health system and policy

1. Leadership & Change
in
Health Systems
ICHS 7
www.hpsa-africa.org
@hpsa_africa
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Introduction to Complex Health
Systems

2. Change:
where do things go wrong?
1.Weak design

3. Re-design process
• How are intervention effects likely to
ripple through system (consider the
BBs)?
• What re-design could
– offset negative effects?
– take advantage of positive synergies?

4. In strengthening design, need also to
consider:
Who to co-design with & how manage the
process?
How can implementation/change be
better managed?

5. Change:
where do things go wrong?
2.Weak change management
(implementation)

6. Causes of failure
A poor design and
implementation plan
A weak enabling
environment
A case of ignoring red
tape and bottlenecks
A failure to learn
Failure
Kusek et al. 2013
Lack of senior management support; not listening to
critics; poor communication; lack of stakeholder
management plan; poor use of formal & informal
networks
Failure to admit
mistakes; aversion to
risk taking

7. Recognising complexity
• Complexity implies unpredictability
• Complex challenges require people and
organisations to change, often in
profound and fundamental ways

8. Change
does not happen by itself
has to be led and managed
occurs through people
and groups

9. Leadership:
Enabling others to face challenges
and achieve results under complex
conditions

10. Two key starting points for
leaders
• Personal reflection:
– hopes, aspirations, beliefs, interests, power
• Review of past experience:
– as influence over other agents
– as influence over implementation feasibility

11. Moving towards shared, inclusive,
collective, distributed
Leadership

12. Leadership for complexity
1. Shared sensemaking > collective
mindsets to support change
2. Creating connection > relationships
that enable change
3. Navigation > learning from innovation
& emergent strategies
Drath 2003

13. Commitment planning
• Describe the future & publicise the
change = the basis for commitment
• Commitment planning:
– Who must be committed?
– What current commitment level?
– What changes need and how bring about?
(Barnes, 1995)

14. Planning for commitment change
Key agents No
commitment
(oppose)
Let it happen
(no active
support)
Help it happen
(need their
support)
Make it
happen
(willing to
lead)
CEO OX
Chairman
medical staff
committee
O X
Staff member
A
O X
Staff member
B
O X
Consultant C O X
Consultant D X O
Manager E O X

15. Change as political negotiation
• Select 4-5 most influential stakeholders who impact
on change & who you want to influence
– Identify potential senior champions and critics
• Think about how they will assess success of your
proposal & develop a plan to influence them so they
judge innovation a success
• Use positive support of these agents to influence
others
(Osborne and Brown, 2005)

16. Think about the use of
power
• Planned & imposed change may
encourage compliance without
commitment
• because it fails to provide spaces for the
new forms of sensemaking necessary to
support the intended changes

17. • Compliance: you do
something because
you have to
– Do just what is
required and no
more
– Purposively do the
wrong thing
• Commitment: you
want to do
something, you
believe in it

18. Power in health systems
From top
to bottom
From
bottom to
top

19. Sensemaking
• For organisational change to succeed it
must involve shifts in shared
assumptions and beliefs about how
things happen in the organisation and
how people act – changes in mindsets
of organisational agents
(Balogun 2006)

20. Leading sensemaking
• The way managers understand,
interpret, create and diffuse sense of
the information surrounding strategic
change
(Rouleau and Balogun 2007)

21. Pay attention to staff
• Ensure early involvement of staff in change
process
• Help staff face up to change
• Work through face to face communication
• Listen (and talk)
• Be positive in working to gain commitment to
change, enabling staff to see opportunities
not just threats
(Osborne and Brown, 2005)

22. Build commitment
Sensemaking:
• What visions?
• What messages?
• What ideas?
How build trust?
• What are agents’
natural attractors?
(values, behaviours
that people and the
organisation are
drawn towards)
• What simple rules?
(principles for
action)

23. Advice networks
Trust networks
Communications
networks
Visible: the formal organisation
Vision, Mission, Structure, Job
descriptions, Goals, Strategies,
Operating policies complicated
Invisible: the informal organisation
Power and influence patternsGroup
dynamics
Impulsiveness
Feelings
Interpersonal relations
Organisational culture
Individual needs
complex
Adapted from
Kusek et al.
2013
Tap into the
power of:
Building commitment

24. In a complex adaptive system
‘...organisational change is not
management induced. Instead,
organizational change is emergent
change laid down by choices made on the
front line’ (Weick 2009: 239)

25. Plan small wins
• Rather than being overwhelmed by the
difficulty of bringing about necessary
‘big changes’, break down the change
into a series of smaller steps or ‘small
wins’ that move towards that change
• Eat an elephant bite by bite

26. • A small win is a concrete, complete, implemented
outcome of moderate importance.
• By itself, one small win may seem unimportant.
• Once a small win has been accomplished, forces are set
in motion that favor another small win.
• When a solution is put in place, the next solvable problem
often becomes more visible.
• This occurs because new allies bring new solutions with
them and old opponents change their habits.
• Additional resources also flow toward winners, which
means that slightly larger wins can be attempted.
Karl Weick from “Small Wins: Redefining the Scale of Social
Problems,” American Psychologist, January 1984

27. Two types of small wins
1. Actions that can be implemented
quickly and successfully, and so build
support for change
2. The continuous application of a small
action targeting a key constraint to
change – and opening up opportunities
for longer-term and more radical
change

28. Type 1:
• Team building
workshop, getting
people to know each
other, planning new
initiative, generating
improved short -
term work
performance
Type 2:
• Breaking down
hierarchical barriers
by calling each other
by first name,
supporting
recognition of each
other as people,
encouraging
working together
and building trust
over the long-term

29. Benefits of small wins
• Reduces fear of change
• Clarifies direction
• Increases possibility of early successes,
which boost support for further action
• Helps us to feel good

30. And…
• Can’t pre-plan everything!
• Important to encourage learning through
doing
• In ways that build support and
commitment!
• Feedback loops matter
• Take risks & learn from mistakes

31. Learning through doing
• Apply the PDSA cycle to each small win
to provide basis for next cycle of action
P (lan)
D (o)
S (tudy)
A (ct)

32. Identify the problem
Design programme
interventions
Implement and field test
Measure and give feedback
Have time for review, discussion,
revision
Implement and field test the
revised programme
Measure and give feedback, then
repeat throughout implementation
Adaped
from Kusek
et al. 2013,
p.63

33. Five rules to increase
chances of success
1. Build commitment to getting things done
2. Manage stakeholders: keep your champions
close but your critics closer
3. Work with the Informal networks in your
organisation
4. Manage processes
5. Learn as implement
Kusek et al., 2013

34. Five simple rules of large scale
Health System change
1. Engage individuals at all levels in
leading the change efforts
2. Establish feedback loops
3. Attend to history
4. Engage physicians
5. Involve patients and families
Best et al. 2013

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Introduction to Complex Health Systems, Presentation
7. Copyright CHEPSAA (Consortium for Health Policy &
Systems Analysis in Africa) 2014, www.hpsa-africa.org
www.slideshare.net/hpsa_africa
This document is an output from a project funded by the European Commission (EC) FP7-Africa (Grant no.
265482). The views expressed are not necessarily those of the EC.

36. The CHEPSAA partners
University of Dar Es Salaam
Institute of Development Studies
University of the Witwatersrand
Centre for Health Policy
University of Ghana
School of Public Health, Department of
Health Policy, Planning and Management
University of Leeds
Nuffield Centre for International Health and
Development
University of Nigeria Enugu
Health Policy Research Group & the
Department of Health Administration and
Management
London School of Hygiene and
Tropical Medicine
Health Economics and Systems Analysis
Group, Depart of Global Health & Dev.
Great Lakes University of Kisumu
Tropical Institute of Community Health and
Development
Karolinska Institutet
Health Systems and Policy Group,
Department of Public Health Sciences
University of Cape Town
Health Policy and Systems Programme,
Health Economics Unit
Swiss Tropical and Public Health
Institute
Health Systems Research Group
University of the Western Cape
School of Public Health