Transcript Towards a mid range theory of implementation

Towards a mid range theory of
implementation
B.V.L.Narayana
7/7/2015
1
Structure of presentation
Motivation
Problem definition—literature review
Research problem
Methodology
Context
Findings
Discussion
Contributions and limitations
7/7/2015
2
Health indices comparison
Indicator name
Av. Value
for
India
Lowest in any
state
Highest in any state
Infant mortality rate
58
13( Manipur )
76 ( Madhya Pradesh)
Maternal mortality ratio
301
110 ( Kerala )
517( Uttar Pradesh)
Institutional deliveries ( %)
40.7
12.2 (Nagaland)
99.5( Kerala)
Full ANC check up ( %)
50.7
16.5 ( Bihar)
96.5 ( Tamil Nadu)
Children fully immunized
43.5%
80.8 % (TN)
20.1( Nagaland)
Children breastfed at birth
23.4 %
7.2% (UP)
65.4(Mizoram)
Children underweight ( < 3)
45.9%
22.6 (Sikkim)
60.4 (Madhya Pradesh)
Utilization of government
7/7/2015
facilities by poorest
37.9%
19.4% ( Bihar)
55 % ( Karnataka)
Source: Health profile of India 2006
3
Motivation
Disparity in societal progress
distribution of mortality and morbidity
Between developed and developing countries
Between states in India
Conditions preventable
Proven cost effective interventions available
Common health care programmes
Why the disparity in India
Reason : low usage of interventions
7/7/2015
4
Motivation
India and other developing countries
 Investments and funding (Bajpai, Dholakia and Sachs 2006; CMH
2001)
Mediated through good governance (Wagstaff and
Claeson 2004 )
Institutional factors (NCMH 2005; Wagstaff and Claeson 2004)
 Poor managerial and technical capacities—training,
epidemiology, data collection
Service delivery mechanisms (Bajpai and Goyal 2001;
Mavalankar 1999; Seshadri rao 2001; Wagstaff and Claeson 2004)
7/7/2015
Implementation is one of the key issues
5
Literature review
Health care
•Academic
•Practice
Program
evaluation
Policy
Implementation
Implementation
Content Structure
7/7/2015
Implementation
Frame works
Resource
Allocation
process
STRATEGIC MANAGEMENT
Strategic
consensus
6
Literature review
 Research dominated by
 Extreme emphasis on content
 Studies looking at impact evaluation –emphasis on cross
sectional studies or limited variables
 Implementation taken as given neglected in research- 21/227/990; >90%; 48/230
 Lack of processual studies
 Only set of variables identified
 Fragmented and dispersed theory
 Lack of dominant framework or theory to guide research
7/7/2015
7
Literature review Health care
 Key word search
Only 48/ 230 related to implementation
 Focus on
 Disease specific issues
Policy issues
 Identification of factors influencing Implementation
 Studies show poor methodological design (Olivera-cruz,
Hanson and Mills 2001
)
 Paucity of processual studies (NCMH 2005; DCP 2006; Huicho et al 2005;
Gilson and Mills 1995)
•LACK OF LINKAGE OF INFLUENCING FACTORS TO PROCESS
OF IMPLEMENTATION
7/7/2015
•NO DOMINANT FRAME WORK OR PROCESS MODEL
8
Literature review
Policy implementation
> 90% of articles focus on formulation
variables (Sinclair 2001).
Paucity or total lack of processual studies and
a process model to inform practice ( De Leon 1999)
Identified construct “ Implementation
organisation” ( Hjern and Porter 1981)
•LACK OF LINKAGE OF INFLUENCING FACTORS TO PROCESS
OF IMPLEMENTATION
•NO DOMINANT FRAME WORK OR PROCES MODEL
7/7/2015
•NO CUMULATION OF THEORY ON IMPLEMENTATION
9
Approach
Variables/part
process
Focus
Full set of
variables/
process
Top down
7/7/2015
Bottom up
Van meter
Van Horne
1974
Integrated
Theoretical gap
Sabatier
1992
Rainey Fenger, klok
Steinbeur
2001
Maier and
1999
O’toole
2001
Maier and
Brinkerhoff
Cline
Terpstra
Stoker
O’toole 1999
1999
2000
1989 Havinga
Matland
Pearson –
2001
1995
Nelson
John
Lloyd
Vangan 2005
1999 Grantham Ryan 1996
1999
Streab
huxam
2001
Willoughby
2003
Dyer
Schofield
O’toole
2005
1999
Ben zadok
2004
2004
Sorg
2006 Hjern, porter
Butler
Zahardias
1983 Mcnulty
2003
2003
Morgan-2005
1981
Content
Orientation
Process
10
Review of literature Strategy content
Evolution of literature
Predominant emphasis on content (Ginsberg and
Venkatraman 1985; Dess et al 1995; Pettigrew et al 2002)
Review shows only 21/227/991 articles looked at
implementation (Hutzschenreuter and Kleindienst 2006 )
Concentrate on variables of specific interest
 Trust (strategic alliances) (Kauser and Shaw 2003)
 Culture (mergers and acquisitions) (Cartwright and
Schoenberg 2006 )
Structural form ( diversification) (Whittington 2002)
Managerial initiative (innovations) (Damanpour 1991 ; Dobni
2006)
7/7/2015
11
Review of literature
Strategy implementation
Strategic consensus literature:
Heavy emphasis on top management
Important to look at consensus at all levels for development
of theory on strategy process (Bourgeois 1985; Priem and Dess 1995).
The literature on the implementation frame
works
Only lists the variables; Scarce empirical validation
Lack of cumulated theory
•LACK OF LINKAGE OF INFLUENCING FACTORS TO PROCESS
OF IMPLEMENTATION
• NO EMPIRICALLY VALIDATED FRAMEWORK
•NO MID RANGE THEORY ON IMPLEMENTATION
7/7/2015
12
Strategy implementation frameworks
Process models
Full
Partial
Content models
Full
Partial
Empirical Conceptual Empirical Conceptual Empirical Empirical
Hambrick
and
Canella
(1989)
Bromiley
(1993);
Bower
and
Gilbert
(2005);
Okumus
(2003)
7/7/2015
Hart (1992)
Argyris
(1989)
Skivington
and Daft
(1991)
Miller (1997)
Feurer, R;
Chaharba
ghi, K
and
Wargin,
(1995)
Bourgeois and
Brodwin
(1984);
Waterman,
Peters and
Philips
(1980)
Joyce and
Hrebinia
k (2005)
Roth and
Morrison
(1992);
Klein
and
Sorro
(1992);
Govindar
ajan
(1984);
Nutt
(1987)
13
Approach
Variables/part
process
Focus
Full set of
variables/
process
Top down
7/7/2015
Bourgeois,
Brodwin
1984
Hart
1992
Integrated
Bottom up
Hambrick,
Joyce
2005
theoretical
gap
Bower,
Gilbert2005
Hambrick,
Canella
1989
Okumus
2001
Bromiley
1993
Roth,
Morrison
1992
Govindarajan
1984
Klein,
Sorro
1990
Content
Miller
1997
Nutt
1987
Feurer
1994
Skivington,
Daft
1991
Argyris
1989
Orientation
Process
14
Resource allocation process
 The way the resources are allocated in the firm
shapes the realized strategy of the firm
 Is an iterative process (Bower and Gilbert 2005 ) .
 Is a process model of strategy implementation with
realized strategy as the outcome
•HAS NOT ADDRESSED THE LINK TO PERFORMANCE
•HAS NOT BEEN STUDIED IN SERVICE INDUSTRIES
7/7/2015
15
Literature review
HEALTH CARE
POLICY
IMPLEMENTATION
Lack of a dominant process frame work
Lack of linkage of influencing factors to process
of implementation; No mid range theory
of implementation
Resource allocation process model
link to performance
STRATEGY
IMPLEMENTATION
7/7/2015
Resource allocation process model
Empirical validation in services sector
16
Research opportunities
Lack of a dominant process frame work
Resource allocation process model
link to performance
Resource allocation process model
Empirical validation in services sector
RESEARCH
OBJECTIVE
Lack of linkage of influencing factors to process
of implementation; requirement of a theory
of implementation
7/7/2015
17
Research objective
Develop a Mid range theory on
implementation which would be the basis
for a dominant operational framework and
Develop an Operational process framework for
Implementation, which can help practice in
Health care, Policy Implementation, and Strategy
Implementation.
7/7/2015
18
Research questions
What are the processes at various levels, which
comprise the phenomenon of implementation?
What are the influencing factors and characteristics
of these processes at each level?
Are there any linkages among various influencing factors
and characteristics of the processes – within the process
and across the processes?
How do these processes interact; at the same level
and across levels; to influence the final outcome
following implementation of strategies or policies?
How do these interactions among the various factors of the
7/7/2015 processes finally lead to performance?
19
Need for health care research
Globalization has lead to (CMH 2001)
Interdependencies among economies of countries
Increased risk from epidemics
Interdependencies among health systems is
increasing
Health status of population key to
economic development (WDR 1993)
Increased spending on health
Need research to facilitate effective use of
money, interventions
7/7/2015
20
Motivation
 Why health care?
Problem embedded in health care
Health - a social and economic asset
Role of management to solve societal problems
 Why India and public health care programmes
Same problem found in Indian context
Structuring of interventions done through programmes
convenience
 Why implementation
Key issue in addressing problem
7/7/2015
21
Research methodology
 Processual study (Pettigrew 1997)





Looks at sequence of events, actions and activities
over time in a context to explain why, what and how of
a phenomenon- longitudinal
Implementation of four national health programmes
Rural health context in 3 states– Gujarat, Tamil nadu and
Kerala
Two stage sampling (Patton 2002)
Choice of programmes to cover variation in
programme characteristics
Choice of states based on exemplars in category
Choice of units based on performance categorization
Multiple case embedded design, multiple embedded units
of analysis
Retrospective histories of key informants ;documents to
validate issues; >3 years time period of data collection
7/7/2015
22
Processual study
 Purpose is to
describe , analyze, and explain what, why and how of some
individual or collective action
 Embeddedness
study across many levels of analysis
 Role for action and context in explanation
Duality of actors and contexts, Shaping and getting shaped
 Temporal
Sequence and flow of events
 Holistic explanation
Find patterns, underlying mechanisms
 Link processes to location and outcomes
7/7/2015
23
High
Requirement of intensity of resource
High
Intra organisation coordination
Low
Low
7/7/2015
health
AIDS
Condom use
AIDS
fertility
Mental
health
RCH
ORS
CANCER
Iodine
Vitamin
deficiency A deficiency
measles
NLEP
II
Vector
control
TB
Blindness
control
IDSP
ICDS
Small
pox
Low
Intensity of interactions
Low
Intersectoral coordination
High
High
24
High
Medium
Low
Degree of cooperation required
Categorization of programmes
NVBDCP
NIDDCP
RNTCP;
Adolescent
diseases
NBCP;
NLEP
Low
7/7/2015
ICDS; FP
Mental
health; AIDS;
MH ; Cancer
IDSP
CH
Medium
Intensity of resource utilization
High
25
Categorization of units
Poor
Moderate
Good
Dharampur, Kaprada
Mahesana district and
TU
Kheda
Nalia; Khambadia
Jamnagar;
Sabarkantha
Khedbrahma
Chatiyarada; Pij
Vellore
Kalyanpura
Medha adhraj
Palana, Akhaj, Pansina
Kaatch, Valsad
Nes, vadatra, Kadi TU
Andimadam,
varadarajapettai
Kothara
Trivandrum
Kottayam
Mallapuram
Kerala, Gujarat
Tamil nadu
Ammapalayam,
Kolganatham
Surendra nagar
7/7/2015
Perambulur
26
Research methodology
 4 case histories at state health system level
 Iterative process for building explanations ( Yin 2003; Orton
1997; Langley 1999)-represented as visual maps
 Within case analysis leading to identification of
factors explaining performance
 Cross case analysis– used SPICE framework–
confirmation of patterns and development of an operational framework-
 Literature enfolding (Eisenhardt 1989) to position emergent
findings
 Developed a conceptual framework
 Validated operational framework by mapping to theory
 From these two emerged –implementation theory
7/7/2015
27
Research methodology-
(Langley 1999; 2007)
PROCESSUAL STUDY
Deals with sequence of events, involve multiple
levels and units of analysis—boundaries are
ambiguous
Are temporally embedded in varying details
Helps understand how things evolve over time
and why they evolve in such a way
Consist of largely stories- events activities and
choices ordered over time
Cases are the output
7/7/2015
28
Research methodology-
(Langley 1999; 2007)
 Strategies used to do analysis
Use key resources as the anchor point
 Helped in structuring and attention giving
 Identified based on overall common theme emerging from
analysis of cases at all levels
Narrative strategy
 Initial analysis. Put data collected as a narrative and
construct around embedded units of analysis and in a
temporal bracketing
 Gives detailed story , organizes data
 Facilitated identification of overall theme or pattern
running across all data
7/7/2015
29
Research methodology-
(Langley 1999; 2007)
Used iterative inductive process to
generate findings (Orton 1997) and
ordered sequence of events
Used visual mapping to represent the
probable causal linkage of events and
outcomes in each case let at each level of
analysis—created through an iterative
process as above
7/7/2015
30
Research methodology-
(Langley 1999; 2007)
 Used synthetic strategy
use of SPICE framework
Develop and compare patterns
 Two approaches overall
From data to findings—generate operational framework
Position the identified variables in extant theory to
generate conceptual framework
Validate framework in theory
Generate tentative theory through inspirational
deduction of gaps in conceptual framework based on
extant theory.
7/7/2015
31
Concepts
 Implementation of strategy
 formal allocation of work roles and the
 administrative mechanisms to control and integrate such activities
 including those that cross the formal organizational boundaries (Child
1972).
 Policy Implementation
 actions by people that are directed at achievement of objectives set
forth in the policy decision (Van meter and Van Horne 1974).
 Characteristics ( Hrebiniak and Joyce 2001)
 Is a dynamic, non linear process
 Multiple variables interacting, reciprocal causality( Fajourn 2000)
 Takes time
7/7/2015
(Miller 1997)
– for effect, for study
32
INDIA THE CONTEXT
National health policy(2002) ; By 2010 the
goals stated to be achieved are ( sujata rao 2004):
7/7/2015
increase public investment from 0.95 of GDP to 2-3%
of GDP
increase utilization of primary care facilities from 19%
to 75%
reduce MMR(maternal mortality ratio) by 75%( from
540 to 135)
reduce IMR( infant mortality rate from 62/1000 to
<30/1000
eradicate polo, eliminate leprosy
reduce deaths due to TB and malaria by 50%
33
Comparison of programmes
Characteristic
NBCP
RNTCP
NVBDCP
RCH
Number of
components
Two
One
Two
Four
Technology used
Mediating
Long linked
Intensive
Long linked + intensive
Dependencies
within group
Pooled
Sequential
Sequential
Reciprocal
Dependencies
across group
None
None
Reciprocal
Reciprocal
Components
under direct
control
All
All
One
Varying levels
Control
mechanisms
Financial
incentives
Cooperation,
material
incentives-skills
Cooperation
Cooperation, financial
incentives in some
cases
Key resources
Surgeons
LT,MO
MO,LT
MO, FHW, specialists
Mechanisms to
7/7/2015
get alternate
resources
Pooling,
contracting
Community
provision,
contracting
Community
provision,
Pooling, community
34
provision, contracting
Comparison of programmes
Characteristic
NBCP
RNTCP
NVBDCP
RCH
Lead/lag of impact
of interventions
None
Moderate, 6-9 months
Moderate for vector
control measures
Long lag
Requirement of skill
levels
High at tertiary or
secondary
level
Medium at PHC level
Low
Low to very high
Degree of
standardization
of treatment
Very high
High
High
Low to very high
Task grouping
At highest level
At programme unit level
At field unit level
At field unit level
Scope for resource
transfer
Very high
Restricted
Minimal
Minimal
Evaluation and
control
At highest
aggregate
level
At unit level
At lowest level
At lowest level
Coordination costs
Low
Medium
Very high
Very high
Facilitation by
Planning,
incentives,
innovation in
technology
Planning, standard
guidelines, training,
cooperation
Planning, continuous
feed back,
cooperation,
coordination
Planning, continuous
feed back,
35
cooperation,
coordination
7/7/2015
Impact of normative programme structure
 Varying coordination costs
(Thompson 1967)
Planning, routinisation, learning,
communication and feed back
 Persistent commitment of funding of activities
Newly added and old
 Positioning of actors—implementation
organization (Hjern and Porter 1981)
Determines type of administrative structure to be
positioned
7/7/2015
36
Comparison of processes across states
 Gujarat–
 Poor validity of base data, Top down target setting
 Decentralized recruitment, ban on posts filling, contractual appointments
with low payments
 Process outcome monitoring system, Programme oriented training
 Tamil nadu
 Community needs assessment approach with vital events surveys
 Well developed monitoring and evaluation system
 Emphasis on continuous skill development
 centralized recruitment with stand by provisions
 Kerala–
 CNAA process, programme oriented training

Decentralized recruitment
7/7/2015
37
Unit level analysis
19 units- 4 taluks, 2 TB units, 13 PHCs
Factors identified
MOs interest and supervision
Work load feasibility
 Appropriateness and Adequacy of facilities and equipment;
Adequacy of key staff; case load
 Infrastructure provision- roads, communication etc
 Management of work load- micro planning, facilitation
Availability and Use of alternate resources
Staff interest and supervision; consensus on targets
Role of distal factors—infrastructure—roads,
education, communications, transport, geography
7/7/2015
38
Emerging pattern-unit level analysis
KOLGANA
THAM -ve
resource
provision
mechanisms
minimal
vacancies
inadequate
facilities
MEDHA
ADHRAJ +-
PIJ -ve
vacancies partly
managed, MO
planning or area
seggregation
facilities
adequate
workload
dispute
no vacancies
PALANA
+ve
AMMAPALAYAM
-VE
high turnover
of MO and
supervisors
manageable
level of
vacancies
supervsion and
motivation of
staff
DHARAMPUR
,KAPRADA
-ve
poor
supervision
very high percentage of
vacancies;
unmanageable,affecting
motivation of staff and
MO
NALIA
block -ve
KALYANPURA
-ve
NES
fluctuating
performance
MO initiatives on
work management,
motivate staff; higher
percentage of
vacancies
MO interest and
supervision; small
percentage of vacancies
vacancy of
supervisor
KADI TU
-ve
KHEDBRAHMA
block -ve
unmangeable
level of
vacancies
work load
dispute
ANDIMADAM
+VE
KOTHARA -ve
work-load
dispute
PANSINA
+ve
effect of vacancies
amplified by
contractual staff
KHAMBADIA
block -ve
MOJIDAND
-ve
7/7/2015
39
MAHESA
NA TU-ve
AKHAJ +ve
CHATIYADARA
-ve
VADATRA
-ve
Unit level model of implementation
Supervision
Adequacy of
services
Case load
work load
feasibility
Mechanisms to
get alternate
resources
Motivation to
produce
(MO)
MOs interest
and
supervision
Service
delivery
Microplanning,
Team work,
Technical inputs
Work
facilitation
Management
of work load
Emoluments
Motivation to
produce(staff)
Impact on
programme
indicators
Provision and
Utilisation of alternate
resources
Adequacy of
staff
7/7/2015
Adequacy of
facilities
Infrastructure- roads,
communication
Felt participation in
decision making
40
District level analysis
27 case lets, 9 districts of Gujarat and
Tamil nadu
Factors identified
Adequacy of key staff
Utilization of alternative resources
Focus of CDHO/programme head on
Provision of key staff
Monitoring and supervision
Emphasis on skill development and learning
Role of distal factors-contractual appointments,
reduce FHW training slots
7/7/2015
41
Analysis of Districts NBCP
Training
and
equipment
Programme
head focus
High skill
capability of
surgeons
Perambulur
Direct
control
Availability
of surgeons
Incentives
--monetary and
capital
7/7/2015
Government
surgeons
Achieved
targets
Low enrollment
of NGOs and
PPs
High enrollment
of NGOs and
PPS
Mahesana
Low skill
capability of
surgeons
Valsad
Not
achieved
targets
Sabar kantha
42
Analysis of districts -RNTCP
SABARKA
NTHA +ve
KHEDA
+ve
MAHESA
NA +-
resource
provision
mechanisms
interest of
DTO
inadequate
MOand LTs
adequate LTs
and MO s
7/7/2015
high involvement
of PPs
VALSAD
+ve
very high
involvement
of PPs
KAATCH
-ve
other staff
vacancies
less
involvement
of PPs
adequate MOs
, manageable
LTs vacancies
VELLORE
+ve
managed LT
and MO
vacancies
unmangeable
LT and MO
vacancies
adequate LTs
manegeable
MO vacancies
JAMNAGAR
+ve
DTO
initiatives
DTO
iniatives
associated
high turn
over of
supervisors
SURENDRA
NAGAR +-
43
contractual
appointments
PERAMBU
LUR -ve
Analysis of districts -NVBDCP
resource
provision
mechanisms
KHEDA
+ve
KAATCH
-ve
Mmpw
vacancies,community
workers given
facilitative
measures
LT adequate,
adequate
MLV,GAM
SABARKA
NTHA +ve
not so effective
alternate options
LT vacancies
unmanageable
LT vacancies
manageable,
adequate
MLV,GAM
LT candidates
not joining on
contract
community
workers
inadequately
taken
VELLORE
+-
VALSAD
(dharampur and
kaprada) -ve
community
workers
adequate
MAHESANA
+ve
7/7/2015
LTcandidates
and community
workers not
available
SURENDRA
NAGAR -ve
JAMNAGAR
-ve
44
Analysis of districts -RCH
Resource
provision
mechanisms
VELLORE
+ve
KHEDA
+ve
KAATCH
-ve
adequate
facilities
staff
recruitment
managed
candidates not
available
impacting all
programmes
vacancies
generated
staff vacancies
not manageable
focus and
motivation of unit
head
VALSAD(dharamp
ur, kaprada )-ve
staff vacancies
manageable
contractual
appointments
impacting work
SABARKANTHA
+ve
interest of
unit head
7/7/2015
MAHESANA
-ve
SURENDRA
NAGAR -ve
JAM NAGAR
-ve
(Khambadia
taluk)
45
“Key resources”
 Are resources linked to service delivery
 Execute critical components of service delivery
 Render multiple components of service delivery
 Are
 Valuable
Rare as they lack alternatives
Inimitable
Non- substitutable– as alternatives are same staff in
private context
Some components can be done by alternate people—
provision of MLVs, GAM, incorporation of Private
sector– called adaptation mechanisms
7/7/2015
46
Model of implementation –district level
Personnel
policies
Learning,
training
Programme
officer
vacancies
CDHO
focus
Emphasis on
skill
development
Programme
officer
supervision
Iniatives
Utilisation of
Adaptation
mechanisms
Adequacy
of key staff
MOs
motivation
to produce
Adequacy of
facilities
Policies on
development
of
infrastructure
7/7/2015
Adequacy
of services
Process
Monitoring
and feed back
47
Percentage difference between rate across states over time
BIRTH RATE
INFANT MORTALITY RATE
TNGUJTN
Year
Ker
ala
TOTAL FERTILITY RATE
GUJKer
ala
TN-
TN-
GUJTN
Kera
la
GUJKerala
GUJTN
Kera
la
GUJKerala
1972
14.74
3.7
17.89
5.47
47.93
50.78
30.36
-5.13
26.79
1975
16.58
8.79
23.91
24.66
51.79
64.94
27.27
10.53
33.33
1983
18.42
10.75
27.19
17.92
62.07
68.87
21.43
21.21
38.1
1987
22.08
9.58
29.55
21.65
63.16
71.13
27.78
15.38
38.89
1992
26.33
14.49
37.01
13.43
70.69
74.63
31.25
22.73
46.88
1997
25.78
5.79
30.08
14.52
77.36
80.65
33.33
10
40
2004
29.63
11.11
37.45
22.64
70.73
77.36
35.71
5.56
39.29
7/7/2015
48
Analysis at State level
3 states – Gujarat, Tamil nadu, Kerala
4 cases
Factors identified
Ability to generate resources
Role of top management in
7/7/2015
Consistent allocation of financial resources
Policies to create and maintain infrastructure and key
resources
Focus on implementation of initiatives
Identification, acceptance and implement initiatives
facilitating alignment of services over time
Identification of key resources
49
Provision of mechanisms for alternate resources
Policy decisions
Department decisions
Personnel matters
Training
Infrastructure
Processes
Community involvement
Top management
7/7/2015
Comparison of factors influencing performance of the health system in states of Tamil nadu and Gujarat
Gujarat
Tamil nadu
Increase capacity of MCS, Paramedical schools
Policy decisions
Expand capacity of MC, paramedical schools
Closure of FHW schools
Feeder cadres for MMPW,FHW,LT
Ban on appointemnet-20% regular posts
Resource provision on merits
Insistence on contractual appointments
Department decisions
Centralized management of personnel
Uniform payment for contractual appointments
Emphasis on infrastructure and facilities development
Provide community workers
Personnel matters
Regular regularization and promotions
Use of FHW schools for FHS courses
Faster mechanisms to manage vacancies
Allow feeder cadres for MMPW selection
Counseling procedure and postings
Initiative of CDHO’s
Initiatives
Delays in confirmations and promotions
Training
Emphasis on training
Non payment of traveling allowance
Greater interaction with medical colleges
Rigidity of rules
Avenues for transfer of technology and skills
Non adherence to regulatory body criteria
Emphasis on technical inputs
Poor interaction with medical colleges
Historical inputs
Giving up of regional deputy directors system
Poor receptivity to concepts
Evolution of department into directorate
Emphasis on training
Evolution of codes and dedicated PH cadre
Problems of access and social factors
Poor data reliability and reporting systems
Processes
Developed reporting systems and data reliability
Innovations
Process monitoring systems
Poor micro planning of initiatives
Learning and system adaptation
Rigidity of system
Innovations
Lack of management skills
Receptivity to concepts
Involvement of NGOs and PPs
Better management skills
Linkages with community
Better micro planning of initiatives
Commitment
Locus of innovation management
Overbearing attitude
Strategy
Services through out reach strategy
Prioritization of initiatives and focus
Community involvement
Involvement of NGOs and PPs
Linkages with community
50
Top management
Commitment
Balance with other stake holders
Top management
Historical and socio-cultural factors
Community involvement
Infrastructure
Education and health
Health care programmes
Manpower
7/7/2015
Comparison of factors influencing performance of health system in Kerala over time
Kerala pre 1985
Kerala post 1980
Commitment
Top management
Lack of Commitment
Sensitivity to community needs
Insensitivity to community needs
High awareness of personal hygiene
Infra-structure
Growth of private sector
Early introduction to modern medicine
Reduced emphasis on public sector
Relatively high female literacy
Adequacy of generation of manpower
Impact on health seeking behavior
Less utilization of government services
Longer education tenure of females
Locus of tech. And skill induction
Impact on women’s life
Man-power
Unwillingness to join govt. Service
Ascendancy of nuclear family
Unwillingness to work
Social and land reforms
Socio-cultural factors
Impact of return of emigrants
Impact of reforms
Increased spending power
Pressure to find work
Changing needs of people
Emigration and import of knowledge
Community
Changing health seeking behavior
Public pressure for reform
Increased out of pocket expenses
Ease of access
Health system
Poor data validity and reliability
Emphasis on development of facilities
Unwilling administrators
Growth of public sector facilities
Services and services delivery
Adequacy of manpower
Lack of Management skills and poor planning
Adequacy and use of resources
Lack of technical skills
Primary role of government
Problem of Access to system
Greater acceptance of government services
Inadequacy of resources and facilities
Emphasis on good implementation
Diminished role of PH officials
Willingness to work
Inertia of system
Essential role for public health qualified people
Inadequacy of manpower
Poor supervision and monitoring
Training
Poor emphasis on training
Poor interaction with medical colleges
51
Model of implementation at state level
Generation
and
maintenance of
infrastructure
Consistent
allocation of
financial resources
assurance of
resource
generation
Top
management
commitment
Identification,
acceptance and
implementation
of initiatives
Training
incentives
Emphasis on
skill develo
pment
community
pressure
7/7/2015
Pay and
emoluments
Provision of
mechanisms of
alternate
resources
Focus on im
Identification plementation
of key
resources
Generation of
key resources
Incentives for
selection and
retention of key
resources
Maintenance of
key resources
CDHO &
Programme
officer focus
Utilisation of
alternate
52
resources
Discussion -Resource allocation
 Resource allocation and management of resources
 All pervasive in process of implementation
 Consists of generation, budgeting, distribution and utilization
 Across programme analysis reveals
 Evolution in terms of levels
 Evolution in terms of positioning of administrative control
• Decided where the components got executed
• Increased importance to CDHO,MO,DHS initiatives
• Level of positioning of governance mechanisms
 Iterations of this led to realized strategy
 Implementation necessitates adequacy of resources required as
per service delivery mandated
 Driven by focus of respective unit heads in an integrated
manner
7/7/2015
53
Resource dependency
 Focus on specified type of resources
Identified as “key resources”
Have VRIN like qualities
Determine resource dependency of programme
Cumulatively- resource dependency of the state system
Management of resource dependency
 Determined performance of units—TN,GUJ; Kaatch,kheda
 Function of –quality and quantity of “key resources”
•
•
•
•
•
Identification of “key resources”
Providing direction to macro processes
Provision of alternate resources- adaptation mechanisms
Market activities undertaken
Workload
 Function of a “functional cognitive architecture” (Amin and
Cohendet 2004)
7/7/2015
• For management over time
54
Resource dependency
 Identification of “Key resources”
 Is a function of level where situated attention is
 Done at top management level—TN,Kerala
 Not done in Gujarat –FHW schools closure, training, MC
linkages,
 Identification
 Drives search processes-recruitment, budgeting, initiatives
acceptance
 Makes it purpose driven (Simon and March 1959)
 Better strategic choices
 Determines strategic reference point (Figenbaum, Hart and
Schniedel 1996). –convergence; drives macro processes
 Macro processes are governance processes at
organizational level (Van de van 1976; Williamson 1999).
7/7/2015
55
Resource dependency
 Management of shortage of key resources is a
function of
Total work load
Availability of Adaptation mechanisms
Utilization of such mechanisms
 Alternate resources are
Staff or mechanisms doing same work either in full or partly
of the key resource/staff
 Utilization and impact of alternate resources
depends
On initiative of unit head
Availability of such mechanisms
7/7/2015
Total work load
56
Resource dependency
 Other factors affecting
Quantity of resources required (Van de van 1976)
Quality of resources– VRIN qualities
Market activities undertaken
Alignment to market activities over time
 Cognitive architecture (Amin and Cohendet 2004)
Is the aggregated position of control of all macro processes
Key to attention and issue and opportunity identification
Drives search processes
Helps drive all macro processes
Administrative structures channel flow of information for
coordination
7/7/2015
57
Resource dependency
Shortage of key resources –impact
Depends on quantum and duration of such shortage
through management of administrative mechanisms
Unmanageable- carry out essential work only
Determined by evaluation indicators
Done by consensus on scope,level and content
Manageable – engages attention of unit head
Use or introduction, repositioning of administrative
mechanisms-TN
• Depends on initiative of unit head
Solutions to shortage based on level where problems are
perceived
• Is a function of situated attention--Gujarat
7/7/2015
58
Solutions moderated by contextual factors-Kheda, Kaatch
Resource dependency
 Management of resource dependency
Ensures unit head’s “Motivation to produce” (Simon and march 1959)
Ensures supervision
Staff discipline and “Motivation to produce”
work facilitation
Availability of alternate resources for use
Ensure comprehensive execution of micro processes
Is a function of
Perception of ability to manage workload
• Drives the personal initiative of unit heads
Perception of inability to manage workload
Reduces “Motivation to produce”– poor performance
Micro processes are operational processes at work
unit or departmental level (Van de van 1976; Williamson 1999)
7/7/2015
59
Administrative mechanisms
 Positioning of administrative mechanisms
Varies across programme and states
 NBCP– Incentivisation; direct control; monitoring
• Common across all states
 RNTCP– Quality control, consultants evaluations
• Direct field supervision, PHI monitoring
• Common across all units
 NVBDCP– field visits, unit level reporting and monitoring;
supervision of spraying and surveillance
• Common across all units
 RCH– varies across states based on monitoring system used
• TN– process monitoring; independent outcome evaluation
• Gujarat- intermediate outcome and activity monitoring
• Kerala- outcome and activity monitoring
Variation in performance across units due to
7/7/2015
 Variation in effectiveness of monitoring and positioning and
use of resources
60
Integrated operational framework for
implementation
Learning
and training
Community
pressure
Top mgmt
focus on
implementation
Ability to
generate
resources
Consistent
allocation of
financial
resources
Provision of
mechanisms for
alternate
resources
Identification,
acceptance of
initiatives
7/7/2015
Emphasis on skill
development
Identification
of key
resources
Provision of
key
resources
Creation of
facilitues and
infrastructure
Case load
Adequacy
of services
Adequacy
of facilities
Work load
feasibility
CDHO/
programme officer
focus and
supervision
Adequacy
of key staff
Felt
participation in
decision making
Work planning
and facilitation
MOs
motivation to
produce
Motivation to
produce (Staff)
Service
delivery
Impact on
progarmme
indicators
Utilsation of
alternate
resources
Supervision
Process
monitoring and
feed back
Management
of work load
Asess Needs
of population
served
61
Conceptual framework
MANAGEMENT OF
RESOURCE
DEPENDENCY
IMPLEMENTATION
IS A FUNCTION OF
MANAGEMENT OF
RESOURCE
DEPEDENCY
Key to diagram
green box --main
message; yellow
boxes -- constructs;
blue boxes -intermediates actions
at Macro level; violet
box -- intermediate
actions at micro
level; non coloured
boxes -- main
actions and
7/7/2015
outcomes
COMPREHENSIVE
EXECUTION OF
MICRO-PROCESSES
IDENTIFICATION
OF "KEY
RESOURCES"
KEY RESOURCES
ATTENTION
to issues
identified from
environment
COGNITIVE
ARCHITECTURE
Search
processes and
outcomes
Actions of
operational
level actors
Management of
"Key resources"
-- resource
dependency
Determines types of
Governance structures
IDENTIFICATION OF
MACRO-PROCESSES
FOR DIRECTION
Identification of
degree of
cooperation and
coordination among
actors
IMPLEMENTATION
ORGANISATION
Utilisation of
Resources
procured
62
Mid range theory of implementation
Autonomous initiatives
Customer/
community
aspirations
FOCUS OF TOP
MANAGEMENT
STRATEGIC
CONTEXT
RESOURCE
DEPDENDEN
CY
FOCUS OF
DISTRICT
HEAD
STRATEGY
AND
INITIATIVES
FOCUS OF
UNIT HEAD
Initiative
Initiatives
RESOURCE
ALLOCATION--Budgets, --infrastructure,
-----Training focus,
--- linkages with
resource providers,
identification of key
resources
RESOURCE GENERATION
7/7/2015
PROVISIONING
OF RESOURCES--service deliverers,
consumables,
-----training
RESOURCE DISTRIBUTION
SERVICE
DELIVERER
S-- numbers,
skills,
consumables
SERVICE
DELIVERER
ACTIONS
RESOURCE UTILISATION
OUTCOME
Structural
context
63
Contributions
 Generates a mid range theory of
implementation
Integrates across disciplines
Key message – implementation is a function of
management of resource dependency
Characterized by identification of “key resources”
Requires attention of top management
Direction of macro processes
Governance of micro processes
To deliver stated services and achieve objectives
Gives a dominant framework for implementation
7/7/2015
64
Contributions
Develops an operational framework of
implementation
Consists of observable physical actions taken at
various levels (Alpert 1938)
Explains direct and interactive effects of variables
identified
Validated by using 4 cases
Mapped onto conceptual bases in extant theory
Immense value to practioners in fields of health care;
strategy implementation and policy implementation
7/7/2015
65
Limitations
Conducted in the context of health care at
the interface of public and business policy
Needs to be validated in other contexts
Needs to be validated in other streams of
literature
7/7/2015
66
ANY QUESTIONS
7/7/2015
67