Advancing the application of systems thinking in health: South African examples of a leadership of sensemaking for primary health care
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Date
2014
Journal Title
Journal ISSN
Volume Title
Publisher
Biomed Central
Abstract
BACKGROUND: New forms of leadership are required to bring about the fundamental
health system changes demanded by primary health care (PHC). Using theory about
complex adaptive systems and policy implementation, this paper considers how
actors' sensemaking and the exercise of discretionary power currently combine to
challenge PHC re-orientation in the South African health system; and provides
examples of leadership practices that promote sensemaking and power use in
support of PHC.
METHODS: The paper draws on observational, interview, and reflective data
collected as part of the District Innovation and Action Learning for Health
Systems Development (DIALHS) project being implemented in Cape Town, South
Africa. Undertaken collaboratively between health managers and RESEARCHERS, the
project is implemented through cycles of action-learning, including systematic
reflection and synthesis. It includes a particular focus on how local health
managers can better support front line facility managers in strengthening PHC.
RESULTS: The results illuminate how the collective understandings of staff
working at the primary level - of their working environment and changes within it
- act as a barrier to centrally-led initiatives to strengthen PHC. Staff often
fail to take ownership of such initiatives and experience them as disempowering.
Local area managers, located between the centre and the service frontline, have a
vital role to play in providing a leadership of sensemaking to mediate these
challenges. Founded on personal values, such leadership entails, for example,
efforts to nurture PHC-aligned values and mind-sets among staff; build
relationships and support the development of shared meanings about change; instil
a culture of collective inquiry and mutual accountability; and role-model
management practices, including using language to signal meaning.
CONCLUSIONS: PHC will only become a lived reality within the South African health
system when frontline staff are able to make sense of policy intentions and
incorporate them into their everyday routines and practices. This requires a
leadership of sensemaking that enables front line staff to exercise their
collective discretionary power in strengthening PHC. We hope this
theoretically-framed analysis of one set of experiences stimulates wider thinking
about the leadership needed to sustain primary health care in other settings.
Description
Keywords
Discretionary power, Complex adaptive systems, Primary health care
Citation
Gilson, L., Elloker, S., Olckers, P. & Lehmann, U. 2014. Advancing the application of systems thinking in health: South African examples of a leadership of sensemaking for primary health care. Health Research Policy and Systems, 12