This presentation is based on detailed case study research in two South African district hospitalsIt involved investigating the implementation of two equity-oriented policiesIn essence, we wanted to understand the factors that influenced implementation, especially institutional factors such as trust and organisational culture and factors related to the exercise of powerIn this presentation, I will not be giving all the descriptive detail of how these two policies are implemented in the respective hospitals. Instead, I want to use some of this detail to make one of the key arguments about policy and practice to emerge from this study. This argument is...
...how a policy is implemented is influenced in significant ways by frontline providers and managers. Their influence and actions can be understood with reference to: 1) the nature of a policy and the meanings and understandings associated with it, 2) the nature of the general organisational context within which the policy is being implemented.This means that implementation is filtered through any number of local attitudes, meanings and contexts (that may or may not be favourable to it). And that it therefore needs to be thought of as something that requires active and strategic management so as to engage with the different influences and try and ensure success. This is in distinction to an approach that would, for example: expect the official pronouncement of senior officials to be the final word on policy, expect frontline providers to behave as intended by the policy simply because they are the “lowest” link in the bureaucracy, that would as a default position rely on training to address any implementation problems.
I will now try to briefly illustrate each of the elements of this argument. First, the influence of frontline providers and managers.Of course, many frontline managers and providers influence how policies are implemented by doing things in accordance with policy. However, the notion of their influence is perhaps most immediately apparent when one considers things they do that contrast quite fundamentally with how one would expect them to act, given the policies they are supposed to be implementing (as shown in this table).Taken together, all the actions of frontline managers and providers in our case study hospitals tell certain broad, overall stories about how they have shaped the implementation of the UPFS and PRC. I will now turn briefly to these overall stories and to the key influence over the policy implementation developments of the nature and meaning of policy, and features of the overall organisational environment.
Here, we have a similar overall story in both hospitals: one of management interest in and support for the policy, one where the hospital devotes a lot of resources and time to the implementation of the policy, and one where the main focus is revenue generation, not the granting of exemptions.This is supported by elements of the policy nature and meaning, e.g. that payment is the default option in the policy and that the policy is very clear about collecting money, whereas exemptions are more complicated. Also, the association with the hospital revenue target encourages people to view successful implementation as raising revenue.It is also supported by elements in the organisational environment:Culture: such a detailed and specific policy that delimits things fairly well is suited to organisations that value organisation and control. By its very nature this policy helps the hospitals to be organised about its implementation and to exercise control. Also, these hospitals work through goal-setting and place a high value oin goal- achievement. In this context, the hospital revenue target is a natural one to aim at.Higher trust in A arguable also encourages buy-in into organisational goals and objectives, encourages people to align themselves with the goals of the organisationMoving to PRC implementation...
Here, we have different stories from the case study hospitalsAgain, these different stories can be explained with reference to the nature of the policy, the meanings associated with the policy and the more general organisational environment.Culture: the culture of A is more flexible and can tolerate greater ambiguity. This enables them to cope better with the PRC, which is a very diffuse policy: it has various elements, it can be implemented in any number of ways, and it is not clear how the individual elements come together in one purpose. For B, which has a stronger desire for control and stability, this diffuseness is more difficult to relate to. So, in conclusion...
I have sought to show that policy implementation is significantly affected by local actors, local meanings developed around policies and local organisational contexts. It is therefore best viewed as something that requires active and strategic management, not simply something that will happen by “order” or “trickle down”.If this conceptualisation is accepted, many more implications for policy and practice could be derived from it. For example:It prompts questions about how change processes are likely to develop and what realistic timeframes for changes are?It points to the need to manage software, not just think about hardware in implementationVarious implications for management training and practice
Policy implementation: the influence of frontline staff, the nature and meaning of policy, and the organisational environment
Policy implementation: the influence of frontline staff, the nature and meaning of policy, and the organisational environmentErmin Erasmus, Centre for Health Policy<br />Delivering Effective Health Care for All<br />Monday 29th March, 2010<br />
The research<br /><ul><li>Case study work in two SA district hospitals
Implications for policy and practice<br />How are change processes likely to develop and what are realistic timeframes?<br />Need for managers to be mentored in navigating implementation obstacles, not just trained<br />More than “hardware”. Also the need to manage “soft” elements such as policy meaning, e.g. through performance metrics or tone set by management<br />Need for managers to be able to engage constructively with others’ understandings and interpretations<br />Need for management training that is strategic, not just operational<br />
Research partners<br />Centre for Health Policy, University of the Witwatersrand<br />Health Economics Unit, University of Cape Town<br />London School of Hygiene and Tropical Medicine<br />