On 21st April, 2015 I defended my public health PhD dissertation at Universite
Catholique de Louvain in Brussels. I sought to understand organisational change within district health systems in an Indian district. The research was carried out in Tumkur district in southern Karnataka (on which I have blogged a bit). I focused on understanding “change” within a public service bureaucracy like the one we have in Karnataka. A capacity building programme that aimed at improving capacity (and hence performance) of district and taluka (administrative sub-units of the district in Karnataka and some other states in India) health services was the premise and entry-point for me to investigate if and how change can be conceived in a district health system. The PhD itself was thanks to a fellowship from the Institute of Tropical Medicine, Antwerp (Belgium) with whom my Institute (IPH Bangalore) has an institutional collaboration. My guide at the Antwerp Institute was Bart Criel, while my guide at the Universite Catholique de Louvain’s public health department was Jean Macq. A note on my PhD defence is also found at the ITM public health department’s blog here with better photos and the poem (see below).
Change is difficult to conceptualise in a complex open system scenario that is the case with our health systems. There are no clear boundaries for these systems and there are no tangible control knobs for tweaking performance of such systems. The people involved make daily life decisions influenced by a variety of historical and current events and environments; only good-enough explanations of what kind of change to expect may be generated in such scenarios.
The work of various sociologists ranging from Merton’s middle-range theory and Archer’s realist social theory to the more recent work of Ray Pawson’s and Nick Tilley (who brought critical realism inspired thinking from the world of philosophy of science to world of programme evaluation; their approach is rather aptly termed realist evaluation) conceive a deeper layer at which a somewhat universal explanation for many of the social phenomena lies, albeit modified by particular local contextual conditions that allow such universal mechanisms to trigger outcomes only in particular contexts. The realist evaluation approach harnesses this three-way context-mechanism-outcome co-occurrence as an analytical tool to make sense of the complex nature of change one sees in health and other social systems.
Two presentations based on the more technically oriented private defence (viva) and the final public defence are available on Slideshare.
In my application of the realist evaluation approach to understanding capacity building, there have been many lessons learned. The very very short narrative summary is below while a somewhat poetic one is further down. A longish summary along with chapter-wise summary is here. The full dissertation can be downloaded here and a reflective afterword is here. The dissertation draws from chapters written based on papers including an invited paper in the journal, Indian Anthropologist on evaluating healthcare interventions in India, a paper based on the realist evaluation study protocol in BMJ Open, a paper describing the intervention and development of the hypotheses, and the analysis and the results in a special issue on application of systems thinking in health in the journal Health Research Policy and Systems (with the support of the WHO Alliance for Health Policy and Systems Research). A dump of references used is here.
In countries such as India, local health systems struggle to utilise their resources optimally and to deliver quality health services in an effective manner. While the reasons for these are many, poor health management capacity has been postulated to contribute to this problem. Understanding how public health organisations can move towards change through capacity building interventions is crucial to strengthening health systems. By studying a capacity building intervention of health managers in Tumkur district of southern India using realist evaluation approach, we advance the understanding of how these interventions could contribute to organisational change. We find that capacity building programmes need to go much beyond transfer of knowledge and skills in order to effect organisational change and identify several individual and institutional factors and various alignments within decentralising local health systems that are crucial to achieving change. We conclude that human resources management strategies in Karnataka ought to invest in altering workplace conditions and organisational culture through restructuring the current health bureaucracy so that committed health managers could better utilise change opportunities presented by capacity building programmes.
Thanks to Tanya, here is a video of the public defence.
There are of course a lot of people to thank; a narrative acknowledgement of
several special people is here. The PhD years were also eventful to say the least; various personal and professional achievements as well as disappointments and a few too many bereavements dotted the journey. A long journey indeed from medicine to public health and then some.
In future, looking forward to continue my work at the Institute of Public Health Bangalore and contribute to a better understanding of how to improve public health management in India and elsewhere though better research methods, better teaching and some on-ground action in Tumkur and Chamarajanagar districts of Karnataka. Some of my recent teaching assignments include courses I teach or co-teach at Azim Premji University, Bangalore, PHFI’s Indian Institute of Public Health’s Bangalore campus as well as a course for under-grad students from Duke University. Recent methodological journeys span a WHO-Alliance funded project on improving access to medicines at government primary health centres which marries a cluster randomised control trial with a theory-driven inquiry (a so-called mixed methods approach) to a UNICEF funded participatory action research with various people, organisations and movements in Chamarajanagar to improve maternal healthcare among indigenous communities. Perhaps such individual journeys will result in some tangible benefit? Time only and perhaps policy will tell…