Advancing the application of systems thinking in health: South African examples of a leadership of sensemaking for primary health care

Health Research Policy and Systems

Uta Lehmann¹  Patti Olckers²  Soraya Elloker³  Lucy Gilson⁴ 

[1] School of Public Health, University of the Western Cape, Robert Sobukwe Road, Bellville 7535, South Africa;Western Cape Department of Health, Klipfontein/Mitchells Plain Sub-structure Office, Lentegeur Hospital, Highlands Drive, Lentegeur, Mitchells Plain 7785, South Africa;City of Cape Town Department of Health, Mitchell’s Plain health sub-district, Park Avenue, Mitchell’s Plain 7785, South Africa;Department of Global Health and Development, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK

关键词: Sensemaking;    Primary health care;    Leadership;    Front line workers;    Complex adaptive systems;    Discretionary power;   

Others  :  802212
DOI  :  10.1186/1478-4505-12-30

 received in 2014-01-08, accepted in 2014-04-28,  发布年份 2014

【 摘 要 】

Background

New forms of leadership are required to bring about the fundamental health system changes demanded by primary health care (PHC). Using theory about complex adaptive systems and policy implementation, this paper considers how actors’ sensemaking and the exercise of discretionary power currently combine to challenge PHC re-orientation in the South African health system; and provides examples of leadership practices that promote sensemaking and power use in support of PHC.

Methods

The paper draws on observational, interview, and reflective data collected as part of the District Innovation and Action Learning for Health Systems Development (DIALHS) project being implemented in Cape Town, South Africa. Undertaken collaboratively between health managers and researchers, the project is implemented through cycles of action-learning, including systematic reflection and synthesis. It includes a particular focus on how local health managers can better support front line facility managers in strengthening PHC.

Results

The results illuminate how the collective understandings of staff working at the primary level - of their working environment and changes within it – act as a barrier to centrally-led initiatives to strengthen PHC. Staff often fail to take ownership of such initiatives and experience them as disempowering. Local area managers, located between the centre and the service frontline, have a vital role to play in providing a leadership of sensemaking to mediate these challenges. Founded on personal values, such leadership entails, for example, efforts to nurture PHC-aligned values and mind-sets among staff; build relationships and support the development of shared meanings about change; instil a culture of collective inquiry and mutual accountability; and role-model management practices, including using language to signal meaning.

Conclusions

PHC will only become a lived reality within the South African health system when frontline staff are able to make sense of policy intentions and incorporate them into their everyday routines and practices. This requires a leadership of sensemaking that enables front line staff to exercise their collective discretionary power in strengthening PHC. We hope this theoretically-framed analysis of one set of experiences stimulates wider thinking about the leadership needed to sustain primary health care in other settings.

【 授权许可】

   
2014 Gilson et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

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