This document discusses improving health care practices in developing countries. It outlines objectives of identifying an effective pathway for change, core principles, and factors for building local capacity. The challenges of change efforts and scale-up are discussed. Research shows many health care practice changes are not sufficiently scaled up. The document emphasizes the importance of generating long-term commitment to change through understanding the full change process. It discusses roles of local, mid-level and supporting change agents in diffusing innovations to improve health.

1. 14/08/2010
AND
IMPROVING HEALTH CARE
Dr Rajeev Kashyap.
Sr. Dental Surgeon
Dr Rajeev Kashyap
PATHWAY TO CHANGING

2. OBJECTIVES
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Dr Rajeev Kashyap
1. An effective pathway to changing and improving
health care practices in developing countries.
2. Core eight principles for supporting a change in
health care practices.
3. Identify success factors that build local capacity and
smooth the way for effective change in health care
practices.
4. Steps to support a change in practices, from initiation
through widespread use.
5. The process for building scale-up into the change
process from the beginning.
6.The principles for effectively communicating change
to varied audiences and generating long-term
commitment throughout the process.

3. FOCUS
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Focuses on changes in
Clinical practices,
Behavioral practices of providers,
and
Management practices at service delivery sites.
Changes in management systems and
organizational structures and strategies are
equally important in supporting and reinforcing
the service delivery changes

4. THE CHALLENGE – INCREASE THE
IMPACT OF EACH CHANGE
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Ministries of Health,
 Nongovernmental organizations (NGOs),
 Donors
 Cooperating agencies
All want to improve the health of populations.
As a representative of one of these entities, you
share responsibility for making or supporting
sustainable changes in health services that will
impact the lives of impoverished families
throughout the countries in which you work.


5. IMPROVEMENTS YOU SEEK FACE
FORMIDABLE ODDS
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A high percentage of change efforts fail.
 A high percentage of scale-up efforts fall short.
 A small percentage of these health improvements
meet expectations.
Can help you understand what is missing from
many change efforts and how to supply these
elements so your efforts can achieve sustainable
results.


6. RESEARCH STUDIES
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Studies have shown that despite extensive
funding, many changes in health care
practices are not sufficiently scaled up.
They don’t reach the point where they
influence national health indicators.

7. THE MISSING PATHWAY FOR CHANGE
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8. MISSING PATHWAY FOR CHANGE
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In improving service delivery practices, people
often involve stakeholders. Together, they
develop and strive to implement plans for
improvement.
Yet these plans and their implementation often
leave out a critical process for change and longterm commitment.

9. CHANGE PROCESS
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An effective change process is a recipe for
Selecting, Adapting, Implementing, and
Scaling up effective practices in a way that will
achieve health results and sustain those results
over the years.
 When we understand the change process, we are
less likely to underestimate the time and effort it
takes to make change stick.
 To ensure that people carry out the change
process, you need to generate their long-term
commitment.


10. COMMITMENT
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Commitment to change is the determination to
carry the process to the end.
 The change is complete when all program levels,
working together, continually produce desired
results as they implement, or support, the
changed practices.
 When stakeholders are committed to change,
they don’t give up when they encounter barriers –
nor do they stop when donors turn their
resources toward other needs.


11. ROLES IN CHANGING HEALTH SERVICES
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12. WHAT DO WE MEAN BY HEALTH DELIVERY
PRACTICES?
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Health delivery practices In health programs,
changes can be made in:
 Clinical practices
 Providers' behaviours and attitudes
 Management practices
 Management systems
 Organizational structures and strategies
Changes in the first three elements often have
the most direct influence on services. But broader
changes in systems, structures, and strategies
are important factors in bolstering, maintaining,
and expanding the more direct changes.

13. LOCAL CHANGE AGENTS

WHAT ?
With local change teams initiatives and carry out
change in the service delivery practice.
WHERE ?
Service delivery sites.
Dr Rajeev Kashyap

WHO?
Clinicians, Local managers and Health Services
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14. MID-LEVEL CHANGE AGENTS AND
CHAMPIONS OF CHANGE

WHAT ?
Can either act as change agents themselves or as
champions to support local support agents.
WHERE ?
District or Provincial headquarters or with the
central or national NGO`s organization.
Dr Rajeev Kashyap
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WHO?
 Mid level managers of public or private sector
organizations.


15. SUPPORTERS OF CHANGE: INDIVIDUALS
AND CHANGE COORDINATION TEAM
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WHO?
National, regional or international leaders decision
matter or donors.
 WHAT ?
Foster change and support change agents and
change teams at all levels
 WHERE ?
National or Regional ministries of health , NGO`s
or USAID mission or other international
agencies.


16. ROLES IN THE CHANGE PROCESS
(CONTINUED)
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Clinicians apply effective practices in their
delivery sites to save lives and reduce illness.
They can make substantial improvements in
maternal health, child health, reproductive
health, family planning, and infectious diseases.

17. ROLES IN THE CHANGE PROCESS
(CONTINUED
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Mid-level managers can lead and champion
changes in health delivery practices.
 Senior management needs to visibly support
the changes and those who are leading the
change process.


18. ROLES IN THE CHANGE PROCESS
(CONTINUED)
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National, regional, and international decision
makers support these changes in health delivery
practices.
They act as matchmakers, creating a marriage between:
 Effective practices for clinical and programmatic work
and
 Successful practices for change and scale-up
 As a member of the last group, you can learn how to
support the change process and gain the ongoing
commitment of the implementers and managers.
 Your contribution can significantly increase the
chances of producing long-term improvements in
health
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19. DIFFUSION OF INNOVATIONS
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The change process you will learn in this session includes elements from
an approach known as the diffusion of innovations.
 The approach was developed to speed up a "natural" progression
where new, often more effective practices replace older practices over
time. But it can take decades or even centuries for the old practices to
die out. Agents can help this progression by working with others to
"diffuse" the new practices.
 The diffusion is the process by which an innovation is simplified and
communicated through certain channels over time among members of
a social system.
 Originating through the work of agricultural extension agents, this
approach has been applied in a broad range of areas, from business
and education to public health. In public health, it has been used to
bring about small-scale behavior change in communities, and more
recently, to change management practices in health care programs.
 The diffusion approach is especially useful for helping ministries of
health and NGOs adopt and sp new practices in health care. Source:
Rogers 2003

20. RESULTS OF DIFFUSION
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Diffusion of innovations is central to
everything we do to improve health.
 Diffusion often begins by simplifying and
adapting an innovation that has succeeded
on a small scale.
 Improvements spread faster when you
strategically communicate while supporting
a change in practices.


21. EVIDENCE & HISTORY
Dr Rajeev Kashyap
In 1601, a simple experiment yielded
convincing evidence that a small amount of
lemon juice each day could prevent scurvy.
The results were reported but generally
ignored. It wasn't until 193 years later,
when a young naval physician documented
convincing evidence about the effects of
lemon juice and made it known to political
decision makers, that life-saving lemon
juice was provided to the crews of all
sailing ships
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22. SUPPORTING AND LEADING CHANGE
roles in the
Local change agents,
 Mid-level change agents and champions,
and
 Supporters of change

Dr Rajeev Kashyap
who play all three
change process:
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There are some widely accepted principles
for change that offer a grounding for those

23. PRINCIPLES FOR CHANGE
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24. PRINCIPLE 1: CHANGE MUST MATTER
TO THOSE MAKING THE CHANGE.
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Align staff responsibilities, environment, and
resources, and set the stage for sustained
commitment to implementation.
 Change must offer clear benefits to those who
must implement the new practice at the hospital,
clinic, community, or family level, and to their
clients.
 The change will offer great advantages to these
groups, but the potential implementers may have
a very different perception. They may see a
different set of benefits, no benefit, or actual
disadvantages that will result from the change.


25. EXPECTED RESULTS OF THE CHANGE
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Work environment
Job satisfaction
Dr Rajeev Kashyap
discussions or focus groups are a
good way to learn what they think the
benefits can be.
 Taking views into account will help you
think through all the implications of the
change.
 The clear benefits for clients
 The clear benefits for service
providers in:
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 Informal

26. CHANGE AGENTS
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Principle 2: A credible, committed change agent is
critical for change in health care practices.
 Change agents are people who lead groups in developing,
applying, and advocating for new practices. They transmit
their commitment and enthusiasm to those who do the dayto-day implementation that ultimately translates new
practices into norms.
Examples of change agents
 A hospital director who improves linkages and referrals
among facilities
 A district health officer who secures matching grants and
uses them to improve local health services
 An experienced, effective clinic nurse who teaches mothers
to use local ingredients for effective oral rehydration
therapy
 An engineer who finds a locally appropriate way to improve
water filtration


27. EARLY ADOPTERS
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People known as "early adopters" have the
characteristics and credibility to influence others.
 These people can be the most effective internal
change agents. Scaling up change often requires
recruiting change agents from among early
adopters at various levels in large programs


28. CHANGE AGENTS AND EARLY
ADOPTERS
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Early adopters are opinion leaders in their
work or social settings.
 Often well respected and connected, they
tend to be chosen as leaders or
representatives in their work or social
groups.
 They are more willing to take risks and try
new things than later adopters.


29. PRINCIPLE 3: SUPPORTING THE CHANGE
AGENT GIVES THE AGENT THE CREDIBILITY
AND CONFIDENCE TO LEAD.
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Motivation and support for change agents and
their teams throughout implementation and
scale-up significantly increases the chances of
institutionalizing the change.
 Provide ongoing positive reinforcement,
appreciation, encouragement, recognition, and
legitimacy to change agents.
 Share knowledge about pathways to successful
change and assist change agents to develop
leadership skills, so that they can engage the
commitment of their staff and sustain it over the
long term, assessments of anticipated benefit.


30. COMMIT TO A CHANGE
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Of particular importance are skills
 to plan for implementation,
 scale-up, and
 sustainability right from the beginning of the
change process.
 This can help to develop these skills in change
agents and their supervisors by giving feedback
and support as they plan and address their
ongoing challenges.

31. PRINCIPLE 4: CHANGE IS MORE LIKELY TO SUCCEED WHEN
LEADERSHIP AT EACH ORGANIZATIONAL LEVEL SUPPORTS IT
AND WHEN IT IS INTRODUCED INTO AN ENVIRONMENT
WHERE CHANGE IS AN ONGOING PRACTICE.
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Dr Rajeev Kashyap
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Supportive leadership: Because change agents are
usually working at organizational levels closest to the
delivery of services, they often need an
influential senior manager as their sponsor or
champion in the change process.
This person uses his or her influence to open doors for
the change agent, to be the agent's intermediary with
senior management, and to help improve the
environment for change.
In some instances, the champion selects the change
agent. In other situations the change agent is in place
before the champion is recruited. In either case, the
champion may be your most direct contact with a
change agent at the service delivery or district level.
Source: Management Sciences for Health 2004
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32. PRINCIPLE 4 (CONTINUED)
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Dr Rajeev Kashyap
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Supportive Environment: Studies and experience show that
successful adaptation and adoption of new practices occurs most often
in programs or work groups where the environment is marked by the
following characteristics:
Knowledge sharing happens at all levels. Top leaders and
leaders at all levels readily share information and knowledge, and
encourage their staff to do the same. They send a clear message: This
change is important and I stand behind it.
Making changes is routine. Leading change is part of ongoing
organizational practice. Staff are encouraged to make small, practical
improvements routinely, not just to undertake big changes in a crisis.
Work teams are cross-functional. Work teams are designed to
bring together people with varied perspectives who can build on one
another's ideas.
Prudent risk taking is rewarded. Staff are rewarded or
acknowledged for asking questions, taking risks, and challenging the
status quo to fulfill their program's mission more effectively.
Sources of change are trustworthy. Staff members trust the
honesty and credibility of the people who are promoting change.
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

33. PRINCIPLE 5: CLARITY IS NEEDED ON THE
PURPOSE, BENEFITS, AND ANTICIPATED
RESULTS OF THE CHANGE
Dr Rajeev Kashyap
You can help the change agent to communicate
clearly to all staff the reasons for the change,
what results are likely to ensue, and the ways in
which each staff member will benefit from the
change.
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

34. PRINCIPLE 6: PROVIDING ONGOING SUPPORT TO THOSE WHO
WILL IMPLEMENT THE CHANGE HELPS MAINTAIN THEIR
DEDICATION AND CREATES A SUPPORTIVE NETWORK FOR
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Dr Rajeev Kashyap
The change agent can encourage continuous staff
involvement and generate the enthusiasm
needed to carry the change through to results
and incorporation into standard procedures.
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THE CHANGE AGENT.

35. PRINCIPLE 7: CLEARLY ASSIGNED AND ACCEPTED
RESPONSIBILITY FOR IMPLEMENTING THE CHANGE
INCREASES THE CHANCES OF SUSTAINING THE CHANGE AS A
Dr Rajeev Kashyap
Unless every staff member understands and agrees
to her/his specific responsibilities, critical
elements can fall through the cracks, reducing
the likelihood of achieving the desired results
If staff are held accountable for making the change
happen, the change agent needs to:
 Encourage staff to recognize the necessity and
priority of the proposed change
 Provide them with the information, resources,
and skills they need to take on new
responsibilities
 Integrate new responsibilities into their
performance plan and hold them accountable
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PART OF ONGOING WORK

36. PRINCIPLE 8: START WHERE YOU CAN
AND START NOW.
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In some ways, this is the most important principle. If
you wait for ideal conditions and a perfect
environment in which all the principles are
manifested, no changes will ever be initiated. The
perfect is the enemy of the good.
 As a supporter of change, you can help to create the
best possible environment for change, and then move
the process forward. With your support, a capable,
motivated change agent and champion can work with
the principles to make the best of imperfect
conditions.
Together, you can make impressive improvements in
health delivery practices and bring the benefits of
change to providers and clients alike.


37. SELECT A SITE FOR TESTING
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Criteria for Choosing the Site
 Size and client load: The demonstration site should be
small enough to try the practice rapidly and inexpensively,
but typical of the settings that will be using the new
practice. The change coordination team could analyze
caseloads to choose a facility with enough clients to show
the impact of the new practice.
 Staff cooperation: The best demonstration sites will have
some key staff who are early adopters, who are likely to
want to cooperate in testing a new, promising practice. In
some instances, it may be appropriate to test the practice
at the change agent's own site first, building on his or her
rapport with staff.
 While selecting the initial testing site(s), the change
coordination team can identify other sites where the
practice will likely be implemented if the first tests are
successful.

38. WHY TEST?
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A small-scale demonstration lessens the risk
of costly mistakes.
 It facilitates future adoption and support,
especially if the change agent is an opinion
leader.
 Early success reinforces stakeholders'
motivation for continued energy and
investment.
 If accurately measured and clearly
communicated, evidence of improvement
will persuade staff of the value of the new
practice and encourage its incorporation
into day-to-day practices.


39. DEVELOP THE TEST PLAN
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To complete this plan, the change agent and your
change coordination team can:
 Develop indicators to monitor progress, and
ultimately, evaluate whether the change has
succeeded in meeting the challenge
 Clarify roles and responsibilities for the change
coordination team, the champion, the change
agent, and his/her local change team
 Identify tools that have proven useful in carrying
out comparable changes
 Plan for linkages to other sectors, systems, and
programs.

40. ESTABLISH GUIDELINES
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Planning together gives the change agent
guidelines to lead the demonstration process.
These guidelines allow every player to know what
s/he should do, and to be held accountable
throughout the process.
 Guidelines establish a framework for scheduling
and help to set priorities and mobilize resources
needed for the test.


41. REVIEW PAST CHANGE EFFORTS
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Before embarking on the demonstration, your
change coordination team can suggest that the
program assess past change efforts – those that
succeeded as well as those clouded by failure.
 An honest appraisal will reveal which approaches
and activities to repeat and which to do
differently in this new demonstration


42. COMMITMENT TO SUPPORT
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One of the most valuable things your change
coordination team can do is to publicly commit to
provide support for testing the new practice. The
plan should incorporate offers from members for
a variety of services, including:
 Technical support in adapting, testing, and
evaluating
 Financial resources
 Support in setting up a system and defining
criteria for acknowledging individual staff efforts

43. TRANSITION TO MORE SITES
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From one test site, your change coordination
team can help move to new sites to test the new
practice under different conditions (rural versus
urban, hospital versus health center, application
by less professional staff, etc.).
 Often the change agent becomes a facilitator for
managers who implement the change at other
sites under his or her direction.


44. THINKING ABOUT SCALE-UP FROM THE
START
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Preliminary planning is essential to anticipate and
lay the groundwork for the complexities of
scaling up.
Start with the action plan you developed when
defining a challenge and flesh out the details
concerning:
 Roles
 Sites
 Resources
 Partners
 Communication
 Review of past change efforts

45. PLANNING FOR SCALE-UP
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This step should always be included in
planning for demonstration projects.
 Purposeful change can create faster
transformation than normal program
expansion that has predictable periods of
stagnation.
 Given the rapid effect of many planned
changes, it is wise to be prepared for
success and scale-up.


46. SUBJECT OF SCALING UP
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A question of strategy: What strategies most effectively produce
the desired leap?
A question of impact: How should the desired impact be
measured?
A question of sustainability: How do we maintain the gains of
an expanded and comprehensive program?
A question of access: What kind of coverage is enough to qualify
as “scaled up”?

A question of supply and demand: What is being scaled up?

A question of cost: How much will it cost to scale up?


A question of resources: What resources are needed and how
can they be mobilized?
A question of timing: When is the right time to scale up?
Dr Rajeev Kashyap
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A question of capacity: What management, technological, and
human competencies are necessary to bring programs to scale?
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A question of change: How do w e know when we have
achieved scale?

47. PLANNING FOR SCALE-UP
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Dr Rajeev Kashyap
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Roles: Clearly divide roles and responsibilities along technical and, if
appropriate, geographical lines. This will foster efficient use of support and
resources.
Research: Set a research agenda to supply the data needed to guide the
change, including such methods as focus group discussions, document review,
and operations research. The goal is to use the simplest, least expensive, least
burdensome research method that will yield the information you need.
Sites: Identify the types of sites where successful new practices should be
introduced, and the units that will need to support these sites in carrying out
the practices.
Resources: Estimate the costs of introducing the new practices at each
potential site. Consider staff, supplies, information, and funding needed to roll
out the practices regionally or countrywide. Identify likely sources that can
meet these needs.
Partners: Identify potential partners to help attain the needed resources and
broaden the reach of the new practices. Identify other stakeholders who will
need to be on board.
Communication: Analyze potential obstacles that may hinder the successful
implementation of the practices and determine where advocacy and
dissemination of results may help to reduce these obstacles.
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48. PHASE 2: PLAN FOR DEMONSTRATION
AND SCALE-UP
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49. COMMUNICATION IS SO CRITICAL
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To communicate change, begin by knowing your
audience.
For both internal and external audiences, you will
want to convey the answers to these questions:
Why are we making this change?
How will it affect this audience?
How will our program and our clients benefit from
the change?
At internal organizational meetings, you might also
encourage discussion of two additional questions:
What may make the change hard to achieve?
What can we all do to help?
For external audiences, public discussions, notices,
interviews, and news reports are all ways to raise
awareness and acceptance of coming changes.
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50. ENCOURAGE TRUST AND COOPERATION
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Dr Rajeev Kashyap
Manage expectations. A critical role of the change
coordination team and senior management is to
manage the expectations of those who will be affected
by the coming change. You can anticipate that most
people will have one of four reactions:
 Be satisfied just to know what is going on
or
 Greet the new practice with enthusiasm
or
 Recommend modifications to the approach
or
 Be skeptical that meaningful change will
happen

51. PRACTICES THAT MAINTAIN TRUST
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Consistent and honest messages
 Effective performance of the change agent
and local change team
 Solicitation of and response to feedback
 Free flow of information on
progress throughout the demonstration
 Availability to staff and community leaders
 Open discussion of important issues that
arise during the demonstration


52. AGREE ON ADAPTATIONS
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Adapting: To fit the set of effective practices to
the program and test setting, the change agent
and local change team analyze similarities and
differences between their setting and the ones
where the practice has been used before. They
can then make needed adaptations, drawing on
elements in the organizational culture that will
support the change.
 Adapting a practice for testing in a new
setting may involve simplifying it.
 Fewer and less complex components will
speed implementers' understanding of the
content and purpose of a change, and make
them more willing to try it.


53. MONITOR FOR TEST RESULTS
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Dr Rajeev Kashyap
One valuable contribution could be to collaborate in developing
indicators to monitor changes in such areas as:
 Health problems among the population being served
 Quality and use of services
 Performance of service providers
 Capacity to deal with constraints
 Implementation of the change process
Monitoring also supports a dynamic change environment by:
 Encouraging honest feedback
 Making objective determinants of success visible to all players
 Enabling the change agent and local change team to identify
and address barriers to change
Honesty is critical. It will seriously undermine the change
effort if those doing the test feel compelled to come up with
positive results no matter what they actually find.

54. MARK THE CONCLUSION OF THE TEST
A public event is a good way to celebrate the end of a
demonstration and reward the efforts of the many
people involved.
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This is a good way to share findings from the
demonstration, describe successes, and acknowledge the
contributions of each person who implemented the
demonstration and all who supported them.
If the demonstration did not fully succeed, it is still
important to publicly acknowledge everyone's efforts, to ask
participants for the lessons they learned, and to analyze
the reasons for failure that could be counteracted in future
efforts.
This event will encourage a positive mindset among
stakeholders. It will motivate the change agent and local
change team to persist into the next phase, even if they
encounter roadblocks.
Dr Rajeev Kashyap
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55. PHASE 4: GO TO SCALE
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56. SUCCESS
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Success: Your change coordination team can help to
evaluate the results at all demonstration sites and
decide whether or not to go with scale-up. If the
change effort at these sites has been successful, your
team can work with the champion and change agent
to prepare a dissemination package for scale-up.
 A typical package would describe the progression of
the innovation, identify barriers and potential
solutions, and extract lessons from the
demonstrations.
 At this point, the change agent often hands off the
leadership role to another well-connected person who
will manage the expansion to new settings.
 The champion and change coordination team can
work with the change agent to bring his or her
experience to bear on a vision and plan for scaling up.

57. SCALE-UP STRATEGIES
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58. ENGAGE BROADER COMMITMENT
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Shared vision: When you and your change coordination
team helped to initiate the change, you joined with
counterparts and colleagues to envision a better future.
Now, you can repeat the activity on a much larger scale
with organizational managers at different levels, partners,
and donors.
 One way to create a shared vision is to encourage
participants to imagine a future where they have
successfully addressed the challenge, as described in
Session 3, Define the Need for Change.
 First, they individually frame their answers to three
questions.
 What can you visualize that represents that
accomplishment? What will this success look like?
 What obstacles will you have encountered on the way to
this success?
 How will you have worked together to overcome the
obstacles?

59. MONITORING AND EVALUATION (M&E)
Dr Rajeev Kashyap
Monitoring and Evaluation (M&E) is an essential
component of any intervention, project, or
program
14/08/2010


60. QUESTIONS
14/08/2010
Dr Rajeev Kashyap
?

61. Dr Rajeev Kashyap
REF: AS PERCEIVED FROM MANAGEMENT SCIENCES FOR
HEALTH & USAID PROGRAM
14/08/2010
THANK YOU