Schneider Helen, English Rene, Tabana Hanani, Padayachee Thesandree, Orgill Marsha
BMC Health Serv Res. 2014 Nov 29;14:609. doi: 10.1186/s12913-014-0609-y.
Whole-system interventions are those that entail system wide changes in goals, service delivery arrangements and relationships between actors, requiring approaches to implementation that go beyond projects or programmes.
Drawing on concepts from complexity theory, this paper describes the catalysts to implementation of a whole-system intervention in the North West Province of South Africa. This province was an early adopter of a national primary health care (PHC) strategy that included the establishment of PHC outreach teams based on generalist community health workers. We interviewed a cross section of provincial actors, from senior to frontline, observed processes and reviewed secondary data, to construct a descriptive-explanatory case study of early implementation of the PHC outreach team strategy and the factors facilitating this in the province.
Implementation of the PHC outreach team strategy was characterised by the following features: 1) A favourable provincial context of a well established district and sub-district health system and long standing values in support of PHC; 2) The forging of a collective vision for the new strategy that built on prior history and values and that led to distributed leadership and ownership of the new policy; 3) An implementation strategy that ensured alignment of systems (information, human resources) and appropriate sequencing of activities (planning, training, piloting, household campaigns); 4) The privileging of 'community dialogues' and local manager participation in the early phases; 5) The establishment of special implementation structures: a PHC Task Team (chaired by a senior provincial manager) to enable feedback and ensure accountability, and an NGO partnership that provided flexible support for implementation.
These features resonate with the deliberative, multi-level and context sensitive approaches described as the "simple rules" of successful PHC system change in other settings. Although implementation was not without tensions and weaknesses, particularly at the front-line of the PHC system, the case study highlights how a collective vision can facilitate commitment to and engagement with new policy in complex organisational environments. Successful adoption does not, however, guarantee sustained implementation at scale, and we consider the challenges to further implementation.
全系统干预是指那些需要在目标、服务提供安排以及行为主体之间的关系等方面进行全系统变革的干预措施，其实施方法需要超越项目或计划的范畴。
本文借鉴复杂性理论的概念，描述了南非西北省实施全系统干预的推动因素。该省是国家初级卫生保健（PHC）战略的早期采用者，该战略包括基于通科社区卫生工作者设立初级卫生保健外展团队。我们采访了从高级到一线的省级各行为主体，观察了相关过程并查阅了二手数据，以构建一个关于初级卫生保健外展团队战略早期实施情况以及该省促进实施的因素的描述性 - 解释性案例研究。
初级卫生保健外展团队战略的实施具有以下特点：1）省级环境有利，地区和分区卫生系统完善，长期以来支持初级卫生保健的价值观深入人心；2）基于先前的历史和价值观，为新战略打造了集体愿景，从而实现了新政策的分布式领导和自主掌控；3）实施战略确保了系统（信息、人力资源）的协调一致以及活动（规划、培训、试点、家庭宣传活动）的适当顺序安排；4）在早期阶段优先开展“社区对话”并让地方管理人员参与；5）设立了特殊的实施结构：一个由省级高级管理人员担任主席的初级卫生保健任务小组，以促进反馈并确保问责制，以及一个非政府组织合作伙伴关系，为实施提供灵活支持。
这些特点与其他背景下被描述为成功的初级卫生保健系统变革“简单规则”的审议性、多层次和情境敏感方法相呼应。尽管实施过程并非没有紧张关系和弱点，特别是在初级卫生保健系统的一线，但该案例研究突出了集体愿景如何在复杂的组织环境中促进对新政策的承诺和参与。然而，成功采用并不保证大规模持续实施，我们还考虑了进一步实施所面临的挑战。
