conversations with 3 chief executives from each of Health, Councils and Thirds Sector organizations to gather rich data. Using a constant comparative method, key themes emerged, which led to the development of a substantive grounded theory. Results: Strong cohesive themes around culture, power, change and relationships emerged which articulate the barriers and enablers currently in play in implementing transformational change for these sectors. This research has run parallel to the consultation on Health and Social Care Integration, publication of the Public Bodies (Joint working) (Scotland) Act 2014 and the beginning of the implementation of that Bill. The results capture the nuances and deep meaning the Chief executives hold relating to this agenda in Scotland. In the context of Christie’s proposition the three sectors relate to change and transformation as part of a journey and they each have differing barriers and enablers in fully achieving transformative change. Political influence and ‘autonomy to act’, impact on the receptiveness to change and the perception that reform is either an opportunity or a transactional event. Discussions: Across the public service sector Chief Executives recognize fully the key drivers which have resulted in the need for radical change. There is a general dislike of the term “Transformational” and the use of “reform’ is more widely accepted. Health, Councils and Third Sector Chief executives collectively demonstrate a skill-set which is diverse. Emergent change theory drives a more relational based approach to achieving transformational change and the International Journal of Integrated Care – Volume 15, 27 May – URN:NBN:NL:UI:10-1-116999 – http://www.ijic.org/ 15th International Conference on Integrated Care, Edinburgh, UK, March 25-27, 2015 2 leadership skills required to do this are very different to the traditional models of leadership, evident in some parts of Public service. Transformational or radical change does not need to be large to be impactful and Christie’s vision for the people of Scotland is possible to achieve with a greater emphasis on new ways of engaging and thinking about change theory. Conclusion: Public services in Scotland are currently on the edge of something emergent. The desire to reform is clear amongst the leaders across Public services. To achieve the change required at pace and scale, to maintain sustainable services and the outcomes aspired to by the Christie Commission, requires a significant review of how we think about change, engage with the public and third sector and utilize fully the diverse range of skills evident in the chief executives as a whole in Scotland. Readiness for transformational change is variable, indicating that considerable support will be needed to fully achieve this goal. Lessons learned: This research offers an important insight into Scotland’s public service leaders readiness for transformational change. It offers new knowledge and evidence, not published elsewhere. The lessons learnt are topical and of value to many organizations at a time of great change. Limitations: The research samples a cohort of chief executives from the public services in Scotland at a point in time. A substantive theory was generated as a result and in keeping with the methodology and iterative process. Suggestions for future research: Given that the implementation of integrated services is currently underway in Scotland it would be of value to investigate further the views and perceptions of change within the Chief Officers employed and charged with running these new public bodies and contributing to public services reform.

Assessing the effectiveness of conflict management training in a health sector organization: evidence from subjective and objective indicators

This study assessed the effectiveness of an intervention for handling interpersonal conflicts at work. In contrast to the mainstream approach in the health care industry, which focuses on developing formal systems of conflict resolution, our intervention consisted of enhancing health care workers’ conflict management skills through training. A pre- and post-test nonequivalent comparison group design was used (intervention group = 258 workers; comparison group = 243 workers). Participants perceived that the training was successful in reducing the number and intensity of conflicts with co-workers, patients, and patients’ relatives. Moreover, organizational indicators calculated on the basis of data obtained from human resources (HR) records show that the intervention was effective, insofar as the number of requests for third-party interventions to mediate conflicts at work, the number of patients’ complaints, and the level of absenteeism all decreased for trained workers, whereas workers from the comparison group exhibited no corresponding changes over time. In the light of these results, this article discusses the design of conflict management measures which could help improve both employees’ well-being and organizational productivity.

Context for Food-Based Approaches for Improved Feeding of Infants and Children in Ethiopia

Regardless of efforts by the health sector and partner organizations, maternal and child malnutrition is still a challenge in Ethiopia. To describe the context of current infant and child feeding patterns in Ethiopia. Feeding patterns, diet content and quality, and nutritional outcomes and feeding practices of mothers of young children are described from literature review of a number of field studies. Protein and energy deficiencies and multiple micronutrient deficiencies are common. Breastfeeding is often prolonged until 2 years of age, with introduction of small amounts of poor-quality complementary foods. Vitamin A and iodine deficiencies have also been problems. Focus group discussions showed that mothers did not believe that animal-source foods are needed.by young children or schoolchildren. However, the Health Extension Program led by the Federal Ministry of Health promotes optimal child feeding as one of the health extension packages. Continued use of germination and fermentation of cereals should be encouraged to increase bioavailability of trace elements. Use of fat in the diet would increase energy density. To improve the situation, extension education, including nutrition and agricultural expertise delivered in aformat understandable to mothers about appropriate complementary feeding, including animal-source foods, is urgently needed, with expansion of governmental and nongovernmental resources.

Achieving success in reducing teenage pregnancy in Hull.

Teenage pregnancy is a complex issue with a range of contributing risk factors including poverty, low educational attainment, truancy, not being in education, employment or training (NEET), low self-esteem, early sexual activity and poor contraception use. There are disproportionately poor outcomes for those who do become teenage parents. At age 30, teenage mothers are 22% more likely to be living in poverty, 20% more likely to have no qualifications than mothers giving birth aged 24 or over and are much less likely to be employed or living with a partner. Research and evidence-based practice has shown this issue cannot be addressed through a single intervention or service as the majority of teenage pregnancies are unplanned. Instead a consistent and co-ordinated partnership approach at a strategic and operational level across schools, health, youth services, social care and voluntary sector organisations is required to deliver improved outcomes. An early intervention and prevention approach which aims to reduce risks and build resilience, along with effective use of local data and performance management is vital to maximizse impact and ensure those areas/groups of young people most at risk are reached and supported.This paper aims to summarize the successful implementation of the National Teenage Pregnancy Strategy1 at a local level. It aims to inform future commissioning and policy and build on the evidence base to sustain the current downward trend, maximize impact and continue to deliver positive outcomes in a cost effective way for young people on this and other health issues.NATIONAL CONTEXTThe Labour Government's Teenage Pregnancy Strategy for England1 had a national target to reduce under-18 conceptions nationally by 50% by 2010. All local authority areas agreed on a local reduction target ranging between 40% and 60%. If all areas had met their targets then the national 50% target would have been achieved. However impact varied with some areas seeing significant reductions while others saw smaller reductions or even, in some cases, increases. Differing outcomes related to a range of local factors highlighted in this article including level of investment and prioritization of the issue at a senior and political level.The national strategy1 was informed by an international evidence review which identified thirty key action points categorized under four main themes:* joined up action, nationally, regionally and locally;* improved sex and relationship education;* access to youth friendly contraception and sexual health services; and* improved support for young parents to improve the disproportionately poor outcomes for them and their children.There was also a national campaign to reach young people and parents.Over the course of the strategy, further national guidance and updated strategies were published nationally and implemented locally. 2-7. These were informed by emerging evidence which underpinned the importance of key aspects of the strategy including high quality sex and relationships education (SRE)8 and the importance of improving access to and increasing the uptake of contraception.9 Furthermore the guidance was informed by deep dive reviews which compared similar areas (statistical neighbours) with contrasting progress which showed reductions associated with all elements of the strategy being in place.PROGRESS MADE IN HULLReducing under-18 conception rates was identified as a key issue for Hull following the launch of the National Teenage Pregnancy Strategy in 1998. As the strategy developed locally it was further informed by local consultation and research to address gaps in provision and enable service redesign to meet need, including understanding local barriers to accessing services,10 the sexual health needs of boys and young men,11 barriers to preventing unplanned conception,12 an evaluation of support for teenage parents13 and the local biannual Young People's Health and Lifestyle survey. …

Experiences and Attitudes Towards Evidence‐Informed Policy‐Making Among Research and Policy Stakeholders in the Canadian Agri‐Food Public Health Sector

Policy-makers working at the interface of agri-food and public health often deal with complex and cross-cutting issues that have broad health impacts and socio-economic implications. They have a responsibility to ensure that policy-making based on these issues is accountable and informed by the best available scientific evidence. We conducted a qualitative descriptive study of agri-food public health policy-makers and research and policy analysts in Ontario, Canada, to understand their perspectives on how the policy-making process is currently informed by scientific evidence and how to facilitate this process. Five focus groups of 3-7 participants and five-one-to-one interviews were held in 2012 with participants from federal and provincial government departments and industry organizations in the agri-food public health sector. We conducted a thematic analysis of the focus group and interview transcripts to identify overarching themes. Participants indicated that the following six key principles are necessary to enable and demonstrate evidence-informed policy-making (EIPM) in this sector: (i) establish and clarify the policy objectives and context; (ii) support policy-making with credible scientific evidence from different sources; (iii) integrate scientific evidence with other diverse policy inputs (e.g. economics, local applicability and stakeholder interests); (iv) ensure that scientific evidence is communicated by research and policy stakeholders in relevant and user-friendly formats; (V) create and foster interdisciplinary relationships and networks across research and policy communities; and (VI) enhance organizational capacity and individual skills for EIPM. Ongoing and planned efforts in these areas, a supportive culture, and additional education and training in both research and policy realms are important to facilitate evidence-informed policy-making in this sector. Future research should explore these findings further in other countries and contexts.

A qualitative examination of the health workforce needs during climate change disaster response in Pacific Island Countries.

BackgroundThere is a growing body of evidence that the impacts of climate change are affecting population health negatively. The Pacific region is particularly vulnerable to climate change; a strong health-care system is required to respond during times of disaster. This paper examines the capacity of the health sector in Pacific Island Countries to adapt to changing disaster response needs, in terms of: (i) health workforce governance, management, policy and involvement; (ii) health-care capacity and skills; and (iii) human resources for health training and workforce development.MethodsKey stakeholder interviews informed the assessment of the capacity of the health sector and disaster response organizations in Pacific Island Countries to adapt to disaster response needs under a changing climate. The research specifically drew upon and examined the adaptive capacity of individual organizations and the broader system of disaster response in four case study countries (Fiji, Cook Islands, Vanuatu and Samoa).Results‘Capacity’ including health-care capacity was one of the objective determinants identified as most significant in influencing the adaptive capacity of disaster response systems in the Pacific. The research identified several elements that could support the adaptive capacity of the health sector such as: inclusive involvement in disaster coordination; policies in place for health workforce coordination; belief in their abilities; and strong donor support. Factors constraining adaptive capacity included: weak coordination of international health personnel; lack of policies to address health worker welfare; limited human resources and material resources; shortages of personnel to deal with psychosocial needs; inadequate skills in field triage and counselling; and limited capacity for training.ConclusionFindings from this study can be used to inform the development of human resources for health policies and strategic plans, and to support the development of a coordinated and collaborative approach to disaster response training across the Pacific and other developing contexts. This study also provides an overview of health-care capacity and some of the challenges and strengths that can inform future development work by humanitarian organizations, regional and international donors involved in climate change adaptation, and disaster risk reduction in the Pacific region.

P121 How implementing deciding right in Cumbria supports good practice in Advanced care planning (ACP): a case study

IntroductionDeciding Right (DR) is an integrated approach to making decisions about future care. It draws together statute and good practice for ACP with children, young people and adults across all...

The perceived importance and the presence of creative potential in the health professional's work environment

The value of creative employees to an organisation's growth and innovative development, productivity, quality and sustainability is well established. This study examined the perceived relationship between creativity and work environment factors of 361 practicing health professionals, and whether these factors were present (realised) in their work environment. Job design (challenges, team work, task rotation, autonomy) and leadership (coaching supervisor, time for thinking, creative goals, recognition and incentives for creative ideas and results) were perceived as the most important factors for stimulating creativity. There was room for improvement of these in the work environment. Many aspects of the physical work environment were less important. Public health sector employers and organisations should adopt sustainable strategies which target the important work environment factors to support employee creativity and so enhance service quality, productivity, performance and growth. Implications of the results for ergonomists and workplace managers are discussed with a participatory ergonomics approach recommended. Practitioner summary: Creative employees are important to an organisation's innovation, productivity and sustainability. The survey identified health professionals perceive a need to improve job design and leadership factors at work to enhance and support employee creativity. There are implications for organisations and ergonomists to investigate the creative potential of work environments.

Understanding NHS Policy Making in England: The Formulation of the NHS Plan, 2000

Research Highlights and Abstract The article investigates which of two competing accounts of contemporary British policy making better captures the nature of policy making during episodes of major reform of the English NHS. The analysis of the formulation of the English NHS Plan 2000 suggests that the Asymmetric Power Model better describes the reality of NHS policy making under New Labour than the Differentiated Polity Model. Although the process of developing the Plan showed signs of a more open policy process, it was tightly controlled and personally led by the Secretary of State for Health and his close advisers, reflecting an underlying British political tradition that emphasises the idea that the NHS has to be continuously improved with change led from above by central government. However, when compared to the processes underpinning Thatcher's Ministerial Review of the NHS and the 2010 Coalition government's White Paper, if ever NHS policy making in England were to have come close to the Differentiated Polity Model, it would have been during the formulation of the 2000 NHS Plan. Through a case study of the formulation of the English NHS Plan 2000, this article investigates which of two competing models of the British policy process—the Differentiated Polity and Asymmetric Power Models—better describes the reality of major NHS reform policy making under New Labour. The process of developing the Plan showed signs of a more open policy process, seemingly closer to the DPM. There was contestability of policy advice and limited involvement of the medical profession through its representative bodies. However, the process was tightly controlled and personally led by the Secretary of State and his advisers, with the direct involvement of the Prime Minister throughout. Two key moments of interest group involvement—the Modernisation Action Teams and the signing of the Plan by health sector organisations—were marked by power asymmetries. Overall, the APM better describes the reality of major reform policy making under New Labour.

Building capacity: leadership and HCAs (2/2)

The article describes the processes of a business project that was carried out in 2010. It is the personal leadership journey of a nurse managing a change process for an organisation and the principles in the article are applicable to any health and social care sector organisations. It uses the characteristics from Factor 8 Diverse Leaders and demonstrates how a project such as this can address the challenges, be aligned to the organisation's strategic vision and produce outcomes. The report will illustrate the inter-relatedness of the characteristics of good leadership. It concludes with a series of questions and an example to help those who may be interested in starting a project that could challenge and develop their capacity as leaders.

Use of health systems evidence by policymakers in eastern mediterranean countries: views, practices, and contextual influences

BackgroundHealth systems evidence can enhance policymaking and strengthen national health systems. In the Middle East, limited research exists on the use of evidence in the policymaking process. This multi-country study explored policymakers’ views and practices regarding the use of health systems evidence in health policymaking in 10 eastern Mediterranean countries, including factors that influence health policymaking and barriers and facilitators to the use of evidence.MethodsThis study utilized a survey adapted and customized from a similar tool developed in Canada. Health policymakers from 10 countries (Algeria, Bahrain, Jordan, Lebanon Oman, Pakistan, Palestine, Sudan, Tunisia, and Yemen) were surveyed. Descriptive and bi-variate analyses were performed for quantitative questions and thematic analysis was done for qualitative questions.ResultsA total of 237 policymakers completed the survey (56.3% response rate). Governing parties, limited funding for the health sector and donor organizations exerted a strong influence on policymaking processes. Most (88.5%) policymakers reported requesting evidence and 43.1% reported collaborating with researchers. Overall, 40.1% reported that research evidence is not delivered at the right time. Lack of an explicit budget for evidence-informed health policymaking (55.3%), lack of an administrative structure for supporting evidence-informed health policymaking processes (52.6%), and limited value given to research (35.9%) all limited the use of research evidence. Barriers to the use of evidence included lack of research targeting health policy, lack of funding and investments, and political forces. Facilitators included availability of health research and research institutions, qualified researchers, research funding, and easy access to information.ConclusionsHealth policymakers in several countries recognize the importance of using health systems evidence. Study findings are important in light of changes unfolding in some Arab countries and can help undertake an analysis of underlying transformations and their respective health policy implications including the way evidence will be used in policy decisions.

Developing Nontraditional Community Health Placements

Building capacity for student clinical experiences has become a key concern for nurse educators in the 21st century. For community health faculty, traditional placements at public health departments or other health-affiliated organizations often do not provide adequate numbers or types of placement opportunities. Wishing to expand experiences for its undergraduate program, faculty at a midwestern university have developed and nurtured long-standing collaborative relationships with organizations not typically used by schools of nursing. Such partnerships are often called "nontraditional," with the understanding that they are not affiliated with the typical health sector organizations. This article introduces two of these partnerships, describes the process used to establish and maintain them, and identifies the outcomes achieved by students, clients, and organizations.

High performance work systems: the gap between policy and practice in health care reform

Studies of high-performing organisations have consistently reported a positive relationship between high performance work systems (HPWS) and performance outcomes. Although many of these studies have been conducted in manufacturing, similar findings of a positive correlation between aspects of HPWS and improved care delivery and patient outcomes have been reported in international health care studies. The purpose of this paper is to bring together the results from a series of studies conducted within Australian health care organisations. First, the authors seek to demonstrate the link found between high performance work systems and organisational performance, including the perceived quality of patient care. Second, the paper aims to show that the hospitals studied do not have the necessary aspects of HPWS in place and that there has been little consideration of HPWS in health system reform. The paper draws on a series of correlation studies using survey data from hospitals in Australia, supplemented by qualitative data collection and analysis. To demonstrate the link between HPWS and perceived quality of care delivery the authors conducted regression analysis with tests of mediation and moderation to analyse survey responses of 201 nurses in a large regional Australian health service and explored HRM and HPWS in detail in three casestudy organisations. To achieve the second aim, the authors surveyed human resource and other senior managers in all Victorian health sector organisations and reviewed policy documents related to health system reform planned for Australia. The findings suggest that there is a relationship between HPWS and the perceived quality of care that is mediated by human resource management (HRM) outcomes, such as psychological empowerment. It is also found that health care organisations in Australia generally do not have the necessary aspects of HPWS in place, creating a policy and practice gap. Although the chief executive officers of health service organisations reported high levels of strategic HRM, the human resource and other managers reported a distinct lack of HPWS from their perspectives. The authors discuss why health care organisations may have difficulty in achieving HPWS. Leaders in health care organisations should focus on ensuring human resource management systems, structures and processes that support HPWS. Policy makers need to consider HPWS as a necessary component of health system reform. There is a strong need to reorient organisational human resource management policies and procedures in public health care organisations towards high performing work systems.

(P1-16) Local Health-Related Capacities in the Northern Haiti Post-Earthquake Response

BackgroundThe January 2010 earthquake affected many services in Haiti, including health care. After the disaster, top-down response from international sources seemed like the only solution. While the existing health system was fragile, opportunities likely existed for incorporating bottom-up approaches in the capital and other cities, such as Cap Haitien in the North.ObjectiveThe study aims to: (1) identify available local health-related resources; (2) examine how these were, or were not, utilized in response efforts; and (3) evaluate the level of coordination among health delivery groups, particularly preparedness and recovery.MethodsThis case study included 11 key informant interviews at two hospitals (six at Justinian and five at Milot) and an organizational analysis of cooperation among 16 health-related organizations operating in northern Haiti. Disaster preparedness and recovery data for the health-sector organizations were obtained using a validated survey instrument and the Program to Analyze, Record, and Track Networks to Enhance Relationships (PARTNER) tool that uses the principles of Social Network Analysis (SNA) to elucidate the makeup of collaborative relationships.ResultsDuring the response phase, command-and-control approaches from international healthcare organizations had a roll given the numbers of people affected and the overwhelmed local response capabilities. Pre-disaster vulnerabilities limited response capacity. Even during response, opportunities existed for integrating established groups. Generally, this was not a model utilized by international organizations, although some examples were present.ConclusionsThe external infusion of money, priorities, and forces potentially may harm the current system, rather than build upon it. International aid provides free health services beyond treatment of earthquake-related injuries, taking the place of some service functions of the Haitian system. Eventually, this could erode aspects of the Haitian health system. Alternative models of aid may better incorporate and integrate existing structures. Disaster planning is linked intrinsically to strengthening the health system as a whole.

A epidemia de AIDS no Brasil e as desigualdades regionais e de oferta de serviço

The aim of this study was to identify different profiles in the AIDS epidemic in Brazil by relating them to the health sector's organization, situations involving increased risk of infection, and the degree of implementation of the response by health services. The Brazilian municipalities (counties) were grouped according to the magnitude of the epidemic and its trends from 2002 and 2006, and were then studied using indicators obtained from secondary databases. Municipalities with large epidemics (39%) displayed more situations associated with risk of infection, and those with an upward trend in incidence (11.5%) showed a lower degree of response. Cities with large epidemics but with downward or stable trends had 68.6% of all the anonymous testing centers and 75.8% of the outpatient clinics, and performed 81.4% of all the HIV antibody tests in the health system. Preventive measures in schools and primary health services showed low coverage rates. Differences were observed between geographic regions. Inequalities in the degree of implementation of the response to HIV may contribute to different profiles in the epidemic around the country.

Levels of Job Satisfaction among Healthcare Providers in CGHS Dispensaries

In the labour-intensive health sector industry the quality of services is ultimately linked to the skills, motivation and satisfaction of the workers providing the healthcare services. Thus in order to study the job satisfaction level of the healthcare providers, so as to suggest measures to enhance it, the present study was carried out at CGHS which is one of the biggest public health sector organisations in the country and caters to a huge section of the organised sector. Understanding the healthcare provider’s work satisfaction is crucial to the understanding of the dynamics of the healthcare provider’s work force. Job satisfaction has been shown to be important in the retention of the healthcare providers in a given community as low job satisfaction has been associated with an intention to relocate. Recent studies have reported that low levels of job satisfaction among healthcare providers affect the patient-provider relationship and also compromise the quality of healthcare services. The study was undertaken to assess the levels of job satisfaction among the healthcare providers in CGHS dispensaries. A standardised tool developed by Peter Warr, John Cook and Toby Wall (1979) was used to measure the healthcare providers’ job satisfaction in the present study. For this study 250 healthcare providers working in the CGHS dispensaries of Delhi were interviewed. This included 100 doctors, 50 nurses and 100 paramedics which included both pharmacists and lab technicians. The findings of this study indicated that the levels of job satisfaction were not very high among the healthcare providers who were interviewed.

Partnership and capacity-building strategies in community sports and recreation programs

Partnerships between the health sector and various organizations in the community have been encouraged as a new strategy to develop sports and recreation programs, and achieve public health objectives related to obesity prevention. The purpose of this study was to investigate the partnership-related processes and capacity-building strategies associated with the successful implementation of sports and recreation programs. The research design was a multiple-case study with cross-case comparisons. Eight sports and recreation programs funded by the Victorian Health Promotion Foundation were investigated. Data collection included: semi-structured interviews with grant recipients and key partnership members (n=22); and document analysis. A capacity-building framework was used to guide data analysis. The findings showed that partnerships without the engagement of key stakeholders and a diversity of skills, resources, and approaches were limited to ‘come and try’ events rather than structured sports and recreation programs in the short term. Addressing the development of partnerships, by implementing a phased approach to program development and implementation may assist the sports and recreation sector build capacity to participate in partnership approaches to health promotion.

Organizaciones privadas del sector salud de maracaibo: estrategias financieras y ventajas competitivas

The objective of the research was to analyze the financial strategies for developing competitive advantages in the private health sector organizations in Maracaibo, Venezuela, through a descriptive methodology that required documental analysis and the application of a survey as tool for data collection, to the financial managers of the health centres of the city. A trend was found in the financial strategies of giving importance to the generation of business value and shareholder value, as well as a dual type of internal-external funding that positively affect the development of competitive advantages that allow them to face the dynamism imposed by the context.

Addressing Structural Inhibitors of Change in Public Health Sector Organizations: A South African Case

This article draws attention to the structural inhibitors of effective service delivery within a South African public health organization and outlines a new initiative that aims to facilitate the decentralization of decision-making power in an attempt to transform the service offered by this organization. The intervention outlined utilizes a participatory action research (PAR) methodology. As the problem addressed by this intervention is a political one, a social constructionist theoretical framework was adopted. The article reports on a current intervention that, if successful, will bring significant change to a public health service and will highlight the role of political factors in the inhibition or facilitation of change in public health services. It draws attention to the political and structural factors that undermine the capacity of a public health service to manage a range of communicable diseases, especially new drug-resistant variants of TB. This phenomenon is a growing global problem and the article outlines an innovative initiative that is attempting to address it. It is still too early to comment on the political success of the PAR initiative regarding the decentralization of powers within this service. However, the intervention has already created strong morale capital (resources such as courage, commitment and resilience) in district teams that were previously demoralized. The analysis of the situation is based upon the author's experience of this service over a period of 10 years.

Determinants of Implementation Effectiveness

Many innovations in the health sector are complex, requiring coordinated use by multiple organizational members to achieve benefits. Often, complex innovations are adopted with great anticipation only to fail during implementation. The health services literature provides limited conceptual guidance to researchers and practitioners about implementation of complex innovations. In the present study, we adapt an organizational framework of innovation implementation developed and validated in a manufacturing setting and explore the extent to which it aptly characterizes implementation in health sector organizations. Through comparative case studies of four cancer clinical research networks, we illustrate how this conceptual framework captures key determinants of the implementation of new programs in cancer prevention and control (CP/C) research and helps explain observed differences in implementation effectiveness. Key determinants include management support and innovation-values fit, which contribute to an organizational "climate" for implementation. We explore the implications for researchers and managers.