Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

How to work with intangible software in public health systems: some experiences from India

How to work with intangible software in public health systems: some experiences from India This commentary focuses on “intangible software”, defined as the range of ideas, norms, values and issues of power or trust that affect the performance of health systems. While the need to work with intangible software within health systems is increasingly being recognized, the practical hows of doing so have been given less attention. In this com- mentary, we, a team of researchers and implementers from India, have tried to deliberate on these hows through a practice lens. We engage with four questions of current relevance to intangible software in the field of health policy and systems research (HPSR): (1) Is it possible to rewire intangible software in health systems? (2) What approaches have been attempted in the Indian public health system to rewire intangibles? (3) Have such approaches been evalu- ated? (4) What practical lessons can we offer from our experience on rewiring intangibles? From our perspective, approaches to rewiring intangible software recognize that people in health systems are capable of visioning, thinking, adapting to and leading change. These approaches attempt to challenge the often-unchallenged power hierarchies in health systems by allowing people to engage deeply with widely accepted norms and routinized actions. In this commentary, we have reported on such approaches from India under six categories: approaches intended to enable visioning and leading; approaches targeted at engaging with evidence better; approaches intended to help health workers navigate contextual complexities; approaches intended to build the cultural competence; approaches that recognize and reward performance; and approaches targeted at enabling collaborative work and breaking power hierarchies. Our collective experiences suggest that intangible software interventions work best when they are codesigned with various stakeholders, are contextually adapted in an iterative manner and are implemented in con- junction with structural improvements. Also, such interventions require long-term investments. Based on our experi- ences, we highlight the need for the following: (1) fostering more dialogue on this category of interventions among all stakeholders for cross-learning; (2) evaluating and publishing evidence on such interventions in nonconventional ways, with a focus on participatory learning; and (3) building ecosystems that allow experiential learnings on such interventions to be shared. Keywords: Health systems strengthening, Intangible, Leadership, Awards, Supervision, India, Low- and middle- income countries, Competence, Power, Trust The field of health policy and systems research (HPSR) emphasizes thinking of health systems as complex and *Correspondence: sudha_ramani@yahoo.com adaptive entities that are shaped by human agency and Oxford Policy Management, New Delhi, India action [1, 2]. Seen through this lens, the capacities within Full list of author information is available at the end of the article © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Ramani et al. Health Research Policy and Systems (2022) 20:52 Page 2 of 10 Fig. 1 Conceptualizing health systems. Health systems conceptualized as comprising hardware and software, and situated in specific contexts [3, 4] a health system can be examined in terms of its hard- policies are, at the very core, determined by underlying ware (human resources, infrastructure, financial inputs) values and ideas that shape the behaviours of people and tangible software (regulations, formal processes, [11]. Others have contended that health policies and technical capacities), as well as intangible software (val- programmes must acknowledge and work with intan- ues, norms, attitudes and relationships)—the three being gibles within more widely scoped system-strengthening dynamic parts of a whole [3, 4] (see Fig.  1). The HPSR efforts [4 , 12, 13]. In general, however, there has been lens not only acknowledges the myriad interdependen- limited discussion of what approaches can be practi- cies among these three components, but also emphasizes cally taken to rewire intangibles in health systems. their embeddedness in diverse social and political con- When we started working on this commentary, we texts [1, 2]. found that very few papers could give us practical sug- This commentary focuses on intangible software, gestions on approaches to rewiring intangible elements defined as the range of ideas, norms, values and issues in health systems. Thus, in an attempt to engage with of power or trust that guide attitudes and behaviours intangibles through a practice lens, a team of Indian in health systems, and that underpin the relationships colleagues (implementers, researchers, evaluators, and between different health system actors [4]. The need to those who wear mixed hats) have compiled the various explicitly work with intangible elements in the health approaches to working with rewiring elements that we system has gained increased attention. Indeed, recent have come across in the course of our work. Drawing empirical studies in many different low- and middle- on our joint experiential knowledge in the Indian public income countries (LMICs) have highlighted how perverse health setting, with support from pertinent literature, intangible software within health systems—including the we have tried to engage with four guiding questions: demotivation of staff, lack of support and leadership, risk-averseness and hesitancy to implement new poli- 1. Is it possible to rewire intangible software in health cies—undermines various system improvement efforts systems? [5–9]. Further, evidence suggests when software elements 2. What approaches have been attempted in the Indian are positively oriented—for example, in health facilities public health system to rewire intangibles? where trusting and collaborative relationships exist—the 3. Have these approaches been evaluated and proven performance of health workers, as well as the quality of worthy of programmatic investment? care provided by them, tends to be better [10]. 4. What are our practical learnings on rewiring? Despite an increasing recognition of the need to work with intangible software in health systems, the more These guiding questions emerged from practice practical hows of doing so have been less clear. Some rather than theory. Our engagement with these guid- have argued that system reform efforts must begin with ing questions in this commentary is intended as a start- the intangibles, since changes in health systems and ing point to deeper empirical and theoretical work. We R amani et al. Health Research Policy and Systems (2022) 20:52 Page 3 of 10 Box 1: Approaches intended to rewire intangible software in health systems Approaches intended to enable visioning and leading These approaches focus on enabling health workers to see value in their routine work and recognize themselves as leaders, and in doing so work towards recognizing and rewriting some of the systemically embedded routine scripts and practices that hinder change. Approaches targeted at engaging with evidence better These approaches work on the premise that health workers at all levels need to engage with data with more intensity than as “fillers” of forms, and that if they are given an opportunity to do so, they have the capacity to critically engage with evidence and think of locally relevant solutions. Approaches intended to help health workers navigate contextual complexities This cluster of ideas recognize that the day-to-day contexts that health workers have to reckon with are complex and challenging, and that there is a need to support health workers to handle such challenges, rather than blaming them for nonachievement or for being risk-averse. Approaches intended to build the cultural competence of health workers and to enhance community relationships These approaches focus on sensitizing health workers to the needs of the community, providing a better sociocultural—and a more humane—orientation to health providers. Approaches that recognize and reward performance These approaches are intended to recognize existing “exemplars” in the system, and to honour and reward them for their personal values, humane orientation, community relationships, innovations and commitment to their work. These awards are not meant to be for the achievement of numerical targets in the conventional sense. Approaches targeted at enabling collaborative work and breaking power/gender hierarchies This set of approaches is targeted at breaking gen- der and power hierarchies in the system and enabling collaborative work across cadres or different teams of people. have discussed our thoughts on each of these questions sense-making within health systems through research below. partnerships, have shown promise in nurturing positive change [18]. From Guatemala, one study documents sys- 1. Is it possible to rewire intangible software in the temic changes achieved through a humanized version health system? of supportive supervision to community health workers In practice settings in India, we have often observed [19]. From India, the Ekjut trial, based on participatory that perverse intangibles within health systems are learning and action (PLA) techniques, has demonstrated considered as either unmodifiable or as too difficult to how such techniques can enhance community relation- change. Very few initiatives to rewire intangibles have ships with health systems [20, 21]. In general, docu- been tried, and even fewer have been documented. mentation on working with intangibles is limited across Hence, we have tried to make a case below as to why we LMICs, but the above examples do suggest that interven- consider intangibles to be amenable to change. tions to rewire intangibles have potential. From our perspective, approaches to rewiring intan- gible software recognize and celebrate the human ele- 2. What approaches have been attempted in India to ment in health systems. We see these approaches as rewire intangibles? being derived from an “actor-centric” philosophy that From the authors’ collective knowledge of the Indian recognizes that people working in health systems are landscape, we have tried to compile a list of interventions not automatons who carry out tasks mechanically. that have been tried in India to enable the rewiring of Rather, they are individuals with agency, who are capa- perverse software in the public health system. We have ble of self-mastery, learning, visioning, collaborating, and compiled the interventions into six inductively derived adapting to and leading change [14, 15]. The actions and categories, described in Box 1. decisions of people are underpinned by their lifeworlds or lived realities [16, 17], which can be understood and reoriented in favour of broader health system goals. From In January 2020, a team at Oxford Policy Management (OPM) undertook a this standpoint, it is possible to work with intangibles rapid exercise to identify a list of intangible software interventions that have been attempted in the public health system in India by connecting with sev- in order to improve performance and practice, and to eral academicians, evaluators and implementors. We started with an initial list strengthen health systems overall. Also, since individu- of people identified by the OPM team internally and snowballed from there als in the health system are embedded within formal and (we contacted 47 organizations in total). We produced a series of 12 case studies on rewiring intangible interventions, based on our conversations with informal power hierarchies within health systems, work- different people. In May 2020, the OPM team reconnected with interested ing with intangibles is almost always an exercise in chal- stakeholders to coproduce this commentary. We jointly decided on four guid- lenging existing power relationships. ing questions and then reflected on these four questions using the case studies as the basis for inductively emerging themes. The team at OPM did the first There are documented examples across LMICs that round of the cross-case analysis and wrote the first draft of this commentary. highlight that working with intangibles is possible. The Subsequently, all authors have commented and reviewed various sections of learning sites from Kenya and South Africa, which were the paper verbally or through email. More details on the processes we fol- lowed can be obtained by writing to the corresponding author. attempts to systematize processes of reflection and Ramani et al. Health Research Policy and Systems (2022) 20:52 Page 4 of 10 In Table  1, we present Indian examples of the is because rewiring interventions have complex change approaches described in Box  1. We have included inter- mechanisms that work or do not work depending on ventions attempted at both the managerial level and on several factors in the context. An illustration of this com- the frontlines of the public health system. Only a few of plexity has been presented in an evaluation by Prashanth these have been formally documented. The kind of inter - et al. (2014) of an intervention to strengthen district-level ventions we have compiled here aimed at “first-order” managerial skills undertaken by the Institute of Public culture change [22]: that is, they were about enabling Health, Bangalore. Conducted by applying a realist lens, people in the health system to do similar activities that this evaluation highlights several contextual factors that they had been doing all along but with a slight twist or a played a role in determining the ultimate impact of the difference. managerial intervention, including staff turnover and the existence of infrastructural support. The authors of 3. Have interventions on rewiring intangibles been this evaluation point out that a decontextualized proof evaluated and proven worthy of programmatic of concept may simply not exist for the kind of interven- investment? tion they had tried; and applying a “what worked, why This question gets asked by many well-intentioned and for whom” approach was probably a more practical governments and donor agencies who are interested in way to assess the merits of their efforts [23]. Such argu - investing in rewiring interventions. These entities have ments have been put forth by Sardan and colleagues [13] expressed justifiable worries about the lack of concrete as well, from their experience in sub-Saharan Africa. proof that such interventions are worthy of investment. Sardan and colleagues have particularly emphasized the We have attempted to put together our thoughts on this danger of copying intervention approaches without tak- issue below. ing into account the subtle contextual nuances that made There is a slowly growing body of evidence from differ - these approaches a success in the first place [13]. Cleary ent LMICs that points towards the promise of rewiring and colleagues offer similar arguments for evaluating intangible software. The learning site approach in Kenya a leadership intervention in South Africa through an and South Africa, which uses PLA methods and encour- “action-learning” design, which provided multiple oppor- ages reflective practices, has highlighted the potential to tunities for adapting and tailoring the intervention [29]. improve social and emotional skills among health staff u Th s, rather than traditional evaluation techniques (like and to stimulate learning processes, and overall, better measuring impact), evaluations that gather rich learnings relationships in the system [18, 26]. The Health Workers and help to iteratively produce more potent and practical for Change approach, which uses a series of participatory ways to rewire intangible software might be more useful workshops to sensitize health workers to gender issues, for implementers of such approaches. has shown positive changes after these workshops in Another factor that makes the evaluation of rewir- some places, but not all [27, 28]. Some interventions like ing approaches difficult is the timing. Many rewiring supportive supervision, appreciative enquiry in systems approaches aim at long-term, slow change, but usually and PLA have also been tried and declared as promising evaluations of interventions tend to be carried out simul- [19, 20] (also refer to Table  1 example 8). However, con- taneously or immediately after the intervention. A recent ventional proof of concepts—that is, evidence through review of learning and development programmes in conventional experimental methods where one can Africa notes that the effects of these programmes may attribute change in community-level outcomes to par- become clear only after several years, and may not be vis- ticular interventions—may not always exist for the inter- ible in immediate assessments [30]. We concur on this ventions described in this note. point that we might not be able to capture the true effect In fact, many of the intervention examples from our of interventions on intangibles within more immediate work that we have listed in Table  1 do not have decon- time frames. We also feel that the lack of funding and textualized proofs of concept. For one, proofs of causal expertise within programmes to conduct long-term eval- relationships between such interventions and commu- uations is also a deterrent. That is, many a time, evalua - nity-level outcomes are not easy to establish. Even if tors have to be externally hired for the purpose, and this these interventions have been evaluated or examined, the is particularly disproportionately expensive in LMICs end results of these evaluations need to be viewed with when the interventions being tried are small-scale and caution and not taken as indicating blanket “success” or dependent on tight budgets. “failure” of the intervention (refer to Table 1, examples 1 to 5). We feel that combined successes and failures in the 4. What works in practice? Some lessons from our same intervention need to be accepted, and impact eval- experiences uations may not be able to capture these nuances. This R amani et al. Health Research Policy and Systems (2022) 20:52 Page 5 of 10 Table 1 Examples of interventions that have been attempted to rewire intangible software in India The approach Example Some learnings reported by the implementers Approaches intended to enable visioning and leading 1. No one wants to feel like their job is meaningless: informal When a community monitoring intervention was initiated by the High-level support from the state authorities and government gatherings and discussions to understand overarching policy Society for Community Health Awareness Research and Action orders are needed. Not all people were willing to collaborate and visions and values (SOCHARA) in Tamil Nadu, frontline workers were worried that be a part of this process, despite the existence of a government this “monitoring” process would be used to unfairly accuse them order. It was found that in some geographical pockets, people of faults that they believed to be systemic. Hence, the workers were more willing, and that these pockets could be used to dem- were unwilling to cooperate. However, rather than start with onstrate to the others who were hesitant the usefulness and value an attitude of confrontation, staff from SOCHARA spent a lot of of this community monitoring process time just informally talking to health workers about notions of accountability and helping them understand why community monitoring processes had value and meaning. The informal dis- cussions helped the health workers to accept the intervention 2. Leadership trainings and nonclinical capacity-building The Institute of Public Health has conducted district-level There were anecdotes regarding resistance from the public sector initiatives training programmes to build “champions” and “leaders” in staff to being trained as some of them felt that they were being Karnataka. There were reports of initial resistance to the training tested. It took some time for the staff to relax into the programme. as there was a belief among the health workers that they were The evaluation found that the responses from different geograph- being tested during these training sessions. Hence, prior to the ical divisions varied training, an extended rapport-building phase was necessary. A detailed evaluation of this training programme has been published [23] 3. It is one champion who can nurture others: Exposure of staff An ex-medical officer from a primary health centre shared that People learn both good and not-so-good practices from champi- to inspirational examples in the state she hailed from (anonymized), new recruits were ons; thus, the champions must be carefully chosen. Even champi- exposed to exemplars or positive deviants in the public health ons can’t work without basic infrastructural support system. This was done as a part of their induction training and aimed to provide new recruits with good role models to look up to, and, in the long term, to potentially add to the tribe of posi- tive deviants in the health system Approaches targeted at engaging with evidence better 4. Helping routine data to speak differently through eye- A series of workshops was conducted by the National Health In some of the district pockets, the officials had attempted to opening data workshops Systems Resource Center on recognizing and engaging with recognize inequities and reach the more vulnerable in their pro- health inequities in the data that health workers routinely gramme in practical ways encountered. These workshops gave people an opportunity to relook at routine data through a different lens—what the staff had earlier perceived as boring, routine data was used to enable a process of reflection 5. Reinforcement of achievements locally using local data One researcher-cum-implementor used facility-level data in a The lack of supporting infrastructure is a deterrent to even the low-income state in India to engage in discussions with primary most motivated of nurses care nurses. Nurses looked at synthesized data and tried to reflect on their local achievements. The self-recognition of posi- tive achievements seemed to play an important role in boosting local morale Approaches targeted at navigating complexities in the context Ramani et al. Health Research Policy and Systems (2022) 20:52 Page 6 of 10 Table 1 (continued) The approach Example Some learnings reported by the implementers 6. Buddy systems This has been tried in some public medical college hospitals in The buddy system example here focuses on doctors, but it was different states in India. Buddy systems attempt to pair young suggested that it would be useful to have buddies across cadres. recruits with champions or exemplars, who serve as mentors and This system would be more effective if exemplars/stalwarts in support new workers through complex decision-making the health systems came forward themselves to be “buddies” to younger staff 7. Putting people in a safe space outside of work to reflect: infor - A district-level official from one of the southern states in India Such workshops should be long-term, have repeated sessions mal reflective spaces conducted a series of residential workshops with the heads of over time, and preferably be residential—so that space to reflect different implementation bodies across sectors in order to break and bond together without the interference of routine work is the hesitancy of people as regards collaborating across sectors. enhanced These workshops provided space for reflection and bonding away from work. No targets or checklists were used or discussed Approaches intended to build the cultural competence of health workers and to enhance community relationships 8. Common understandings: people and the system need to The Ekjut trial on PLA took place in Jharkhand and Orissa. In this The intervention needs to be participatory, even at the expense of understand each other intervention, regular and iterative meetings were facilitated by time issues. Change is a time-consuming process accredited social health activists (ASHAs) (link workers associated with the Indian public health system) with women’s groups over 31 months [21] 9. How to talk to the community trainings: explicit soft skills and In 2018–19, the Center for Enquiry into Health and Allied Themes Programme staff realized that conveying some of these concepts, communication trainings (CEHAT ) led a training intervention on domestic violence for such as “equity” and “gender responsiveness”, during training health workers in two tertiary care hospitals in Maharashtra [24]. was not straightforward. It was perceived by staff that attitudinal By codesigning the intervention with stakeholders, incorporat- changes were easier to bring about in younger staff ing mixed-cadre training sessions and including explicit “soft skill” communication skills as part of the training, this training worked towards tweaking the culture within health facilities to be more sensitive to domestic violence issues Approaches that recognize and reward performance 10. Social awards and incentives The Kayakalp award scheme is run by the central health ministry Social awards have to be used carefully—for wrongly chosen in India and recognizes and awards health facilities that demon- award schemes (or corrupt awarding practices) can be demotivat- strate their commitment to cleanliness, hygiene and infection ing control practices Approaches targeted at enabling collaborative work and breaking power/gender hierarchies 11. Building confidence: training on soft skills, public speaking Basic Health Services in Udaipur offered nurses formal leadership Structural and software interventions were needed to help nurses and speaking in English positions at primary care clinics [25]. The organization noticed take up leadership positions. Leadership workshops must be seen that nurses were culturally hesitant about taking up leadership only as one important step in trying to break down power hierar- positions. The nurses were trained using a hybrid technical and chies. Building leadership skills takes time soft skills module to build their rigour and confidence. It was reported that public-speaking skills, and particularly learning to speak in English, helped to boost nurses’ confidence 12. Sensitization workshops within the health system The Resource Group for Education and Advocacy for Community An evidence base was needed to make a stronger case for gender Health (REACH) in Tamil Nadu has been supporting the Revised responsiveness before embarking on the workshops, and this National Tuberculosis Control Programme [now the National TB was achieved through a TB and gender assessment, followed by Elimination Programme (NTEP)], to adopt a gendered lens to TB. the adoption of a gender framework by the national programme. As part of these efforts, a gender-responsive training curriculum Such trainings must try to balance concepts along with granular was developed and piloted with NTEP in October 2020. The action, and help participants understand how they can apply their training used participatory techniques (including power walks) learning in their specific roles to sensitize people to power and gender hierarchies R amani et al. Health Research Policy and Systems (2022) 20:52 Page 7 of 10 In the section we highlight some practical tips on work- facilities after their visit, and share this ranking through ing with intangible software. a feedback box in the facility. The purpose of this inter - vention was to identify and motivate good doctors in Hardware and software go hand in hand It is important the public sector. However, it was found that doctors that intangible software interventions are implemented tried to rig the voting system in their favour—since the hand in hand with improvements in hardware and tangi- doctors viewed the voting system as a form of ranking, ble software. We give two examples below that illustrate rather than as a feedback mechanism. u Th s, the system the need for combined hardware–software interven- was not able to truly identify the “good” doctors through tions. Authors AU and PB were involved in conducting this intervention. This experience taught the managerial a series of training programmes for frontline counsellors staff that rewiring interventions need to be tweaked to in the public health system on the reproductive rights of the context, and one of the ways to do this is through the women. These trainings emphasized inculcating coun - participation of local stakeholders right from the design selling skills using a rights-based approach (rather than stage of the intervention. Another example of this kind coercing women to adopt family planning methods). was noted by SA. SA, based on her experience of work- However, it was found that after receiving the training, ing on a codesigned curriculum for health workers on the trained counsellors went to work in a context that domestic violence, emphasized that codesigning inter- was highly target-oriented, and the counsellors felt they ventions is not a one-off process. The NGO she worked had no room to practically apply the rights-based ori- with had conducted a domestic violence programme entation that they had obtained during their training. In in 2018–19 that tried to sensitize health workers to the addition, it was reported that the hospital facility heads needs of women who face domestic violence [24]. Before used counsellors for work other than counselling, and this training was launched, the technical content had the counsellors, who were contractual employees, felt already been discussed with the health workers, and uncomfortable protesting against their diluted counsel- their inputs had been obtained. But during the train- ling roles. All this highlights that the usefulness of rewir- ing, a training facilitator used a fictitious example of a ing software approaches can be diluted if other structural woman from an ethnic minority to illustrate the concept systemic changes do not accompany these interven- of vulnerability. This example was misconstrued by one tions (refer to Table  1, examples 3, 5 and 11). We share participant, who took offence against being thought of another learning on the same lines from Basic Health as “vulnerable”. Following this incident, the content of Services, a nongovernmental organization (NGO) in the training was revised again to make it more sensitive the state of Rajasthan in India which runs primary care to the participants’ feelings. SA emphasized that truly clinics led by nurses. Nurses from these areas did not codesigning an intervention is an iterative process that is think of themselves as “leaders” of independent clinical time-consuming and one that involves immense effort if work [25]. To change these attitudes, this NGO offered it is to be done right. nurses formal roles that conferred more power on them (structural change). The NGO also held iterative techni - Each place might need a different “hook”, and not eve - cal and confidence-building training sessions to enable rything works everywhere Not everything works for eve- the nurses to think of themselves as change-makers and ryone when it comes to modifying intangibles, and this leaders (software change). We note that this combination limitation has to be accepted. This learning can be seen of structural and software elements in this intervention, across almost all interventions in Table  1. If we believe entwined deliberately, had the potential to change the that people are unique and are bound to use agency dif- existing status quo for nurses. ferently, we need to enable the use of this agency for positive change. But, at the same time, we need to accept Codesigning interventions with stakeholders Intan- the inherent nonuniformity that is bound to surface in gible software interventions work with complex ideas, our enabling efforts. For instance, one of our authors ideologies and concepts that are not easy to work with. (anonymized) shared the experience of being involved Hence, rewiring interventions can fail in their purpose in a national-level training workshop. Among the train- if they are not codesigned with relevant stakeholders ees, many did not incorporate new learnings in their (refer to Table 1, examples 1, 6, 7, 9 and 10 that highlight practice, but others seriously attempted to change some need for codesigning and mention field-level suggestions existing managerial practices in accordance with the new for improving specific intangible interventions). One of learnings and demonstrated fantastic local-level results. our authors (anonymized) spoke of how the local health The evaluation by Prashanth et al. (2014) also pointed to department in their area tried to set up a system whereby how each subdivision in a district responded differently patients could rank a doctor from public primary care to a management training programme, and it noted that Ramani et al. Health Research Policy and Systems (2022) 20:52 Page 8 of 10 the response of people in complex systems is not always of working on gender and tuberculosis. They observed predictable. Among us, we have noted the need to start that within the national programme on tuberculosis, the with small changes and not be discouraged by uneven or managerial cadres were mostly male, and issues of “gen- nonuniform results. A tribe of “positive” change-makers der” were a very novel concept in these circles. Both RA needs to be built over time; it helps to start with a few and AS highlighted the need for patience and for empa- who are more inclined and able to foster change, and thy with people who are involved in the change process, eventually snowball from there. and they noted that “change is never easy for anyone”. They emphasized the need for empathetic discussions, Nurturing spaces for reflection within existing rou - trust-building and bonding, along with hard evidence to tines If we think of health systems as complex adaptive bring about a “slow” change. All of us writing this paper systems, this implies that there are adaptive mechanisms have expressed similar sentiments, the general consen- within such systems that work to maintain the status sus being that the chances of achieving instant results quo—even when this status quo is widely acknowledged through intangible software interventions are very low. as deficient [31]. One way to help people question this status quo is to enable a process of reflection and think - Concluding thoughts ing among health workers and managers. Reports of the Complexity theories on systems thinking emphasize that learning sites’ experience have captured several mecha- bringing about change is a messy, nonlinear and unpre- nisms through which developing spaces for iterative dictable process and that change agents need to work reflection and learning within practice settings offer with multiple underlying issues in health systems [12]. scope for building “everyday resilience” in health systems, Despite recognition of complexity in the change pro- by building three kinds of capacities—cognitive, behav- cess, we feel that in India, like in many other LMICs, ioural and contextual [26, 32]. As a group, we believe that most efforts to bring about change continue to focus on many people who join public services have good inten- the tangible aspects of the health system. Our collec- tions and are intrinsically motivated to help patients; tive experiences show that intangible software interven- however, much of this enthusiasm gets chipped away tions—that aim to change leadership behaviours, trust, due to tough work schedules and constrained support motivation, power balance and the values of health sys- in work settings. Offering spaces for reflection can help tem actors—are often considered to be risky ventures health workers gain renewed vigour and hope, and can that may not yield predictable results. Difficulties in open up their minds to finding solutions (refer Table  1, measuring the impact of such interventions, as well as examples 4, 6, 7 and 12 that highlight such attempts). the scarcity of publications in this area, seem to con- These approaches can be facilitated by trusted external tribute further to the lack of confidence of funders and parties (researchers, NGOs, think tanks). We feel that governments in these efforts. Not surprisingly, the cur - approaches can also be piggybacked onto existing capac- rent situation of health system programming in India ity-building/technical training sessions. For instance, does not appear to favour investments that seek to alter some training sessions on soft skills (talking in English, intangibles. public speaking, confidence-building discussions) can be However, the examples of interventions from India dis- added on to existing new-recruit induction trainings in cussed in this paper suggest that it is possible to attempt primary health facilities or other routine monthly meet- to rewire intangible software in health systems. Such ings. That is, these sessions need not be completely “new” interventions appear to work best when they are code- activities, but rather routine ones with a slight twist in signed, contextually adapted and implemented in con- how they are conducted. junction with structural or hardware improvements. It is important to keep in mind, however, that the road to It takes decades of patience, empathy and investments rewiring intangibles, in local health systems or sub-sys- Intangible software interventions often deal with ideas tems, may often be long and iterative. As Kwamie and and values that are deeply embedded in the social fabric, colleagues point out, we need “long-term, more reflective and changing these is not an easy task. Indeed, it is eas- and potentially unpredictable approaches” to strengthen- ier to change practices through incentives and protocols ing capacities in health systems [33]. Further, evidence than to change underlying attitudes. Yet lasting change on such interventions may need “complexity-sensitive” comes only with attitudinal change. The need for time learning assessments that focus on experiential learnings, and patience has been noted repeatedly (refer to Table 1, rather than objective evaluations. There is also potential examples 2, 7, 8, 11 and 12 that reflect these points). RA to explore more embedded approaches to researching and AS from REACH, in particular, have noted the need such interventions, wherein the ownership of evaluation for empathy, along with patience, from their experience R amani et al. Health Research Policy and Systems (2022) 20:52 Page 9 of 10 and learning rests largely with decision-makers and of practice, online knowledge-sharing platforms and implementers [34]. other such groups of actors can help to augment evidence Since this commentary is intended as a “practice” generation and advocacy on intangible software. paper, we have not focused on the theoretical underpin- nings of the experiential lessons we have shared here. For instance, the learnings from our efforts can be linked to Annexure perspectives from cultural sociology, that highlight how We have appended an infographic that highlights various cultural scripts and repertoires act as a toolkit to shape approaches to rewiring intangible software. This info - action, making change a difficult and nonlinear process graphic is intended for better communication of study [35]. Our findings can also be mapped to scholarship on learnings to a wider audience. organizations and institutions, that offers perspectives on how individual agency relates to formal and informal Abbreviations institutional structures. For instance, work from the field CEHAT: Center for Enquiry into Health and Allied Themes; HPSR: Health of new institutionalism [36], cybernetics such as the via- policy and systems research; LMIC: Low- and middle-income countries; NGO: Nongovernmental organization; NTEP: National Tuberculosis Elimination ble system model [37] and institutional logic perspectives Programme; PLA: Participatory learning and action; REACH: Resource Group [38] can enable further interrogation of the interventions for Education and Advocacy for Community Health; SOCHARA : Society for that we have mentioned in this paper. We invite others to Community Health Awareness Research and Action. take our work further through deeper engagement with Acknowledgements such theoretical perspectives. We would like to thank Dr Vikas Keshri (George Institute of Global Health), Mr Ameerkhan (SOCHARA), Dr Sanjana Mohan (Basic Health Services), Dr Amol Dongre (Pramukhswami Medical College) and Dr Allen Ugargol (IIM Banga- The way forward lore) for speaking to us during the course of this study. We acknowledge the We conclude this commentary with three issues that role of Tom Newton-Lewis (independent consultant), Cindy Carlson (Oxford need attention with respect to rewiring intangible soft- Policy Management) and Rajni Luthra in enabling this study. We thank Dr Lucy Gilson (University of Cape Town) for her suggestions on an initial draft of this ware in health systems. paper. One, we feel that the routine dialogue among govern- ments, researchers, funders and implementers must Author contributions SR, RP, AK, DS and SM were a part of the team from Oxford Policy Manage- encompass explicit discussions on intangible elements ment who conceptualized the commentary, analysed the findings and wrote in health systems. We consider this important as these the first draft of the paper. SA, AS, PB, VY, AU, RA and SK contributed to the stakeholders routinely discuss resourcing (hardware) and writing and discussion of the individual case studies described in this com- mentary. RG, NR and AP contributed to cross-cutting discussions and themes. formal processes (tangible software) for systems improve- All authors have reviewed the paper and added their inputs. SR is the guaran- ment, but side-line discussions on intangible software. tor of the paper. All authors read and approved the final manuscript. This happens possibly because elements of intangible Funding software are challenging to unpack, potentially sensitive The Bill and Melinda Gates Foundation funded the compilation of the soft- and considered difficult to change. However, we believe ware approaches described in this commentary. The grant was managed by that opening difficult dialogues on intangibles in formal Oxford Policy Management Ltd. decision-making spaces can help to develop a collective Availability of data and materials understanding of these ideas, as well as generate more Not applicable. funding and interest in this area. Second, there is a need to build, evaluate and publish Declarations evidence on working with intangibles in diverse fora. Ethics approval and consent to participate Implementers often possess deep knowledge of intangi- Not applicable. ( This is a coproduced commentary.) bles and their workings in specific contexts. They make multiple structured as well as not-so-structured attempts Competing interests The authors declare that they have no competing interests. to modify intangibles, as we observe from the experi- ences shared in this paper. This tacit knowledge is often Author details 1 2 unpublished and remains within specific implementer Oxford Policy Management, New Delhi, India. Evidence Action, New Delhi, 3 4 India. CARE India, New Delhi, India. Achutha Menon Centre for Health groups. We feel that systematic efforts to capture such Science Studies, Thiruvananthapuram, Kerala 695011, India. Resource Group experiential learnings on intangibles are needed. for Education and Advocacy for Community Health (REACH), Chennai, India. Lastly, we feel the need for ecosystems—both nation- Center for Enquiry into Health and Allied Themes, Santacruz East, Mum- 7 8 bai 400055, India. Gender Justice, Oxfam India, New Delhi, India. Women ally and across LMICs—in which experiential learnings 9 10 in Global Health, New Delhi, India. Vikalp Kriya, Panaji, Goa, India. NITI on intangible software can be shared. Such ecosystems 11 Aayog, New Delhi, India. Health Systems Transformation Platform, New Delhi, can be built around formal research–practice collabora- India. tions. Further, informal platforms such as communities Ramani et al. Health Research Policy and Systems (2022) 20:52 Page 10 of 10 Received: 22 December 2021 Accepted: 2 April 2022 (ASHAs) to improve maternal and newborn health in underserved areas of Jharkhand and Orissa: study protocol for a cluster-randomised con- trolled trial. Trials. 2011;12:182. 22. Scott T, Mannion R, Davies HT, Marshall MN. Implementing culture change in health care: theory and practice. Int J Qual Health Care. 2003;15(2):111–8. References 23. Prashanth NS, Marchal B, Kegels G, Criel B. Evaluation of capacity-building 1. Gilson L, Hanson K, Sheikh K, et al. Building the field of health program of district health managers in India: a contextualized theoretical policy and systems research: social science matters. PLoS Med. framework. Front Public Health. 2014;2:89. 2011;8:e1001079. 24. Meyer SR, Rege S, Avalaskar P, Deosthali P, García-Moreno C, Amin A. 2. AHPSR. What is health policy and systems research (HPSR)? Geneva: Strengthening health systems response to violence against women: pro- World Health Organization; 2019. tocol to test approaches to train health workers in India. Pilot Feasibility 3. Ellokor S, Olckers P, Gilson L et al. Crises, routines and innovations—the Stud. 2020;6:63. complexities and possibilities of sub-district management. in South 25. Amin A, Dutta M, Brahmawar Mohan S, Mohan P. Pathways to enable African Health Review 2012/3, Health Systems Trust, Durban, 2013; pp. primary healthcare nurses in providing comprehensive primary health- 161–73. care to rural, tribal communities in Rajasthan, India. Front Public Health. 4. Sheikh K, Gilson L, Agyepong IA, Hanson K, Ssengooba F, Bennett S. 2020;8:583821. Building the field of health policy and systems research: framing the 26. Nzinga J, Boga M, Kagwanja N, Waithaka D, Barasa E, Tsofa B, Gilson L, questions. PLoS Med. 2011;8(8):e1001073. Molyneux S. An innovative leadership development initiative to sup- 5. Guinaran RC, Alupias EB, Gilson L. The practice of power by regional man- port building everyday resilience in health systems. Health Policy Plan. agers in the implementation of an indigenous people’s health policy in 2021;36(7):1023–35. the Philippines. Int J Health Policy Manag. 2021. https:// doi. org/ 10. 34172/ 27. Shaikh BT, Reza S, Afzal M, Rabbani F. Gender sensitization among health IJHPM. 2020. 246. providers and communities through transformative learning tools: expe- 6. Ramani S, Gilson L, Sivakami M, Gawde N. Sometimes resigned some- riences from Karachi, Pakistan. Educ Health (Abingdon). 2007;20(3):118. times conflicted, and mostly risk averse: primary care doctors in India as 28. Webber G, Chirangi B, Magatti N. Promoting respectful maternity care street level bureaucrats. Int J Health Policy Manag. 2021. https:// doi. org/ in rural Tanzania: nurses’ experiences of the “Health Workers for Change” 10. 34172/ IJHPM. 2020. 206. program. BMC Health Serv Res. 2018;18(1):658. 7. Gaitonde R, San Sebastian M, Hurtig AK. Dissonances and discon- 29. Cleary S, Toit AD, Scott V, Gilson L. Enabling relational leadership in pri- nects: the life and times of community based accountability in the mary healthcare settings: lessons from the DIALHS collaboration. Health national rural health mission in Tamilnadu, India. BMC Health Serv Res. Policy Plan. 2018;33(suppl_2):ii65–74. 2020;20(1):89. 30. Johnson O, Begg K, Kelly AH, Sevdalis N. Interventions to strengthen the 8. Scott V, Mathews V, Gilson L. Constraints to implementing an equity- leadership capabilities of health professionals in Sub-Saharan Africa: a promoting staff allocation policy: understanding mid-level managers’ scoping review. Health Policy Plan. 2021;36(1):117–33. and nurses’ perspectives affecting implementation in South Africa. Health 31. Topp SM. Power and politics: the case for linking resilience to health Policy Plan. 2012;27(2):138–46. system governance. BMJ Glob Health. 2020;5(6):e002891. 9. Aberese-Ako M, van Dijk H, Gerrits T, Arhinful DK, Agyepong IA. “Your 32. Gilson L, Ellokor S, Lehmann U, Brady L. Organizational change and health our concern, our health whose concern?”: perceptions of injustice everyday health system resilience: lessons from Cape Town, South Africa. in organizational relationships and processes and frontline health worker Soc Sci Med. 2020;266:113407. motivation in Ghana. Health Policy Plan. 2014;29(Suppl 2):ii15-28. 33. Kwamie A, van Dijk H, Agyepong IA. Advancing the application of 10. Okello DR, Gilson L. Exploring the influence of trust relationships on systems thinking in health: realist evaluation of the Leadership Develop- motivation in the health sector: a systematic review. Hum Resour Health. ment Programme for district manager decision-making in Ghana. Health 2015;13:16. Res Policy Syst. 2014;12:29. 11. Whyle E, Olivier J. Social values and health systems in health policy and 34. Ghaffar A, Gupta A, Kampo A, et al. The value and promise of embedded systems research: a mixed-method systematic review and evidence map. research. Health Res Policy Sys. 2021;19:99. Health Policy Plan. 2020;35(6):735–51. 35. Swidler A. Culture in action: symbols and strategies. Am Sociol Rev. 12. De Savigny D, Adam T. Systems thinking for health systems strengthen- 1986;51(2):273–86. ing. Geneva: World Health Organization; 2009. 36. Schmidt VA. Taking ideas and discourse seriously: explaining change 13. Olivier de Sardan JP, Diarra A, Moha M. Travelling models and the chal- through discursive institutionalism as the fourth “new institutionalism.” lenge of pragmatic contexts and practical norms: the case of maternal Eur Polit Sci Rev. 2010;2(1):1–25. health. Health Res Policy Syst. 2017;15(Suppl 1):60. 37. Beer S. Diagnosing the system for organizations. Chichester: Wiley; 1985. 14. Lipsky M. Street level bureaucracy: dilemmas of the individual in public 38. Thornton PH, Ocasio W. Institutional logics. In: Greenwood R, Oliver C, services. Russell Sage Foundation; 1980. Sahlin K, Suddaby R, editors. The SAGE handbook of organizational insti- 15. Gilson L. Lipsky’s street level bureaucracy. in Oxford Handbook of the tutionalism. CA: Sage; 2008. Classics of Public Policy, Oxford University Press, Oxford, 2015. 16. Long N. Development sociology, actor perspectives. Abingdon: Rout- ledge; 2001. Publisher’s Note 17. Parashar R, Gawde N, Gilson L. Application of “actor interface analysis” to Springer Nature remains neutral with regard to jurisdictional claims in pub- examine practices of power in health policy implementation: an interpre- lished maps and institutional affiliations. tive synthesis and guiding steps. Int J Health Policy Manag. 2021. https:// doi. org/ 10. 34172/ IJHPM. 2020. 19. 18. RESYST/DIAHLS learning site team. Learning sites for health system gov- ernance in Kenya and South Africa: reflecting on our experience. Health Res Policy Syst. 2020;18(1):44. 19. Hernández AR, Hurtig AK, Dahlblom K, San Sebastián M. More than a checklist: a realist evaluation of supervision of mid-level health workers in rural Guatemala. BMC Health Serv Res. 2014;14:112. 20. Rath S, Nair N, Tripathy PK, Barnett S, Rath S, Mahapatra R, Gope R. Explaining the impact of a women’s group led community mobilisation intervention on maternal and newborn health outcomes: the Ekjut trial process evaluation. BMC Int Health Hum Rights. 2010;10:25. 21. Tripathy P, Nair N, Mahapatra R, Rath S, et al. Community mobilisation with women’s groups facilitated by Accredited Social Health Activists http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Health Research Policy and Systems Springer Journals

How to work with intangible software in public health systems: some experiences from India

Download PDF
10 pages

Loading next page...
 
/lp/springer-journals/how-to-work-with-intangible-software-in-public-health-systems-some-ETeBq0JG9b

References (47)

Publisher
Springer Journals
Copyright
Copyright © The Author(s) 2022
eISSN
1478-4505
DOI
10.1186/s12961-022-00848-9
Publisher site
See Article on Publisher Site

Abstract

This commentary focuses on “intangible software”, defined as the range of ideas, norms, values and issues of power or trust that affect the performance of health systems. While the need to work with intangible software within health systems is increasingly being recognized, the practical hows of doing so have been given less attention. In this com- mentary, we, a team of researchers and implementers from India, have tried to deliberate on these hows through a practice lens. We engage with four questions of current relevance to intangible software in the field of health policy and systems research (HPSR): (1) Is it possible to rewire intangible software in health systems? (2) What approaches have been attempted in the Indian public health system to rewire intangibles? (3) Have such approaches been evalu- ated? (4) What practical lessons can we offer from our experience on rewiring intangibles? From our perspective, approaches to rewiring intangible software recognize that people in health systems are capable of visioning, thinking, adapting to and leading change. These approaches attempt to challenge the often-unchallenged power hierarchies in health systems by allowing people to engage deeply with widely accepted norms and routinized actions. In this commentary, we have reported on such approaches from India under six categories: approaches intended to enable visioning and leading; approaches targeted at engaging with evidence better; approaches intended to help health workers navigate contextual complexities; approaches intended to build the cultural competence; approaches that recognize and reward performance; and approaches targeted at enabling collaborative work and breaking power hierarchies. Our collective experiences suggest that intangible software interventions work best when they are codesigned with various stakeholders, are contextually adapted in an iterative manner and are implemented in con- junction with structural improvements. Also, such interventions require long-term investments. Based on our experi- ences, we highlight the need for the following: (1) fostering more dialogue on this category of interventions among all stakeholders for cross-learning; (2) evaluating and publishing evidence on such interventions in nonconventional ways, with a focus on participatory learning; and (3) building ecosystems that allow experiential learnings on such interventions to be shared. Keywords: Health systems strengthening, Intangible, Leadership, Awards, Supervision, India, Low- and middle- income countries, Competence, Power, Trust The field of health policy and systems research (HPSR) emphasizes thinking of health systems as complex and *Correspondence: sudha_ramani@yahoo.com adaptive entities that are shaped by human agency and Oxford Policy Management, New Delhi, India action [1, 2]. Seen through this lens, the capacities within Full list of author information is available at the end of the article © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Ramani et al. Health Research Policy and Systems (2022) 20:52 Page 2 of 10 Fig. 1 Conceptualizing health systems. Health systems conceptualized as comprising hardware and software, and situated in specific contexts [3, 4] a health system can be examined in terms of its hard- policies are, at the very core, determined by underlying ware (human resources, infrastructure, financial inputs) values and ideas that shape the behaviours of people and tangible software (regulations, formal processes, [11]. Others have contended that health policies and technical capacities), as well as intangible software (val- programmes must acknowledge and work with intan- ues, norms, attitudes and relationships)—the three being gibles within more widely scoped system-strengthening dynamic parts of a whole [3, 4] (see Fig.  1). The HPSR efforts [4 , 12, 13]. In general, however, there has been lens not only acknowledges the myriad interdependen- limited discussion of what approaches can be practi- cies among these three components, but also emphasizes cally taken to rewire intangibles in health systems. their embeddedness in diverse social and political con- When we started working on this commentary, we texts [1, 2]. found that very few papers could give us practical sug- This commentary focuses on intangible software, gestions on approaches to rewiring intangible elements defined as the range of ideas, norms, values and issues in health systems. Thus, in an attempt to engage with of power or trust that guide attitudes and behaviours intangibles through a practice lens, a team of Indian in health systems, and that underpin the relationships colleagues (implementers, researchers, evaluators, and between different health system actors [4]. The need to those who wear mixed hats) have compiled the various explicitly work with intangible elements in the health approaches to working with rewiring elements that we system has gained increased attention. Indeed, recent have come across in the course of our work. Drawing empirical studies in many different low- and middle- on our joint experiential knowledge in the Indian public income countries (LMICs) have highlighted how perverse health setting, with support from pertinent literature, intangible software within health systems—including the we have tried to engage with four guiding questions: demotivation of staff, lack of support and leadership, risk-averseness and hesitancy to implement new poli- 1. Is it possible to rewire intangible software in health cies—undermines various system improvement efforts systems? [5–9]. Further, evidence suggests when software elements 2. What approaches have been attempted in the Indian are positively oriented—for example, in health facilities public health system to rewire intangibles? where trusting and collaborative relationships exist—the 3. Have these approaches been evaluated and proven performance of health workers, as well as the quality of worthy of programmatic investment? care provided by them, tends to be better [10]. 4. What are our practical learnings on rewiring? Despite an increasing recognition of the need to work with intangible software in health systems, the more These guiding questions emerged from practice practical hows of doing so have been less clear. Some rather than theory. Our engagement with these guid- have argued that system reform efforts must begin with ing questions in this commentary is intended as a start- the intangibles, since changes in health systems and ing point to deeper empirical and theoretical work. We R amani et al. Health Research Policy and Systems (2022) 20:52 Page 3 of 10 Box 1: Approaches intended to rewire intangible software in health systems Approaches intended to enable visioning and leading These approaches focus on enabling health workers to see value in their routine work and recognize themselves as leaders, and in doing so work towards recognizing and rewriting some of the systemically embedded routine scripts and practices that hinder change. Approaches targeted at engaging with evidence better These approaches work on the premise that health workers at all levels need to engage with data with more intensity than as “fillers” of forms, and that if they are given an opportunity to do so, they have the capacity to critically engage with evidence and think of locally relevant solutions. Approaches intended to help health workers navigate contextual complexities This cluster of ideas recognize that the day-to-day contexts that health workers have to reckon with are complex and challenging, and that there is a need to support health workers to handle such challenges, rather than blaming them for nonachievement or for being risk-averse. Approaches intended to build the cultural competence of health workers and to enhance community relationships These approaches focus on sensitizing health workers to the needs of the community, providing a better sociocultural—and a more humane—orientation to health providers. Approaches that recognize and reward performance These approaches are intended to recognize existing “exemplars” in the system, and to honour and reward them for their personal values, humane orientation, community relationships, innovations and commitment to their work. These awards are not meant to be for the achievement of numerical targets in the conventional sense. Approaches targeted at enabling collaborative work and breaking power/gender hierarchies This set of approaches is targeted at breaking gen- der and power hierarchies in the system and enabling collaborative work across cadres or different teams of people. have discussed our thoughts on each of these questions sense-making within health systems through research below. partnerships, have shown promise in nurturing positive change [18]. From Guatemala, one study documents sys- 1. Is it possible to rewire intangible software in the temic changes achieved through a humanized version health system? of supportive supervision to community health workers In practice settings in India, we have often observed [19]. From India, the Ekjut trial, based on participatory that perverse intangibles within health systems are learning and action (PLA) techniques, has demonstrated considered as either unmodifiable or as too difficult to how such techniques can enhance community relation- change. Very few initiatives to rewire intangibles have ships with health systems [20, 21]. In general, docu- been tried, and even fewer have been documented. mentation on working with intangibles is limited across Hence, we have tried to make a case below as to why we LMICs, but the above examples do suggest that interven- consider intangibles to be amenable to change. tions to rewire intangibles have potential. From our perspective, approaches to rewiring intan- gible software recognize and celebrate the human ele- 2. What approaches have been attempted in India to ment in health systems. We see these approaches as rewire intangibles? being derived from an “actor-centric” philosophy that From the authors’ collective knowledge of the Indian recognizes that people working in health systems are landscape, we have tried to compile a list of interventions not automatons who carry out tasks mechanically. that have been tried in India to enable the rewiring of Rather, they are individuals with agency, who are capa- perverse software in the public health system. We have ble of self-mastery, learning, visioning, collaborating, and compiled the interventions into six inductively derived adapting to and leading change [14, 15]. The actions and categories, described in Box 1. decisions of people are underpinned by their lifeworlds or lived realities [16, 17], which can be understood and reoriented in favour of broader health system goals. From In January 2020, a team at Oxford Policy Management (OPM) undertook a this standpoint, it is possible to work with intangibles rapid exercise to identify a list of intangible software interventions that have been attempted in the public health system in India by connecting with sev- in order to improve performance and practice, and to eral academicians, evaluators and implementors. We started with an initial list strengthen health systems overall. Also, since individu- of people identified by the OPM team internally and snowballed from there als in the health system are embedded within formal and (we contacted 47 organizations in total). We produced a series of 12 case studies on rewiring intangible interventions, based on our conversations with informal power hierarchies within health systems, work- different people. In May 2020, the OPM team reconnected with interested ing with intangibles is almost always an exercise in chal- stakeholders to coproduce this commentary. We jointly decided on four guid- lenging existing power relationships. ing questions and then reflected on these four questions using the case studies as the basis for inductively emerging themes. The team at OPM did the first There are documented examples across LMICs that round of the cross-case analysis and wrote the first draft of this commentary. highlight that working with intangibles is possible. The Subsequently, all authors have commented and reviewed various sections of learning sites from Kenya and South Africa, which were the paper verbally or through email. More details on the processes we fol- lowed can be obtained by writing to the corresponding author. attempts to systematize processes of reflection and Ramani et al. Health Research Policy and Systems (2022) 20:52 Page 4 of 10 In Table  1, we present Indian examples of the is because rewiring interventions have complex change approaches described in Box  1. We have included inter- mechanisms that work or do not work depending on ventions attempted at both the managerial level and on several factors in the context. An illustration of this com- the frontlines of the public health system. Only a few of plexity has been presented in an evaluation by Prashanth these have been formally documented. The kind of inter - et al. (2014) of an intervention to strengthen district-level ventions we have compiled here aimed at “first-order” managerial skills undertaken by the Institute of Public culture change [22]: that is, they were about enabling Health, Bangalore. Conducted by applying a realist lens, people in the health system to do similar activities that this evaluation highlights several contextual factors that they had been doing all along but with a slight twist or a played a role in determining the ultimate impact of the difference. managerial intervention, including staff turnover and the existence of infrastructural support. The authors of 3. Have interventions on rewiring intangibles been this evaluation point out that a decontextualized proof evaluated and proven worthy of programmatic of concept may simply not exist for the kind of interven- investment? tion they had tried; and applying a “what worked, why This question gets asked by many well-intentioned and for whom” approach was probably a more practical governments and donor agencies who are interested in way to assess the merits of their efforts [23]. Such argu - investing in rewiring interventions. These entities have ments have been put forth by Sardan and colleagues [13] expressed justifiable worries about the lack of concrete as well, from their experience in sub-Saharan Africa. proof that such interventions are worthy of investment. Sardan and colleagues have particularly emphasized the We have attempted to put together our thoughts on this danger of copying intervention approaches without tak- issue below. ing into account the subtle contextual nuances that made There is a slowly growing body of evidence from differ - these approaches a success in the first place [13]. Cleary ent LMICs that points towards the promise of rewiring and colleagues offer similar arguments for evaluating intangible software. The learning site approach in Kenya a leadership intervention in South Africa through an and South Africa, which uses PLA methods and encour- “action-learning” design, which provided multiple oppor- ages reflective practices, has highlighted the potential to tunities for adapting and tailoring the intervention [29]. improve social and emotional skills among health staff u Th s, rather than traditional evaluation techniques (like and to stimulate learning processes, and overall, better measuring impact), evaluations that gather rich learnings relationships in the system [18, 26]. The Health Workers and help to iteratively produce more potent and practical for Change approach, which uses a series of participatory ways to rewire intangible software might be more useful workshops to sensitize health workers to gender issues, for implementers of such approaches. has shown positive changes after these workshops in Another factor that makes the evaluation of rewir- some places, but not all [27, 28]. Some interventions like ing approaches difficult is the timing. Many rewiring supportive supervision, appreciative enquiry in systems approaches aim at long-term, slow change, but usually and PLA have also been tried and declared as promising evaluations of interventions tend to be carried out simul- [19, 20] (also refer to Table  1 example 8). However, con- taneously or immediately after the intervention. A recent ventional proof of concepts—that is, evidence through review of learning and development programmes in conventional experimental methods where one can Africa notes that the effects of these programmes may attribute change in community-level outcomes to par- become clear only after several years, and may not be vis- ticular interventions—may not always exist for the inter- ible in immediate assessments [30]. We concur on this ventions described in this note. point that we might not be able to capture the true effect In fact, many of the intervention examples from our of interventions on intangibles within more immediate work that we have listed in Table  1 do not have decon- time frames. We also feel that the lack of funding and textualized proofs of concept. For one, proofs of causal expertise within programmes to conduct long-term eval- relationships between such interventions and commu- uations is also a deterrent. That is, many a time, evalua - nity-level outcomes are not easy to establish. Even if tors have to be externally hired for the purpose, and this these interventions have been evaluated or examined, the is particularly disproportionately expensive in LMICs end results of these evaluations need to be viewed with when the interventions being tried are small-scale and caution and not taken as indicating blanket “success” or dependent on tight budgets. “failure” of the intervention (refer to Table 1, examples 1 to 5). We feel that combined successes and failures in the 4. What works in practice? Some lessons from our same intervention need to be accepted, and impact eval- experiences uations may not be able to capture these nuances. This R amani et al. Health Research Policy and Systems (2022) 20:52 Page 5 of 10 Table 1 Examples of interventions that have been attempted to rewire intangible software in India The approach Example Some learnings reported by the implementers Approaches intended to enable visioning and leading 1. No one wants to feel like their job is meaningless: informal When a community monitoring intervention was initiated by the High-level support from the state authorities and government gatherings and discussions to understand overarching policy Society for Community Health Awareness Research and Action orders are needed. Not all people were willing to collaborate and visions and values (SOCHARA) in Tamil Nadu, frontline workers were worried that be a part of this process, despite the existence of a government this “monitoring” process would be used to unfairly accuse them order. It was found that in some geographical pockets, people of faults that they believed to be systemic. Hence, the workers were more willing, and that these pockets could be used to dem- were unwilling to cooperate. However, rather than start with onstrate to the others who were hesitant the usefulness and value an attitude of confrontation, staff from SOCHARA spent a lot of of this community monitoring process time just informally talking to health workers about notions of accountability and helping them understand why community monitoring processes had value and meaning. The informal dis- cussions helped the health workers to accept the intervention 2. Leadership trainings and nonclinical capacity-building The Institute of Public Health has conducted district-level There were anecdotes regarding resistance from the public sector initiatives training programmes to build “champions” and “leaders” in staff to being trained as some of them felt that they were being Karnataka. There were reports of initial resistance to the training tested. It took some time for the staff to relax into the programme. as there was a belief among the health workers that they were The evaluation found that the responses from different geograph- being tested during these training sessions. Hence, prior to the ical divisions varied training, an extended rapport-building phase was necessary. A detailed evaluation of this training programme has been published [23] 3. It is one champion who can nurture others: Exposure of staff An ex-medical officer from a primary health centre shared that People learn both good and not-so-good practices from champi- to inspirational examples in the state she hailed from (anonymized), new recruits were ons; thus, the champions must be carefully chosen. Even champi- exposed to exemplars or positive deviants in the public health ons can’t work without basic infrastructural support system. This was done as a part of their induction training and aimed to provide new recruits with good role models to look up to, and, in the long term, to potentially add to the tribe of posi- tive deviants in the health system Approaches targeted at engaging with evidence better 4. Helping routine data to speak differently through eye- A series of workshops was conducted by the National Health In some of the district pockets, the officials had attempted to opening data workshops Systems Resource Center on recognizing and engaging with recognize inequities and reach the more vulnerable in their pro- health inequities in the data that health workers routinely gramme in practical ways encountered. These workshops gave people an opportunity to relook at routine data through a different lens—what the staff had earlier perceived as boring, routine data was used to enable a process of reflection 5. Reinforcement of achievements locally using local data One researcher-cum-implementor used facility-level data in a The lack of supporting infrastructure is a deterrent to even the low-income state in India to engage in discussions with primary most motivated of nurses care nurses. Nurses looked at synthesized data and tried to reflect on their local achievements. The self-recognition of posi- tive achievements seemed to play an important role in boosting local morale Approaches targeted at navigating complexities in the context Ramani et al. Health Research Policy and Systems (2022) 20:52 Page 6 of 10 Table 1 (continued) The approach Example Some learnings reported by the implementers 6. Buddy systems This has been tried in some public medical college hospitals in The buddy system example here focuses on doctors, but it was different states in India. Buddy systems attempt to pair young suggested that it would be useful to have buddies across cadres. recruits with champions or exemplars, who serve as mentors and This system would be more effective if exemplars/stalwarts in support new workers through complex decision-making the health systems came forward themselves to be “buddies” to younger staff 7. Putting people in a safe space outside of work to reflect: infor - A district-level official from one of the southern states in India Such workshops should be long-term, have repeated sessions mal reflective spaces conducted a series of residential workshops with the heads of over time, and preferably be residential—so that space to reflect different implementation bodies across sectors in order to break and bond together without the interference of routine work is the hesitancy of people as regards collaborating across sectors. enhanced These workshops provided space for reflection and bonding away from work. No targets or checklists were used or discussed Approaches intended to build the cultural competence of health workers and to enhance community relationships 8. Common understandings: people and the system need to The Ekjut trial on PLA took place in Jharkhand and Orissa. In this The intervention needs to be participatory, even at the expense of understand each other intervention, regular and iterative meetings were facilitated by time issues. Change is a time-consuming process accredited social health activists (ASHAs) (link workers associated with the Indian public health system) with women’s groups over 31 months [21] 9. How to talk to the community trainings: explicit soft skills and In 2018–19, the Center for Enquiry into Health and Allied Themes Programme staff realized that conveying some of these concepts, communication trainings (CEHAT ) led a training intervention on domestic violence for such as “equity” and “gender responsiveness”, during training health workers in two tertiary care hospitals in Maharashtra [24]. was not straightforward. It was perceived by staff that attitudinal By codesigning the intervention with stakeholders, incorporat- changes were easier to bring about in younger staff ing mixed-cadre training sessions and including explicit “soft skill” communication skills as part of the training, this training worked towards tweaking the culture within health facilities to be more sensitive to domestic violence issues Approaches that recognize and reward performance 10. Social awards and incentives The Kayakalp award scheme is run by the central health ministry Social awards have to be used carefully—for wrongly chosen in India and recognizes and awards health facilities that demon- award schemes (or corrupt awarding practices) can be demotivat- strate their commitment to cleanliness, hygiene and infection ing control practices Approaches targeted at enabling collaborative work and breaking power/gender hierarchies 11. Building confidence: training on soft skills, public speaking Basic Health Services in Udaipur offered nurses formal leadership Structural and software interventions were needed to help nurses and speaking in English positions at primary care clinics [25]. The organization noticed take up leadership positions. Leadership workshops must be seen that nurses were culturally hesitant about taking up leadership only as one important step in trying to break down power hierar- positions. The nurses were trained using a hybrid technical and chies. Building leadership skills takes time soft skills module to build their rigour and confidence. It was reported that public-speaking skills, and particularly learning to speak in English, helped to boost nurses’ confidence 12. Sensitization workshops within the health system The Resource Group for Education and Advocacy for Community An evidence base was needed to make a stronger case for gender Health (REACH) in Tamil Nadu has been supporting the Revised responsiveness before embarking on the workshops, and this National Tuberculosis Control Programme [now the National TB was achieved through a TB and gender assessment, followed by Elimination Programme (NTEP)], to adopt a gendered lens to TB. the adoption of a gender framework by the national programme. As part of these efforts, a gender-responsive training curriculum Such trainings must try to balance concepts along with granular was developed and piloted with NTEP in October 2020. The action, and help participants understand how they can apply their training used participatory techniques (including power walks) learning in their specific roles to sensitize people to power and gender hierarchies R amani et al. Health Research Policy and Systems (2022) 20:52 Page 7 of 10 In the section we highlight some practical tips on work- facilities after their visit, and share this ranking through ing with intangible software. a feedback box in the facility. The purpose of this inter - vention was to identify and motivate good doctors in Hardware and software go hand in hand It is important the public sector. However, it was found that doctors that intangible software interventions are implemented tried to rig the voting system in their favour—since the hand in hand with improvements in hardware and tangi- doctors viewed the voting system as a form of ranking, ble software. We give two examples below that illustrate rather than as a feedback mechanism. u Th s, the system the need for combined hardware–software interven- was not able to truly identify the “good” doctors through tions. Authors AU and PB were involved in conducting this intervention. This experience taught the managerial a series of training programmes for frontline counsellors staff that rewiring interventions need to be tweaked to in the public health system on the reproductive rights of the context, and one of the ways to do this is through the women. These trainings emphasized inculcating coun - participation of local stakeholders right from the design selling skills using a rights-based approach (rather than stage of the intervention. Another example of this kind coercing women to adopt family planning methods). was noted by SA. SA, based on her experience of work- However, it was found that after receiving the training, ing on a codesigned curriculum for health workers on the trained counsellors went to work in a context that domestic violence, emphasized that codesigning inter- was highly target-oriented, and the counsellors felt they ventions is not a one-off process. The NGO she worked had no room to practically apply the rights-based ori- with had conducted a domestic violence programme entation that they had obtained during their training. In in 2018–19 that tried to sensitize health workers to the addition, it was reported that the hospital facility heads needs of women who face domestic violence [24]. Before used counsellors for work other than counselling, and this training was launched, the technical content had the counsellors, who were contractual employees, felt already been discussed with the health workers, and uncomfortable protesting against their diluted counsel- their inputs had been obtained. But during the train- ling roles. All this highlights that the usefulness of rewir- ing, a training facilitator used a fictitious example of a ing software approaches can be diluted if other structural woman from an ethnic minority to illustrate the concept systemic changes do not accompany these interven- of vulnerability. This example was misconstrued by one tions (refer to Table  1, examples 3, 5 and 11). We share participant, who took offence against being thought of another learning on the same lines from Basic Health as “vulnerable”. Following this incident, the content of Services, a nongovernmental organization (NGO) in the training was revised again to make it more sensitive the state of Rajasthan in India which runs primary care to the participants’ feelings. SA emphasized that truly clinics led by nurses. Nurses from these areas did not codesigning an intervention is an iterative process that is think of themselves as “leaders” of independent clinical time-consuming and one that involves immense effort if work [25]. To change these attitudes, this NGO offered it is to be done right. nurses formal roles that conferred more power on them (structural change). The NGO also held iterative techni - Each place might need a different “hook”, and not eve - cal and confidence-building training sessions to enable rything works everywhere Not everything works for eve- the nurses to think of themselves as change-makers and ryone when it comes to modifying intangibles, and this leaders (software change). We note that this combination limitation has to be accepted. This learning can be seen of structural and software elements in this intervention, across almost all interventions in Table  1. If we believe entwined deliberately, had the potential to change the that people are unique and are bound to use agency dif- existing status quo for nurses. ferently, we need to enable the use of this agency for positive change. But, at the same time, we need to accept Codesigning interventions with stakeholders Intan- the inherent nonuniformity that is bound to surface in gible software interventions work with complex ideas, our enabling efforts. For instance, one of our authors ideologies and concepts that are not easy to work with. (anonymized) shared the experience of being involved Hence, rewiring interventions can fail in their purpose in a national-level training workshop. Among the train- if they are not codesigned with relevant stakeholders ees, many did not incorporate new learnings in their (refer to Table 1, examples 1, 6, 7, 9 and 10 that highlight practice, but others seriously attempted to change some need for codesigning and mention field-level suggestions existing managerial practices in accordance with the new for improving specific intangible interventions). One of learnings and demonstrated fantastic local-level results. our authors (anonymized) spoke of how the local health The evaluation by Prashanth et al. (2014) also pointed to department in their area tried to set up a system whereby how each subdivision in a district responded differently patients could rank a doctor from public primary care to a management training programme, and it noted that Ramani et al. Health Research Policy and Systems (2022) 20:52 Page 8 of 10 the response of people in complex systems is not always of working on gender and tuberculosis. They observed predictable. Among us, we have noted the need to start that within the national programme on tuberculosis, the with small changes and not be discouraged by uneven or managerial cadres were mostly male, and issues of “gen- nonuniform results. A tribe of “positive” change-makers der” were a very novel concept in these circles. Both RA needs to be built over time; it helps to start with a few and AS highlighted the need for patience and for empa- who are more inclined and able to foster change, and thy with people who are involved in the change process, eventually snowball from there. and they noted that “change is never easy for anyone”. They emphasized the need for empathetic discussions, Nurturing spaces for reflection within existing rou - trust-building and bonding, along with hard evidence to tines If we think of health systems as complex adaptive bring about a “slow” change. All of us writing this paper systems, this implies that there are adaptive mechanisms have expressed similar sentiments, the general consen- within such systems that work to maintain the status sus being that the chances of achieving instant results quo—even when this status quo is widely acknowledged through intangible software interventions are very low. as deficient [31]. One way to help people question this status quo is to enable a process of reflection and think - Concluding thoughts ing among health workers and managers. Reports of the Complexity theories on systems thinking emphasize that learning sites’ experience have captured several mecha- bringing about change is a messy, nonlinear and unpre- nisms through which developing spaces for iterative dictable process and that change agents need to work reflection and learning within practice settings offer with multiple underlying issues in health systems [12]. scope for building “everyday resilience” in health systems, Despite recognition of complexity in the change pro- by building three kinds of capacities—cognitive, behav- cess, we feel that in India, like in many other LMICs, ioural and contextual [26, 32]. As a group, we believe that most efforts to bring about change continue to focus on many people who join public services have good inten- the tangible aspects of the health system. Our collec- tions and are intrinsically motivated to help patients; tive experiences show that intangible software interven- however, much of this enthusiasm gets chipped away tions—that aim to change leadership behaviours, trust, due to tough work schedules and constrained support motivation, power balance and the values of health sys- in work settings. Offering spaces for reflection can help tem actors—are often considered to be risky ventures health workers gain renewed vigour and hope, and can that may not yield predictable results. Difficulties in open up their minds to finding solutions (refer Table  1, measuring the impact of such interventions, as well as examples 4, 6, 7 and 12 that highlight such attempts). the scarcity of publications in this area, seem to con- These approaches can be facilitated by trusted external tribute further to the lack of confidence of funders and parties (researchers, NGOs, think tanks). We feel that governments in these efforts. Not surprisingly, the cur - approaches can also be piggybacked onto existing capac- rent situation of health system programming in India ity-building/technical training sessions. For instance, does not appear to favour investments that seek to alter some training sessions on soft skills (talking in English, intangibles. public speaking, confidence-building discussions) can be However, the examples of interventions from India dis- added on to existing new-recruit induction trainings in cussed in this paper suggest that it is possible to attempt primary health facilities or other routine monthly meet- to rewire intangible software in health systems. Such ings. That is, these sessions need not be completely “new” interventions appear to work best when they are code- activities, but rather routine ones with a slight twist in signed, contextually adapted and implemented in con- how they are conducted. junction with structural or hardware improvements. It is important to keep in mind, however, that the road to It takes decades of patience, empathy and investments rewiring intangibles, in local health systems or sub-sys- Intangible software interventions often deal with ideas tems, may often be long and iterative. As Kwamie and and values that are deeply embedded in the social fabric, colleagues point out, we need “long-term, more reflective and changing these is not an easy task. Indeed, it is eas- and potentially unpredictable approaches” to strengthen- ier to change practices through incentives and protocols ing capacities in health systems [33]. Further, evidence than to change underlying attitudes. Yet lasting change on such interventions may need “complexity-sensitive” comes only with attitudinal change. The need for time learning assessments that focus on experiential learnings, and patience has been noted repeatedly (refer to Table 1, rather than objective evaluations. There is also potential examples 2, 7, 8, 11 and 12 that reflect these points). RA to explore more embedded approaches to researching and AS from REACH, in particular, have noted the need such interventions, wherein the ownership of evaluation for empathy, along with patience, from their experience R amani et al. Health Research Policy and Systems (2022) 20:52 Page 9 of 10 and learning rests largely with decision-makers and of practice, online knowledge-sharing platforms and implementers [34]. other such groups of actors can help to augment evidence Since this commentary is intended as a “practice” generation and advocacy on intangible software. paper, we have not focused on the theoretical underpin- nings of the experiential lessons we have shared here. For instance, the learnings from our efforts can be linked to Annexure perspectives from cultural sociology, that highlight how We have appended an infographic that highlights various cultural scripts and repertoires act as a toolkit to shape approaches to rewiring intangible software. This info - action, making change a difficult and nonlinear process graphic is intended for better communication of study [35]. Our findings can also be mapped to scholarship on learnings to a wider audience. organizations and institutions, that offers perspectives on how individual agency relates to formal and informal Abbreviations institutional structures. For instance, work from the field CEHAT: Center for Enquiry into Health and Allied Themes; HPSR: Health of new institutionalism [36], cybernetics such as the via- policy and systems research; LMIC: Low- and middle-income countries; NGO: Nongovernmental organization; NTEP: National Tuberculosis Elimination ble system model [37] and institutional logic perspectives Programme; PLA: Participatory learning and action; REACH: Resource Group [38] can enable further interrogation of the interventions for Education and Advocacy for Community Health; SOCHARA : Society for that we have mentioned in this paper. We invite others to Community Health Awareness Research and Action. take our work further through deeper engagement with Acknowledgements such theoretical perspectives. We would like to thank Dr Vikas Keshri (George Institute of Global Health), Mr Ameerkhan (SOCHARA), Dr Sanjana Mohan (Basic Health Services), Dr Amol Dongre (Pramukhswami Medical College) and Dr Allen Ugargol (IIM Banga- The way forward lore) for speaking to us during the course of this study. We acknowledge the We conclude this commentary with three issues that role of Tom Newton-Lewis (independent consultant), Cindy Carlson (Oxford need attention with respect to rewiring intangible soft- Policy Management) and Rajni Luthra in enabling this study. We thank Dr Lucy Gilson (University of Cape Town) for her suggestions on an initial draft of this ware in health systems. paper. One, we feel that the routine dialogue among govern- ments, researchers, funders and implementers must Author contributions SR, RP, AK, DS and SM were a part of the team from Oxford Policy Manage- encompass explicit discussions on intangible elements ment who conceptualized the commentary, analysed the findings and wrote in health systems. We consider this important as these the first draft of the paper. SA, AS, PB, VY, AU, RA and SK contributed to the stakeholders routinely discuss resourcing (hardware) and writing and discussion of the individual case studies described in this com- mentary. RG, NR and AP contributed to cross-cutting discussions and themes. formal processes (tangible software) for systems improve- All authors have reviewed the paper and added their inputs. SR is the guaran- ment, but side-line discussions on intangible software. tor of the paper. All authors read and approved the final manuscript. This happens possibly because elements of intangible Funding software are challenging to unpack, potentially sensitive The Bill and Melinda Gates Foundation funded the compilation of the soft- and considered difficult to change. However, we believe ware approaches described in this commentary. The grant was managed by that opening difficult dialogues on intangibles in formal Oxford Policy Management Ltd. decision-making spaces can help to develop a collective Availability of data and materials understanding of these ideas, as well as generate more Not applicable. funding and interest in this area. Second, there is a need to build, evaluate and publish Declarations evidence on working with intangibles in diverse fora. Ethics approval and consent to participate Implementers often possess deep knowledge of intangi- Not applicable. ( This is a coproduced commentary.) bles and their workings in specific contexts. They make multiple structured as well as not-so-structured attempts Competing interests The authors declare that they have no competing interests. to modify intangibles, as we observe from the experi- ences shared in this paper. This tacit knowledge is often Author details 1 2 unpublished and remains within specific implementer Oxford Policy Management, New Delhi, India. Evidence Action, New Delhi, 3 4 India. CARE India, New Delhi, India. Achutha Menon Centre for Health groups. We feel that systematic efforts to capture such Science Studies, Thiruvananthapuram, Kerala 695011, India. Resource Group experiential learnings on intangibles are needed. for Education and Advocacy for Community Health (REACH), Chennai, India. Lastly, we feel the need for ecosystems—both nation- Center for Enquiry into Health and Allied Themes, Santacruz East, Mum- 7 8 bai 400055, India. Gender Justice, Oxfam India, New Delhi, India. Women ally and across LMICs—in which experiential learnings 9 10 in Global Health, New Delhi, India. Vikalp Kriya, Panaji, Goa, India. NITI on intangible software can be shared. Such ecosystems 11 Aayog, New Delhi, India. Health Systems Transformation Platform, New Delhi, can be built around formal research–practice collabora- India. tions. Further, informal platforms such as communities Ramani et al. Health Research Policy and Systems (2022) 20:52 Page 10 of 10 Received: 22 December 2021 Accepted: 2 April 2022 (ASHAs) to improve maternal and newborn health in underserved areas of Jharkhand and Orissa: study protocol for a cluster-randomised con- trolled trial. Trials. 2011;12:182. 22. Scott T, Mannion R, Davies HT, Marshall MN. Implementing culture change in health care: theory and practice. Int J Qual Health Care. 2003;15(2):111–8. References 23. Prashanth NS, Marchal B, Kegels G, Criel B. Evaluation of capacity-building 1. Gilson L, Hanson K, Sheikh K, et al. Building the field of health program of district health managers in India: a contextualized theoretical policy and systems research: social science matters. PLoS Med. framework. Front Public Health. 2014;2:89. 2011;8:e1001079. 24. Meyer SR, Rege S, Avalaskar P, Deosthali P, García-Moreno C, Amin A. 2. AHPSR. What is health policy and systems research (HPSR)? Geneva: Strengthening health systems response to violence against women: pro- World Health Organization; 2019. tocol to test approaches to train health workers in India. Pilot Feasibility 3. Ellokor S, Olckers P, Gilson L et al. Crises, routines and innovations—the Stud. 2020;6:63. complexities and possibilities of sub-district management. in South 25. Amin A, Dutta M, Brahmawar Mohan S, Mohan P. Pathways to enable African Health Review 2012/3, Health Systems Trust, Durban, 2013; pp. primary healthcare nurses in providing comprehensive primary health- 161–73. care to rural, tribal communities in Rajasthan, India. Front Public Health. 4. Sheikh K, Gilson L, Agyepong IA, Hanson K, Ssengooba F, Bennett S. 2020;8:583821. Building the field of health policy and systems research: framing the 26. Nzinga J, Boga M, Kagwanja N, Waithaka D, Barasa E, Tsofa B, Gilson L, questions. PLoS Med. 2011;8(8):e1001073. Molyneux S. An innovative leadership development initiative to sup- 5. Guinaran RC, Alupias EB, Gilson L. The practice of power by regional man- port building everyday resilience in health systems. Health Policy Plan. agers in the implementation of an indigenous people’s health policy in 2021;36(7):1023–35. the Philippines. Int J Health Policy Manag. 2021. https:// doi. org/ 10. 34172/ 27. Shaikh BT, Reza S, Afzal M, Rabbani F. Gender sensitization among health IJHPM. 2020. 246. providers and communities through transformative learning tools: expe- 6. Ramani S, Gilson L, Sivakami M, Gawde N. Sometimes resigned some- riences from Karachi, Pakistan. Educ Health (Abingdon). 2007;20(3):118. times conflicted, and mostly risk averse: primary care doctors in India as 28. Webber G, Chirangi B, Magatti N. Promoting respectful maternity care street level bureaucrats. Int J Health Policy Manag. 2021. https:// doi. org/ in rural Tanzania: nurses’ experiences of the “Health Workers for Change” 10. 34172/ IJHPM. 2020. 206. program. BMC Health Serv Res. 2018;18(1):658. 7. Gaitonde R, San Sebastian M, Hurtig AK. Dissonances and discon- 29. Cleary S, Toit AD, Scott V, Gilson L. Enabling relational leadership in pri- nects: the life and times of community based accountability in the mary healthcare settings: lessons from the DIALHS collaboration. Health national rural health mission in Tamilnadu, India. BMC Health Serv Res. Policy Plan. 2018;33(suppl_2):ii65–74. 2020;20(1):89. 30. Johnson O, Begg K, Kelly AH, Sevdalis N. Interventions to strengthen the 8. Scott V, Mathews V, Gilson L. Constraints to implementing an equity- leadership capabilities of health professionals in Sub-Saharan Africa: a promoting staff allocation policy: understanding mid-level managers’ scoping review. Health Policy Plan. 2021;36(1):117–33. and nurses’ perspectives affecting implementation in South Africa. Health 31. Topp SM. Power and politics: the case for linking resilience to health Policy Plan. 2012;27(2):138–46. system governance. BMJ Glob Health. 2020;5(6):e002891. 9. Aberese-Ako M, van Dijk H, Gerrits T, Arhinful DK, Agyepong IA. “Your 32. Gilson L, Ellokor S, Lehmann U, Brady L. Organizational change and health our concern, our health whose concern?”: perceptions of injustice everyday health system resilience: lessons from Cape Town, South Africa. in organizational relationships and processes and frontline health worker Soc Sci Med. 2020;266:113407. motivation in Ghana. Health Policy Plan. 2014;29(Suppl 2):ii15-28. 33. Kwamie A, van Dijk H, Agyepong IA. Advancing the application of 10. Okello DR, Gilson L. Exploring the influence of trust relationships on systems thinking in health: realist evaluation of the Leadership Develop- motivation in the health sector: a systematic review. Hum Resour Health. ment Programme for district manager decision-making in Ghana. Health 2015;13:16. Res Policy Syst. 2014;12:29. 11. Whyle E, Olivier J. Social values and health systems in health policy and 34. Ghaffar A, Gupta A, Kampo A, et al. The value and promise of embedded systems research: a mixed-method systematic review and evidence map. research. Health Res Policy Sys. 2021;19:99. Health Policy Plan. 2020;35(6):735–51. 35. Swidler A. Culture in action: symbols and strategies. Am Sociol Rev. 12. De Savigny D, Adam T. Systems thinking for health systems strengthen- 1986;51(2):273–86. ing. Geneva: World Health Organization; 2009. 36. Schmidt VA. Taking ideas and discourse seriously: explaining change 13. Olivier de Sardan JP, Diarra A, Moha M. Travelling models and the chal- through discursive institutionalism as the fourth “new institutionalism.” lenge of pragmatic contexts and practical norms: the case of maternal Eur Polit Sci Rev. 2010;2(1):1–25. health. Health Res Policy Syst. 2017;15(Suppl 1):60. 37. Beer S. Diagnosing the system for organizations. Chichester: Wiley; 1985. 14. Lipsky M. Street level bureaucracy: dilemmas of the individual in public 38. Thornton PH, Ocasio W. Institutional logics. In: Greenwood R, Oliver C, services. Russell Sage Foundation; 1980. Sahlin K, Suddaby R, editors. The SAGE handbook of organizational insti- 15. Gilson L. Lipsky’s street level bureaucracy. in Oxford Handbook of the tutionalism. CA: Sage; 2008. Classics of Public Policy, Oxford University Press, Oxford, 2015. 16. Long N. Development sociology, actor perspectives. Abingdon: Rout- ledge; 2001. Publisher’s Note 17. Parashar R, Gawde N, Gilson L. Application of “actor interface analysis” to Springer Nature remains neutral with regard to jurisdictional claims in pub- examine practices of power in health policy implementation: an interpre- lished maps and institutional affiliations. tive synthesis and guiding steps. Int J Health Policy Manag. 2021. https:// doi. org/ 10. 34172/ IJHPM. 2020. 19. 18. RESYST/DIAHLS learning site team. Learning sites for health system gov- ernance in Kenya and South Africa: reflecting on our experience. Health Res Policy Syst. 2020;18(1):44. 19. Hernández AR, Hurtig AK, Dahlblom K, San Sebastián M. More than a checklist: a realist evaluation of supervision of mid-level health workers in rural Guatemala. BMC Health Serv Res. 2014;14:112. 20. Rath S, Nair N, Tripathy PK, Barnett S, Rath S, Mahapatra R, Gope R. Explaining the impact of a women’s group led community mobilisation intervention on maternal and newborn health outcomes: the Ekjut trial process evaluation. BMC Int Health Hum Rights. 2010;10:25. 21. Tripathy P, Nair N, Mahapatra R, Rath S, et al. Community mobilisation with women’s groups facilitated by Accredited Social Health Activists

Journal

Health Research Policy and Systems – Springer Journals

Published: May 7, 2022

Keywords: Health systems strengthening; Intangible; Leadership; Awards; Supervision; India; Low- and middle-income countries; Competence; Power; Trust

There are no references for this article.