Bottom up innovation for health management capacity development: a qualitative case study in a South African health district

Abstract Background As part of health system strengthening in South Africa (2012- 2017) a new district health manager, taking a bottom-up approach to developing management capacity, developed a suite of innovations to improve the processes and practices of managers and NGO partners in monthly district management team meetings. Understanding capacity as a property of the health system not only of individuals , the research explored mechanisms triggered in context, including the initial sensemaking by the district manager, the subsequent sensegiving and sensemaking in the team and how these homegrown innovations interacted with existing social processes and norms within the system to produce outputs.Methods We conducted a realist evaluation complemented by a case study approach over a two-year period (2013-2015) in the district. The initial programme theory development included ten senior manager interviews and a literature review. To understand processes and mechanisms triggered in local context and identify outputs we conducted fifteen interviews with managers in the management team and with seven non-state actors, supplemented by researcher notes and time spent in the district. Thematic analysis was conducted using the Context-Mechanism-Outcome-Actor configuration alongside theoretical constructs. Results The new district manager drew on systems thinking, tacit and experiential knowledge to design bottom up innovations. Capacity was triggered through micro-practices of sensemaking and sensegiving which included using sticks (positional authority, enforcement of policies, over-coding), intentionally providing justification for change and setting the scene (a new agenda, distributed leadership). These micro practices and managers engaging with the new practices, triggered a generative process of buy-in and motivation which influenced managers and partners to participate in new meeting practices within a routine meeting. Conclusion District managers are well placed to design local capacity development innovations and must draw on systems thinking, tacit and experiential knowledge to enable relevant ‘bottom-up’ capacity development in district health systems. Doing so by drawing on intangible soft skills and tangible policy resources (hardware) of the system to influence motivation and buy-in for improved management practices. From a systems perspective, we argue that capacity development can be conceived of as part of the daily activity of managing within routine spaces.