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Towards a mid range theory of implementation

Towards a mid range theory of implementation. B.V.L.Narayana. Structure of presentation. Motivation Problem definition—literature review Research problem Methodology Context Findings Discussion Contributions and limitations. Health indices comparison.

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Towards a mid range theory of implementation

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  1. Towards a mid range theory of implementation B.V.L.Narayana

  2. Structure of presentation • Motivation • Problem definition—literature review • Research problem • Methodology • Context • Findings • Discussion • Contributions and limitations

  3. Health indices comparison Source: Health profile of India 2006

  4. Motivation • Disparity in societal progress • distribution of mortality and morbidity • Between developed and developing countries • Between states in India • Conditions preventable • Proven cost effective interventions available • Common health care programmes • Why the disparity in India • Reason : low usage of interventions

  5. India and other developing countries Investments and funding (Bajpai, Dholakia and Sachs 2006; CMH 2001) Mediated through good governance (Wagstaff and Claeson 2004 ) Institutional factors (NCMH 2005; Wagstaff and Claeson 2004) Poor managerial and technical capacities—training, epidemiology, data collection Service delivery mechanisms (Bajpai and Goyal 2001; Mavalankar 1999; Seshadri rao 2001; Wagstaff and Claeson 2004) Motivation Implementation is one of the key issues

  6. Literature review • Health care • Academic • Practice Program evaluation Policy Implementation Implementation Implementation Frame works Structure Resource Allocation process Content Strategic consensus STRATEGIC MANAGEMENT

  7. Literature review • Research dominated by • Extreme emphasis on content • Studies looking at impact evaluation –emphasis on cross sectional studies or limited variables • Implementation taken as given- • neglected in research- 21/227/990; >90%; 48/230 • Lack of processual studies • Only set of variables identified • Fragmented and dispersed theory • Lack of dominant framework or theory to guide research

  8. Literature review Health care • Key word search • Only 48/ 230 related to implementation • Focus on • Disease specific issues • Policy issues • Identification of factors influencing Implementation • Studies show poor methodological design (Olivera-cruz, Hanson and Mills 2001 ) • Paucity of processual studies (NCMH 2005; DCP 2006; Huicho et al 2005; Gilson and Mills 1995) • LACK OF LINKAGE OF INFLUENCING FACTORS TO PROCESS • OF IMPLEMENTATION • NO DOMINANT FRAME WORK OR PROCESS MODEL

  9. Literature review Policy implementation • > 90% of articles focus on formulation variables(Sinclair 2001). • Paucity or total lack of processual studies and a process model to inform practice ( De Leon 1999) • Identified construct “ Implementation organisation”( Hjern and Porter 1981) • LACK OF LINKAGE OF INFLUENCING FACTORS TO PROCESS • OF IMPLEMENTATION • NO DOMINANT FRAME WORK OR PROCES MODEL • NO CUMULATION OF THEORY ON IMPLEMENTATION

  10. Approach Top down Integrated Bottom up Theoretical gap Van meter Van Horne 1974 Full set of variables/ process Sabatier 1992 Rainey Steinbeur 1999 Fenger, klok 2001 Maier and O’toole 2001 Brinkerhoff 1999 Maier and O’toole 1999 Cline 2000 Terpstra Havinga 2001 Focus Stoker 1989 Matland 1995 Pearson – Nelson 2005 John 1999 Lloyd 1999 Vangan huxam 2003 Ryan 1996 Grantham 2001 Streab Willoughby 2005 Dyer 1999 Schofield 2004 Variables/part process O’toole 2004 Ben zadok 2006 Sorg 1983 Butler 2003 Zahardias Morgan-2005 Mcnulty 2003 Hjern, porter 1981 Content Orientation Process

  11. Review of literature Strategy content • Evolution of literature • Predominant emphasis on content(Ginsberg and Venkatraman 1985; Dess et al 1995; Pettigrew et al 2002) • Review shows only 21/227/991 articles looked at implementation (Hutzschenreuter and Kleindienst 2006 ) • Concentrate on variables of specific interest • Trust (strategic alliances) (Kauser and Shaw 2003) • Culture (mergers and acquisitions) (Cartwright and Schoenberg 2006 ) • Structural form ( diversification) (Whittington 2002) • Managerial initiative (innovations) (Damanpour 1991 ; Dobni 2006)

  12. Review of literatureStrategy implementation • Strategic consensus literature: • Heavy emphasis on top management • Important to look at consensus at all levels for development of theory on strategy process (Bourgeois 1985; Priem and Dess 1995). • The literature on the implementation frame works • Only lists the variables; Scarce empirical validation • Lack of cumulated theory • LACK OF LINKAGE OF INFLUENCING FACTORS TO PROCESS • OF IMPLEMENTATION • NO EMPIRICALLY VALIDATED FRAMEWORK • NO MID RANGE THEORY ON IMPLEMENTATION

  13. Strategy implementation frameworks

  14. Approach Integrated Top down Bottom up Hambrick, Joyce 2005 theoretical gap Full set of variables/ process Bourgeois, Brodwin 1984 Bower, Gilbert2005 Hambrick, Canella 1989 Bromiley 1993 Hart 1992 Miller 1997 Okumus 2001 Focus Skivington, Daft 1991 Roth, Morrison 1992 Feurer 1994 Nutt 1987 Govindarajan 1984 Variables/part process Argyris 1989 Klein, Sorro 1990 Content Orientation Process

  15. Resource allocation process • The way the resources are allocated in the firm shapes the realized strategy of the firm • Is an iterative process (Bower and Gilbert 2005 ). • Is a process model of strategy implementation with realized strategy as the outcome • HAS NOT ADDRESSED THE LINK TO PERFORMANCE • HAS NOT BEEN STUDIED IN SERVICE INDUSTRIES

  16. Literature review HEALTH CARE Lack of a dominant process frame work Lack of linkage of influencing factors to process of implementation; No mid range theory of implementation POLICY IMPLEMENTATION Resource allocation process model link to performance STRATEGY IMPLEMENTATION Resource allocation process model Empirical validation in services sector

  17. Research opportunities Lack of a dominant process frame work Resource allocation process model link to performance RESEARCH OBJECTIVE Resource allocation process model Empirical validation in services sector Lack of linkage of influencing factors to process of implementation; requirement of a theory of implementation

  18. Research objective • Develop a Mid range theory on implementation which would be the basis for a dominant operational framework and • Develop an Operational process framework for Implementation, which can help practice in Health care, Policy Implementation, and Strategy Implementation.

  19. Research questions • What are the processes at various levels, which comprise the phenomenon of implementation? • What are the influencing factors and characteristics of these processes at each level? • Are there any linkages among various influencing factors and characteristics of the processes – within the process and across the processes? • How do these processes interact; at the same level and across levels; to influence the final outcome following implementation of strategies or policies? • How do these interactions among the various factors of the processes finally lead to performance?

  20. Need for health care research • Globalization has lead to (CMH 2001) • Interdependencies among economies of countries • Increased risk from epidemics • Interdependencies among health systems is increasing • Health status of population key to economic development (WDR 1993) • Increased spending on health • Need research to facilitate effective use of money, interventions

  21. Motivation • Why health care? • Problem embedded in health care • Health - a social and economic asset • Role of management to solve societal problems • Why India and public health care programmes • Same problem found in Indian context • Structuring of interventions done through programmes • convenience • Why implementation • Key issue in addressing problem

  22. Research methodology • Processual study (Pettigrew 1997) • Looks at sequence of events, actions and activities over time in a context to explain why, what and how of a phenomenon- longitudinal • Implementation of four national health programmes • Rural health context in 3 states– Gujarat, Tamil nadu and Kerala • Two stage sampling (Patton 2002) • Choice of programmes to cover variation in programme characteristics • Choice of states based on exemplars in category • Choice of units based on performance categorization • Multiple case embedded design, multiple embedded units of analysis • Retrospective histories of key informants ;documents to validate issues; >3 years time period of data collection

  23. Processual study • Purpose is to • describe , analyze, and explain what, why and how of some individual or collective action • Embeddedness • study across many levels of analysis • Role for action and context in explanation • Duality of actors and contexts, Shaping and getting shaped • Temporal • Sequence and flow of events • Holistic explanation • Find patterns, underlying mechanisms • Link processes to location and outcomes

  24. health High High AIDS Condom use AIDS Mental health fertility RCH ORS CANCER Intra organisation coordination Requirement of intensity of resource Vector control Iodine deficiency Vitamin A deficiency TB NLEP II measles Blindness control ICDS IDSP Small pox Low Low Low Intensity of interactions High Low Intersectoral coordination High

  25. Categorization of programmes Mental health; AIDS; MH ; Cancer ICDS; FP NVBDCP High RNTCP; Adolescent diseases IDSP Degree of cooperation required Medium NIDDCP NBCP; NLEP CH Low Low Medium High Intensity of resource utilization

  26. Categorization of units

  27. Research methodology • 4 case histories at state health system level • Iterative process for building explanations ( Yin 2003; Orton 1997; Langley 1999)-represented as visual maps • Within case analysis leading to identification of factors explaining performance • Cross case analysis– used SPICE framework– confirmation of patterns and development of an operational framework- • Literature enfolding (Eisenhardt 1989) to position emergent findings • Developed a conceptual framework • Validated operational framework by mapping to theory • From these two emerged –implementation theory

  28. Research methodology- (Langley 1999; 2007) • PROCESSUAL STUDY • Deals with sequence of events, involve multiple levels and units of analysis—boundaries are ambiguous • Are temporally embedded in varying details • Helps understand how things evolve over time and why they evolve in such a way • Consist of largely stories- events activities and choices ordered over time • Cases are the output

  29. Research methodology- (Langley 1999; 2007) • Strategies used to do analysis • Use key resources as the anchor point • Helped in structuring and attention giving • Identified based on overall common theme emerging from analysis of cases at all levels • Narrative strategy • Initial analysis. Put data collected as a narrative and construct around embedded units of analysis and in a temporal bracketing • Gives detailed story , organizes data • Facilitated identification of overall theme or pattern running across all data

  30. Research methodology- (Langley 1999; 2007) • Used iterative inductive process to generate findings (Orton 1997) and ordered sequence of events • Used visual mapping to represent the probable causal linkage of events and outcomes in each case let at each level of analysis—created through an iterative process as above

  31. Research methodology- (Langley 1999; 2007) • Used synthetic strategy • use of SPICE framework • Develop and compare patterns • Two approaches overall • From data to findings—generate operational framework • Position the identified variables in extant theory to generate conceptual framework • Validate framework in theory • Generate tentative theory through inspirational deduction of gaps in conceptual framework based on extant theory.

  32. Concepts • Implementation of strategy • formal allocation of work roles and the • administrative mechanisms to control and integrate such activities • including those that cross the formal organizational boundaries (Child 1972). • Policy Implementation • actions by people that are directed at achievement of objectives set forth in the policy decision(Van meter and Van Horne 1974). • Characteristics ( Hrebiniak and Joyce 2001) • Is a dynamic, non linear process • Multiple variables interacting, reciprocal causality( Fajourn 2000) • Takes time(Miller 1997) – for effect, for study

  33. INDIA THE CONTEXT • National health policy(2002) ; By 2010 the goals stated to be achieved are ( sujata rao 2004): • increase public investment from 0.95 of GDP to 2-3% of GDP • increase utilization of primary care facilities from 19% to 75% • reduce MMR(maternal mortality ratio) by 75%( from 540 to 135) • reduce IMR( infant mortality rate from 62/1000 to <30/1000 • eradicate polo, eliminate leprosy • reduce deaths due to TB and malaria by 50%

  34. Comparison of programmes

  35. Comparison of programmes

  36. Impact of normative programme structure • Varying coordination costs (Thompson 1967) • Planning, routinisation, learning, communication and feed back • Persistent commitment of funding of activities • Newly added and old • Positioning of actors—implementation organization (Hjern and Porter 1981) • Determines type of administrative structure to be positioned

  37. Comparison of processes across states • Gujarat– • Poor validity of base data, Top down target setting • Decentralized recruitment, ban on posts filling, contractual appointments with low payments • Process outcome monitoring system, Programme oriented training • Tamil nadu • Community needs assessment approach with vital events surveys • Well developed monitoring and evaluation system • Emphasis on continuous skill development • centralized recruitment with stand by provisions • Kerala– • CNAA process, programme oriented training • Decentralized recruitment

  38. Unit level analysis • 19 units- 4 taluks, 2 TB units, 13 PHCs • Factors identified • MOs interest and supervision • Work load feasibility • Appropriateness and Adequacy of facilities and equipment; Adequacy of key staff; case load • Infrastructure provision- roads, communication etc • Management of work load- micro planning, facilitation • Availability and Use of alternate resources • Staff interest and supervision; consensus on targets • Role of distal factors—infrastructure—roads, education, communications, transport, geography

  39. Emerging pattern-unit level analysis

  40. Unit level model of implementation

  41. District level analysis • 27 case lets, 9 districts of Gujarat and Tamil nadu • Factors identified • Adequacy of key staff • Utilization of alternative resources • Focus of CDHO/programme head on • Provision of key staff • Monitoring and supervision • Emphasis on skill development and learning • Role of distal factors-contractual appointments, reduce FHW training slots

  42. Analysis of Districts NBCP

  43. Analysis of districts -RNTCP

  44. Analysis of districts -NVBDCP

  45. Analysis of districts -RCH

  46. “Key resources” • Are resources linked to service delivery • Execute critical components of service delivery • Render multiple components of service delivery • Are • Valuable • Rare as they lack alternatives • Inimitable • Non- substitutable– as alternatives are same staff in private context • Some components can be done by alternate people—provision of MLVs, GAM, incorporation of Private sector– called adaptation mechanisms

  47. Model of implementation –district level

  48. Analysis at State level • 3 states – Gujarat, Tamil nadu, Kerala • 4 cases • Factors identified • Ability to generate resources • Role of top management in • Consistent allocation of financial resources • Policies to create and maintain infrastructure and key resources • Focus on implementation of initiatives • Identification, acceptance and implement initiatives facilitating alignment of services over time • Identification of key resources • Provision of mechanisms for alternate resources

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