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 managerial capacity, developed a suite of innovations to improve the processes and practices of managers and NGO partners in monthly district management team meetings. Using a systems perspective on capacity development, the research explored the initial sensemaking by the district manager, how these homegrown innovations interacted with existing social processes and norms, the mechanisms for change that were triggered and the emergent capacity 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 literature review. To understand processes and mechanisms triggered in local context and identify emergent capacity 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 complex frames, tacit and experiential knowledge to design bottom up innovations, and collective capacity development was triggered through micro-practices of sensemaking and sense-giving. Sensegiving 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, managers engaging with the new practices and social sense-making, influenced the motivation of managers and partners to further participate in new meeting practices, and triggered a generative process of buy-in and emergent capacity in a routine meeting structure. Conclusion District managers are well placed to design local level capacity development innovations and must draw on multiple knowledge forms to enable relevant ‘bottom-up’ capacity development in complex health systems. Managers must draw on their intangible soft skills and the 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 in routine spaces, to unleash capacity.