ROUND TABLE
Leading a change process to improve health service delivery
Pilotage d'un processus de changement visant à améliorer les prestations de service dans le domaine sanitaire
Liderar un proceso de cambio para mejorar la prestación de servicios de salud
Claire Bahamon1; Joseph Dwyer; Ann Buxbaum
Management Sciences for Health, 784 Memorial Drive, Cambridge, MA 02139, USA
ABSTRACT
In the fields of health and development, donors channel multiple resources into the design of new practices and technologies, as well as small-scale programmes to test them. But successful practices are rarely scaled up to the level where they beneficially impact large, impoverished populations. An effective process for change is to use the experiences of new practices gained at the programme level for full-scale implementation. To make an impact, new practices need to be applied, and supported by management systems, at many organizational levels. At every level, potential implementers and likely beneficiaries must first recognize some characteristics that would benefit them in the new practices. An effective change process, led by a dedicated internal change agent, comprises several well-defined phases that successively broaden and institutionalize the use of new practices.
RÉSUMÉ
Dans les domaines de la santé et du développement, les donateurs consacrent des moyens importants à la conception de méthodes et de technologies nouvelles, ainsi que de programmes à petite échelle pour les tester. Toutefois, il est rare que l'application des méthodes ayant subi ces tests avec succès soit transposée à une échelle permettant que les populations démunies en bénéficient largement. Un processus de changement efficace consisterait à utiliser l'expérience acquise dans le cadre du programme de test pour organiser une mise en uvre à plus grande échelle. Pour avoir un impact, les nouvelles méthodes doivent être appliquées et appuyées par les systèmes d'encadrement à plusieurs niveaux organisationnels. A chacun de ces niveaux, les responsables de la mise en uvre et les bénéficiaires potentiels doivent d'abord identifier les aspects de ces nouveaux concepts pouvant leur être profitables. Une personne interne au système et spécifiquement chargée de faire évoluer les procédés pourra alors piloter un processus de changement efficace, comprenant plusieurs phases bien définies, en vue d'élargir le champ d'application des nouvelles méthodes et de les faire entrer dans la pratique.
RESUMEN
En los campos de la salud y el desarrollo, los donantes destinan muchos recursos a idear nuevas prácticas y tecnologías y a emprender programas en pequeña escala para ensayarlas. Pero las prácticas exitosas rara vez se extienden masivamente al nivel en que pueden beneficiar a amplias poblaciones empobrecidas. Una estrategia de cambio eficaz consiste en reproducir las experiencias de nuevas prácticas adquiridas a nivel de programas en aplicaciones a gran escala. Para que realmente tengan impacto, las nuevas prácticas deben ser aplicadas, y respaldadas por sistemas de gestión, a muchos niveles organizacionales. En cada nivel, los ejecutores potenciales y los beneficiarios probables deben reconocer antes que nada en las nuevas prácticas algunas características que puedan beneficiarles. Un proceso de cambio eficaz, dirigido por un agente interno especializado, comprende varias fases bien definidas que amplían sucesivamente el uso de las nuevas prácticas y las institucionalizan.
Introduction
In the fields of health and development, donors channel multiple resources into the design of new practices and technologies, as well as programmes to test them. Yet even while donors fund infrastructure, equipment, supplies, staff development, or research for promising practices, these practices are rarely scaled up1 to the level where they beneficially impact large, impoverished populations.2 To make an impact, effective changes need to be implemented and sustained at many organizational levels. Thus at every level, potential implementers and likely beneficiaries need to recognize some characteristics in a new practice that would benefit them.3 When projected benefits outweigh probable costs, new practices get adopted and processes developed for support.4
In this article we present the critical factors that facilitate change and describe the five phases that constitute a change process that produces results.
Critical factors that facilitate change
An effective process is key to changing service delivery practices in health.4 Five critical factors facilitate effective change in health services: (1) a dedicated, internal change agent, (2) clear purpose, benefits and expected results, (3) clear responsibilities assigned, (4) long-term support for staff, and (5) an organizational environment open to change.
A dedicated internal change agent
An internal change agent is a highly committed individual within the programme who takes responsibility for a change in the long term.5 These individu als are "early adopters" or "opinion leaders"4 who have the credibility to influence others within their environment.3
One example of a change agent is the founder of BRAC, a large NGO in Bangladesh, who developed the initial formula for oral rehydration solution in the late 1960s when he noticed problems undermining oral rehydration programmes there. Over the next 20 years, he created a cadre of field workers who spread the use of the formula door-to-door throughout the country.6 Another example is a hospital director within the province of Negros Oriental in the Philippines who addressed the breakdown of referrals between municipal providers and district hospitals during health sector reform in the 1990s. He spoke with municipal doctors about their concerns and helped them realize that establishing a district health system would improve services. He built the consensus needed for the province to establish health districts. When he later became a district health officer within the province, he built district-wide consensus around proposals to secure grants for improvements.7
In the field of health, early adopters take part in coordinated decision-making about significant new organizational practices. As a result, early adopters not only influence opinions, but lead groups in developing, applying and advocating for new practices. They convey their commitment and enthusiasm to those who do the day-to-day implementation that ultimately translates new practices into norms. Successful change agents hold themselves and the management accountable for facilitating efforts of their staff to achieve results.
When donors and senior managers identify an internal agent to lead a change in practices "within the system," they link the innovation with someone familiar, i.e. with whom staff have already worked. For example, the Governor of Negros Oriental advanced local health care when he asked the enterprising hospital doctor to become a district health officer.7
Clear purpose, benefits and expected results
Before testing a new practice, the change agent secures the support of a "champion," a powerful senior manager, who uses personal influence to overcome indifference or resistance to the innovation. The change agent in turn communicates strategically, through actions and words, to the team and other managers on what the new practice is likely to accomplish. At the same time, the agent learns stakeholders' perceptions of the new practice and uses this information to project its potential benefits, thus making others aware of the importance of the change.
The agent's communication speeds up the adoption of changes in practices. Spontaneous adoption is often slow. For example, lemon juice became integrated into British sailors' diet 193 years after its effect was known.8 Even now, despite increase in media publicity, spontaneous adoption of a simple health practice may still take 20 years.
By clarifying the purpose, benefits and expected results, the change agent also shapes the way others apply new practices. For example, trainers who trained community dispensers through the Cambodian National Malaria Center in the use of artesunate/mefloquine distributed blister packs of these medicn cines only to the trained dispensers, thus discouraging tampering and irrational drug use.9
Clear responsibilities assigned
As change progresses, the change agent and supervisors assign staff roles. The agent makes certain that those who test and implement the practice know their roles and can clearly communicate them to others. This helps in effectively implementing the change and encourages the staff to accept it.
Long-term support for staff
Throughout the change process, testers and implementers run into barriers that impede progress. Other responsibilities may cramp their ability to work through these barriers. The change agent thus engages supervisors and other managers to offer encouragement to the staff, secure institutional and community resources and garner necessary approvals. Supervisors can appropriately motivate staff by entrusting them with the challenge of integrating the new practice(s) into their work, clarifying changes in responsibilities and offering support when needed.
Organizational environment open to change
Changing practices is less difficult if the programme and community involved already empower people to work together to make improvements. If not, the process requires more time and political skill. For example, to adapt a tested approach, the change agent would need to prepare the groundwork for the change by reviewing experiences and noting successes and pitfalls. In this scenario, the senior champion assumes a greater role in protecting the endeavour until successful results are obtained.
The change process
A well-defined change process has five phases: (1) recognize a challenge, (2) identify promising practices, (3) adapt and test a set of practices, (4) implement the new practice(s), and (5) scale up the successful new practice(s).10 The change process is likely to succeed when the five critical factors are integrated into each phase of the process.
Phase 1: Recognize a challenge
Where others see problems, a determined individual recognizes an organizational shortcoming that must be addressed to meet clients' needs. Early in the change process, this person reaches an agreement with others on this challenge and becomes a change agent involving others in creating a vision of a better future that generates commitment. Together, the change team identifies barriers to realizing this vision and the root underlying causes. The team then definess their challenge and develops priority actions which address the root causes.11
Analyses of root causes will help in determining the underlying reason most responsible for each problem. The root causes may relate to people, procedures, policies, or the environment. For example, a human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) programme might define its challenge as "How can we increase the use of voluntary counselling and testing (VCT) when clients will not allow us to test for HIV?" The root causes that limit the use of VCT could include staff fears about those living with HIV/AIDS (people), the lack of treatment sites (policy), lack of networks for treatment referral (procedures), and communal discrimination against those with HIV/AIDS (environment). The use of the Five Whys12 and Fishbone13 techniques can help in exploring the root causes leading to a more robust solution.
Phase 2: Identify promising practices
The change agent identifies new practices that appear to have a high level of success and transferability, and can address the challenge without wasting time thus increasing the chances of impact.14 Next, the change agent mobilizes a team to review the practices and guide the change process. If several possibilities exist, the agent and the team choose more than one set of practices supported by strong evidence, transferability, and the best match to existing needs, programme mission and resources.15 At this point in the process, the agent brings the senior champion on board to determine the feasibility of these practices in terms of estimated time, cost and resources for implementation, as well as their potential for improving quality of care in the long term. Together they select one set of practices and begin planning for additional resources if these practices prove successful enough to be scaled up.
Phase 3: Adapt and test a set of practices
Every new practice needs to be adapted to its setting (i.e. fit to the context and work out any problems) so that others accept it. The change agent and the team analyse the new practices with regard to their setting and adapt them to conform to the unique characteristics of their location. To test the new practices, the agent identifies motivated testers, conveys the purpose of the test and the new practices, assigns staff responsibilities and communicates anticipated results. During the test, the agent develops monitoring processes and engages supervisors and other managers to assist the testers in overcoming barriers. The agent inspires staff about the "wins" achieved, however small.
When a good fit between the setting and practices is achieved, the test is repeated at several different demonstration sites (rural versus urban, and if suitable, clinic versus hospital or with less-expensive categories of staff). At this stage it is critical to evaluate the impact of the practices against predetermined indicators. Comparing these results against results from control settings allows for mid-course adjustments and the decision on whether to implement and scale up.
Phase 4: Implement the new practice(s)
Sometimes known as mainstreaming, this phase helps in building a support base that makes it possible to move from adaptation to actual application and integrates the new practices into the "root" systems of the programme.
The change agent, the team and the champion create opportunities to discuss how the changes link to programmatic goals to enlist the support of senior and other managers in the change effort. They reach an agreement on the required steps, on who would take them, and on the resources (in-kind, technical and financial) to mobilize. They broaden monitoring systems to track the effects of these practices and make adjustments as needed. They work towards supportive policies and management systems, including performance systems, rewards and structures that promote these practices. For example, research has shown that young adult reproductive health programmes have expanded worldwide through the development of curricula and standards of care, training of providers and establishment of policies that raise national awareness and support programme coordination.16
Phase 5: Scale up the successful new practice(s)
Scaling up expands the reach of the new practice(s) within and beyond the programme. The change team evolves into a guiding coalition with authority, contacts and staying power, such as a national publicprivate coalition that can perform outreach to other organizations or other levels, or a district planning board that can organize multiple changes at one level. While the change agent often hands over to a more senior and better-situated person in this phase, there is a need to first lay the groundwork for scale-up. The practices have to be streamlined so that fewer resources are required while maintaining effectiveness, and new communications strategies are developed tailored to different audiences.
The champions who replace the change agent and team form partnerships for planning and implementing the practices, build trust and handle inevitable conflicts among diverse groups. The champions may identify barriers to scaling up and plan mini-pilots to address them. For example, the Ugandan National Tuberculosis and Leprosy Program held a stakeholder workshop with donors when they realized that the scale-up of community-based DOTS for tuberculosis was slowing down. District and sub-district staff jointly identified barriers to progress and, in view of the knowledge about existing incentives and disincentives, devised solutions and planned steps to test them.17,18
Expanding support for the new practices
Throughout the change process, successful change agents and their teams continually face new audiences and need to convey benefits of the new practices to them. Thus, the need for maintaining relationships and effective communication is important. Messages for different audiences about potential results are created, their perceptions are ascertained and then these messages are suitably revised and disseminated to all who are directly and indirectly affected to keep them involved.
Change teams foster relationships with other potential adopters to initiate dissemination of the practices.4 To motivate people to follow, they communicate the urgency of the change by accurately verbalizing the challenge that faces them.19 If during implementation and scale up resistance occurs, change teams need to sympathetically handle individuals' doubts. When convinced, these individuals may welcome opportunities to explore the possibilities the change can bring.20
These messages and relationships need to be supported with evidence of results as they emerge through monitoring and evaluation. Since some practices take years to achieve full impact, a university or government research branch should obtain data prior to implementation and after scale-up to evaluate the effects of the practices.
Conclusion
All levels of government, nongovernmental organizations and communities, international donors and research or technical agencies who strive to improve health are fundamentally either supporting or leading changes in clinical and management practices that support community health. When change agents within health programmes lead others to address critical challenges, they can achieve widespread success by following a change process of adapting, applying and supporting promising practices incrementally throughout their programmes. By helping people perceive the benefits of a proposed change, these agents with their teams can gain widespread commitment to the change; and by integrating the new practices with programmatic values, behaviours and routine processes, they can make the change endure. 
Acknowledgements
We acknowledge the contributions from the Management and Supervision Working Group of the United States Agency for International Development (USAID) supported Maximizing Access and Quality (MAQ) Initiative to the ideas presented in this paper.
Funding: The USAID, Office of Population and Reproductive Health provided funding support for this article under the terms of Cooperative Agreement Number GPO-A-00-05-00024-00. The opinions expressed herein are those of the authors and do not necessarily reflect the views of USAID.
Competing interests: none declared.
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(Submitted: 1 December 2005 Final revised version received: 13 March 2006 Accepted: 20 March 2006)
1 Correspondence to Dr Bahamon (email: cbahamon@msh.org).