Improving facility-based care: eliciting tacit knowledge to advance intervention design

Abstract

Attention has turned to improving the quality and safety of healthcare within health facilities to reduce avoidable mortality and morbidity. Interventions should be tested in health system environments that can support their adoption if successful. To be successful, interventions often require changes in multiple behaviours making their consequences unpredictable. Here, we focus on this challenge of change at the mesolevel or microlevel. Drawing on multiple insights from theory and our own empirical work, we highlight the importance of engaging managers, senior and frontline staff and potentially patients to explore foundational questions examining three core resource areas. These span the physical or material resources available, workforce capacity and capability and team and organisational relationships. Deficits in all these resource areas may need to be addressed to achieve success. We also argue that as inertia is built into the complex social and human systems characterising healthcare facilities that thought on how to mobilise five motive forces is needed to help achieve change. These span goal alignment and ownership, leadership for change, empowering key actors, promoting responsive planning and procurement and learning for transformation. Our aim is to bridge the theory-practice gap and offer an entry point for practical discussions to elicit the critical tacit and contextual knowledge needed to design interventions. We hope that this may improve the chances that interventions are successful and so contribute to better facility-based care and outcomes while contributing to the development of learning health systems.

Keywords: Health services research; Health systems evaluation; Study design.

Figure 1

Facility level improvement—the quality and safety cube. In many LMIC the quality, safety and thus outcomes of facility-based care are undermined by challenges in three core resource areas, inadequate physical or material resources, deficits in workforce capacity and capability, and poor team and organisational relationships. As a result, local facilities operate within the red zone of the cube. Effective interventions that address one or two resource issues may result in unidimensional or bidimensional improvements. However, in weak systems, all three areas need strengthening. Addressing resource inadequacies typically needs to be accompanied by efforts to create and align motive forces if the system status quo is to be changed. Learning across the system and recognising progress can help address unanticipated challenges or consequences and build momentum. (LMIC, low-income and middle-income country).