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| Title |
Advancing the application of systems thinking in
health: realist evaluation of the Leadership
Development Programme for district manager
decision-making in Ghana |
| Author(s) |
Aku Kwamie, Han van Dijk and Irene Akua Agyepong - Personal Name
|
Subject |
Health System and Policy |
| Publisher |
Bio Med Central Ltd |
| Publishing Year |
2014 |
| Specific Detail Info |
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. |
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