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TRANSCRIPT
Leadershipofsensemakingforprimaryhealthcarechanges:LessonsfromtheMitchellsPlainsub-district,SouthAfrica
Introduction
PHCfacilitymanagersandfrontlinestaffinfluencehownationalprimaryhealthcare(PHC)policiesareimplementedandservicesdeliveredthroughtheirroutinepractices.TheSouthAfricanhealthsystemhasanautocratichistoryandinheritedsteephierarchies,whichdiscouragedinitiativeandownership.Nowbothareencouragedandinfactareessentialinimprovingservicedelivery.
Asmiddlemanagers,sub-districtmanagersplayacriticalroleinengagingandsupportingPHCmanagerstothinkandworkdifferently,byhelpingthemtomakesenseofnewPHCpoliciesandtheirrelevanceineverydaypractice,andtotakecollectiveownershipofthesepolicies.
ThisresearchbriefhighlightssomeofthesensemakingactivitiesthathavebeenintroducedinMitchell’sPlainsub-district,andidentifieswhatleadershipofsensemakingentails.
SupportingPHCmanagersthroughaleadershipofsensemaking
Sensemakingis“theprocessindividualsundertakeastheytrytounderstandwhatisgoingonaroundthem,astheytrytomakesenseofeventsandexperiences”.ForPHCmanagersandfrontlinestaff,centrally-ledpoliciesorinitativesabouthowtostrengthenPHCmustmakesensetothemiftheyaretobeincorporatedintotheireverydayroutinesandpractices.Thisincorporationisneededforeffectiveimplementation.
InMitchell’sPlainsub-district,inasituationofmultipledemandsandchallenges,PHCmanagersandfrontlinestaffsometimesdemonstratepassivityintheirroles,andmaybeunwillingtotakeonnewrisksandresponsibilities.Thesebehavioursmayinfluenceimplementation,perhapsevenworkingagainstthegoalsofpolicyreformsaimedatbettermeetingpopulationhealthneeds.ThesechallengeswereidentifiedthroughtheDIALHSlearningsite,andactivitieshavebeenplannedandimplementedtoaddressthem.
TheDistrictInnovation,Action&LearningforHealthSystemsDevelopment(DIALHS)isacollaborativeprojectoftheHealthPolicyandSystems&HealthEconomicsDivisionsoftheUCTSchoolofPublicHealthandFamilyMedicine,theSchoolofPublicHealthatthe
UniversityoftheWesternCape,theCityofCapeTownandtheWesternCapeDepartmentofHealth.Forfurtherinformationcontact:[email protected]
DIALHS Policy Brief
15
November 2016
Activitiestopromotesensemaking:examplesfromtheDIALHSlearningsite
Sub-districtmanagershaveinitiatedvariousactivitiesintendedtoprovidespacesofcollectivesensemakingforPHCmanagers,toencouragethemtotakeownershipandoftheirperformanceandthatoftheirstaff.Theseactivities,somedeliberateandothersspontaneous,havecentredaroundsupportingfrontlinestafftomakesmallchangestotheirroutines.
• OneactivitywasanewcommunityprofilinginitiativetoaddressthefrustrationofPHCfacilitymanagersthattheydidnotknowthecommunitiestheywereserving.Workshopsbetweenhealthauthoritiesandcivilsocietyencouragedconversationsaboutlocalhealthneedsandresourcesamongdifferentstakeholders,whichhassinceledtojointhealthinitiativessuchastacklingenvironmentalhealthproblemsinsomecommunities.
• Anotherrevolvedaroundkeyperformanceareas(KPAs),wherePHCmanagersweresupportedtodeveloptheirownobjectives,activitiesandoutcomeswheretheywereheldaccountableforimplementingagreedactions.
• AseeminglysimpleactionofchangingthenameofthePerformanceDevelopmentReviewmeetingstoManagementandCommunication,movedthetop-downapproachtomoreactiveengagementofstaff.Usingroundstoalloweachpersontogiveinput,rotatingthemeeting’schairandaskingchallengingquestionsdemonstratedequality.Thishasallowedspaceforjointreflectiononfacilitychallengesandsharingofbestpractices,improvedteamworkandconstructiveaccountability.
• Sub-districtmanagersarerolemodellingsystematicapproachestomanagementbybeingontimeformeetingsandrespectfultocolleaguesandcoachingstaff,whiletheresearchteamhavemodelledreflectivepracticethroughtheirownapproachtomanagingmeetings.
Conclusion
Middlemanagers,locatedbetweenthecentreandtheservicefrontline,haveavitalroletoplayinprovidingaleadershipofsensemakinginordertosupportPHCmanagerstotakeownershipofvisionsaboutPHCstrengtheningandincorporatethemintotheirdailypractices.
Sensemakingactivitiesareoftenconcernedwithmakingsmallchangesthatcanbeeasilyacceptedandimplemented,butthathavearippleeffectinthehealthsystemandgeneratelonger-termandlarger-scalebenefits.
Toeffectivelysupportorganisationalsensemaking,middlemanagersmustbeabletoreflectontheirownperspectivesandbehaviours,thinkingabouthowtheywillhelpothersthroughchange.Todothis,theyneedtocreatespacesforconversation,reflectionanddialogue,anddevelopsharedinterpretationsandmeaningsofchange.
AuthorsThisbriefwasbasedonthearticles:
• Crises, routines and innovations: the complexitiesand possibilities of sub-district management, SouthAfrican Health Review, 2012-2013, Health SystemsTrust
• Advancing the application of systems thinking inhealth: South African examples of a leadership ofsensemaking for primary health care, 2014, HealthResearchPolicyandSystems,12:30
TheauthorsthankcollaboratorsoftheDIALHSprojectinMitchells’Plain,thefacilitymanagersandparticipatingstaff,aswellasmembersoftheDIALHSresearchteam.ThisworkwasfundedbytheAtlanticPhilanthropies.
DIAHLSisaRESYST-relatedproject.RESYSTisfundedbyUKaidfromtheDepartmentforInternationalDevelopment.However,theviewsexpresseddonotnecessarilyreflectthedepartment’sofficialpolicies.
Elementsofsensemakingleadership
Byreflectingontheactivitiesundertakeninthelearningsite,fiveelementsofleadershippracticesthathelptosupportPHCmanagershavebeenidentified.
1. Theimportanceofmiddlemanagers’personalvaluesasafoundationforotherleadershipactionLeadershipvaluesandcapabilitiesofparticularrelevancetosensemakingforPHCinclude:concernforthepopulationbeingserved,recognisingthepotentialinotherpeople,andbeingreflectiveandwillingtochangeone’sownpractices.
2. NurturingthevalueandmoralpurposeofPHCstaffMiddlemanagersconstantlyandconsistentlyaffirmtheimportanceofpatientsandthebroaderpopulationintheirengagementswithstaff,forexamplebyencouragingfacilitymanagerstorespondspeedilytopatientcomplaints.
3. BuildingrelationshipsandsupportingthedevelopmentofsharedmeaningsaboutchangeCreatingspacesandprocessesthatbringPHCmanagerstogether,andwithotherlocalactors,enablesthemtoshareknowledgeandideas,challengeandlearnfromeachother.
4. Instillingacultureofcollectiveinquiryandmutualaccountabilitywithinthesub-districtMeetingpracticesthatallowmoreactiveengagementandownershipbyallthosepresent,forexamplebyrotatingthetaskofcharing,canprovideopportunitiestodevelopnewformsofaccountabilityandasharedunderstandingaboutwhatenablesandpreventsprogress.
5. RolemodelmanagementpracticesSub-districtmanagersmodelmoresystematicapproachestomanagementthroughtheirpersonalpractices,forexamplebybeingontimeformeetingsandrespectfulintheirtreatmentofcolleagues.