The five African Health Initiative Population Health Implementation and Training (PHIT)
Partnerships represent a rich and important set of health system strengthening initiatives.
All can be called whole system strengthening initiatives in two important respects.
First, from a health system perspective, as explicitly discussed, all the PHIT Partnerships
are multi-dimensional, seeking to achieve performance improvements by working across
the building blocks and levels of the health system. All address resource needs (human,
financial, and supplies) in some way. The common focus on strengthening information
use in clinical and managerial decision-making, meanwhile, tackles what some regard
as the key leverage point for health system improvement [1] and quality of care is
another such point [2]. Considering the role of community health workers, moreover,
emphasizes that the health system stretches beyond the doors of health facilities,
and that health system development requires combined community and facility-based
actions. Finally, several initiatives emphasize the importance of strengthening supervision
and management coaching and mentoring. Importantly, the different activities within
each partnership are intended to work synergistically together.
Second, although less clearly outlined in these papers, the PHIT Partnerships all
reflect key features of complex social programs (Table 1) and are, in themselves,
dynamic and complex adaptive systems[3]. They have all evolved over time, being developed
and adapted in response to experience in implementation, for example. They have also
all worked through a range of people and relationships. Indeed, as partnerships, the
very essence of these projects is a relationship between actors outside the health
system and those working within it: health workers, facility teams, supervisors, district
management teams and so on. Finally, they have been implemented within, affecting
and being affected by, dynamic, multi-layered contexts – encompassing histories and
past experiences (e.g. of resource availability, management or the usual ways of working),
wider sets of actors and agents (including politicians and donors), organizational
and other health system reform (e.g. decentralization in Mozambique and health insurance
in Ghana) and, no doubt, socio-political change (perhaps, including in patient and
political expectations of the health system).
Table 1
Features of complex social programs
• Based on set of theories and assumptions about how an intervention will lead to
change
• Achieved through active participation of individuals
• Developed and implemented through long process which may be fallible
• Not necessarily implemented in linear fashion and influenced by respective power
of those actors involved in implementation
• Very susceptible to effect of different contexts (e.g. policy timing, organizational
culture and leadership, resource allocation, staffing levels and capabilities, interpersonal
relationships, and competing local priorities and influences)
• Prone to being changed during process of implementation
• Open dynamic systems in themselves, which are able to change the conditions that
enable them to be implemented successfully (generating unintended positive and negative
effects)
Source: Mills et al, 2008 [5], adapted from Pawson et al, 2005 [13]
There is much to learn from these experiences, and evaluation is a central element
of the AHI. Against the backdrop of the increased resources for the “big diseases”
achieved in the early 2000s, this evaluation seeks to show whether or not investment
in health systems and at scale, rather than in particular strategies for managing
responsive primary care conditions, can generate health gain [4]. The effort and time
put into the evaluation itself signals the importance of learning from these experiences
and will also generate methodological lessons.
However, fully capturing the AHI’s lessons about implementing innovative health system
development activities will also require other evaluation approaches. At present,
the primary evaluation question being asked is, in essence: Can multi-dimensional
health system strengthening initiatives offer health gain? This question is of particular
significance in international health debates, and to funding agencies. But it does
not fully address the concerns of those working within health systems and responsible
for their continuous improvement. Over time, they have to manage variable investment
levels and patterns, as well as changing political imperatives, demand patterns, health
needs, and other system shocks. Health system managers are more likely to ask questions,
such as what changes in the health system did these initiatives bring about, and how?
Were there unintended consequences and, if so, how were they managed? What possibilities
did the initiatives create for supporting forward momentum towards long-term health
and development goals? Close examination of implementation experience is also important
in addressing issues, such as “whether the promise of performance gains in well-resourced
pilot studies can be achieved more widely; the replicability of experience across
different contexts; the management strategies that can support effective implementation;
and why change generates unexpected and unwanted effects” [5].
The existing knowledge base provides ideas of the sorts of issues likely to influence
implementation within the PHIT Partnerships. For example, wider experience of health
policy implementation [6] highlights that it:
• often results in unintended and unwanted consequences;
• is always contested by policy actors — not just politicians or interest groups contesting
political agendas, but also, and as importantly, those actors working within the implementation
chain, such as managers, health workers, patients, civil society organizations;
• is strongly influenced by the meanings policy actors attribute to features of design
or to policy goals, which influences how they understand them and then react to them.
The implications are that managing implementation requires deliberate engagement with
the values, interests, and understandings of those actors who might block or subvert
policy change.
Experience of scaling up innovative public health programs also provides insights
into the sorts of issues and management factors that influence the implementation
of new health system initiatives. In a Kenyan program in which private shopkeepers
were trained to provide malaria treatment, successful scaling up was supported by
local level action and learning, combined with management strategies that were responsive
to unexpected events and addressed tensions among implementing actors. The provision
of technical support and adequate resources were, therefore, judged as vital, but
not sufficient on their own to support scale-up [7]. Reflection on the South African
experience in sustaining large scale antiretroviral scale-up, meanwhile, points to
the importance of leadership, a combination of program standardization and flexibility,
“clinical” partnerships, and monitoring and evaluation systems [8]. Broader innovation
literature [9] finally, suggests that in order to institutionalize innovations within
health systems it is essential to reorient existing organizational norms, values,
incentives, and traditions in ways that encourage implementing actors to support new
ways of working.
Implementing change within health systems must, therefore, work across both dimensions
of the “whole system”. Evaluation of implementation requires strategies that take
account of that complexity. This is the aim of “theory driven inquiry” [10]. Such
inquiry moves beyond outlining the basic program theory of an intervention, as reflected
in the PHIT Partnership descriptions presented here. It seeks, in addition, to understand
how an intervention - the management of its implementation, or the way it plays out
in a specific context - influences key actors to behave in ways that support (or work
against) the innovation’s implementation. Identifying these trigger mechanisms, and
the underlying assumptions about how and why they generate the expected behavioral
changes, is the central focus of evaluation. In theory driven inquiry, these ideas
are developed and examined through the process of evaluation and across several case
studies of intervention, and are revised and refined in response to empirical experience.
The primary question of focus in such evaluation is “what works for whom and in what
circumstances”?
A burgeoning range of development and social policy literature provides guidance about
how to develop these theories of change [11]. Drawing specifically on four key sets
of questions [12] could provide the starting point for understanding the experience
of each PHIT Partnership. These questions are:
• What overall health system change/situation does it seek to achieve? (that is plausible
in itself and as a step to health gain) What features of this change/situation are
the focus of partnership activities?
• Who are the agents of change? Which actors have to be involved to support health
system change? What position and interests do they hold in relation to the change(s)
envisaged? How does that influence their response to it?
• What are the expected mechanisms and pathways of change? What behavioral drivers
are embedded in the intervention?
• How does the partnership team (the support or resource team) work (with whom) to
support the intervention directly and to provide a supportive context for the intervention
(e.g., through feedback higher up the system)?
Investigating and understanding the assumptions underlying each partnership’s initial
plans and how these changed in response to experience would also be an essential part
of such evaluation.
The full learning potential of the AHI lies in considering all dimensions of these
health system/whole system changes. Evaluation must move beyond the “did it work”
question, to consider why “it” worked, in what ways, and for whom, and, equally as
importantly, why “it” didn’t work in other dimensions, and for whom. Such knowledge
will add to our understanding of what shapes and filters health system functioning
and performance, as well as offering insights about how to support future health system
development.
List of abbreviations used
AHI: African Health Initiative; PHIT: Population Health Implementation and Training
Competing interests
The author declares that she has no competing interests.