Beruflich Dokumente
Kultur Dokumente
Integrated electronic
Diagnosis Approach (IeDA)
for the management of
childhood illnesses at
primary health facilities
in Burkina Faso
Evaluation
October 2018
2 | London School of Hygene & Tropical Medicine 3
Contents
The study was funded by The Bill & Melinda Context evaluation 10 Analysis 22
Gates Foundation and the Swiss Agency for Mixed methods: embedded A summary of the intervention
realistic evaluation 10 and its outcomes 22
Development and Cooperation
Realistic evaluation design and CMO configurations 23
research methods 12
The new MRT 24
Conceptual framework 12
Discussion and Conclusion 25
Study design 12
Lessons for policy and practice 25
Data collection 13
Methodological lessons 25
Data analysis 13
References 26
Intervention implemented by
© Tdh-Ollivier-Girard
Cover Images:
Ollivier-Girard
4 | London School of Hygene & Tropical Medicine 5
Executive Summary
© Tdh-Ollivier-Girard
health care workers’ (HCW) screened and added throughout the addition, 5 focus groups (on average
will not increase in the near future.
adherence to the IMCI guidelines. study. Various sources of information 11 people per group) were organised
were used: individual interviews and with mothers and carers. During the later phases of the
An evaluation was performed by an document review (project documents analysis, we found that the adoption
independent team from the London as well as national policy documents). process can be grouped according
School of Hygiene and Tropical
managers to district health teams effective and regular support, dialog to their key mechanism and this led
Medicine (LSHTM), United Kingdom, For the implementation evaluation, Results and in a certain measure to Heads to identify their problems and needs to the description of parallel CMO
and Centre Muraz, Burkina Faso. The a set of process research questions
of health centres anytime support is in using the REC and full recognition configurations, each with their own
aim of the realistic evaluation was to were defined prior to the evaluation The actual activities of the
needed. of their role in improving child outcome.
identify the potential mechanisms for and according to the IeDA theory intervention can be summarised
consultations.
change within the IeDA programme of change. Most of the information as follows: (i) Development and Regarding the process of Our analysis identified three
and specify how they are able to collected was triangulated from implementation of improved versions implementation, we noted a good Regading the implementation CMO configurations that indicate
change existing social processes different sources. This was of the REC; (ii) Provision of a six-day coherence between the initial context, we found several potentially causal pathways between sets of
within primary health care facilities. particularly important as the data training course on IMCI guidelines theory of change developed by the important elements in the context management practices and use
were collected retrospectively and REC; (iii) Development of a implementers (MoH and Tdh), the of primary health care in Burkina of REC and we modified the MRT
hence subject to recall biases. quality assurance mechanism; (iv) project management team’s vision Faso in the two regions of Boucle accordingly:
A combination of electronically Monthly supervision of every health and district health teams and health du Mouhoun and Nord. First, all
Methodology documents review and in-depth centre benefiting by the district centres team’s practice. Indeed, in health centres in the two regions The adoption of a computer-based
interviews were conducted in 2017. health team; and (v) Development line with their vision, the project were staffed by at least one nurse decision support tool by health
The realistic evaluation was
of a health information system. We management team motivates the (depending on health centre’s size) staff at primary health care will be
embedded within the steeped In order to capture social phenomena also found important additional health centre staff involved in child who were all aware that management enhanced by having a leadership
wedge trial in order to explain such as management decisions and activities that organically appeared consultations (e.g. nurses, midwives of childhood illnesses is an important focusing on building wide consensus
some of the results of the trial and interactions between individuals, during the implementation of the and nurse assistant) through priority at primary health care, which from surrounding stakeholders (local
explore research questions identified an in-depth qualitative research intervention: the creation of a support
during the trial. The methodology approach was adopted. Various system to respond to breakdowns Table: the three CMO configurations related to IeDA
first focused on implementation sources of data were used by the and questions on the software and
evaluation and then on mechanism of investigator during data collection the tablet; district meetings at least Context Mechanism Outcome (students)
change and context. that took place between January 2016 once a year to enable district health C1. Availability of a support team M1. Promoting amongst healthcare workers O1. Notions of quality in
and October 2017. The combination of teams and heads of health centres to be responsive to healthcare “doing the right thing the right way” approach- childhood illnesses routinised
The implementation evaluation aimed
several data sources proved valuable to discuss about performance and staff questions. es during consultations
to document how the implementation
to the research. Direct observation in find concrete solutions; creation C2. In health centres where the M2. Clear distribution of roles before and O2. Efficient organisation of
of IeDA was organised and achieved,
health centres generated elements of eLearning modules on IMCI nurse is assisted by at least two during child consultations (including triage, the health team
and how the intervention was
of information that helped to identify available on tablets for continuous other members (nurse assis- weight and size measurements, consultation
received. This implementation
new issues or verify assumptions. knowledge development; an inclusive tants or outreach workers) and and counselling)
evaluation focused on fidelity,
The analysis of project reports from and team approach associating in where management flexibility is
dose delivered (completeness),
health facilities helped analyse the allowed
dose received (exposure), reach the implementation process not
implementation of IeDA and the only nurses but also any other staff C3. Strong consensus amongst M3. Introducing at primary health care level O3. Sustained use of REC as a
(participation rate) and recruitment.
vision of the project by managers. In who is directly or indirectly involved stakeholders on the benefits of the notion of individual accountability and routine practice
The context evaluation aimed to addition, interviews and focus group introducing REC responsibility and collective contribution to
in managing child consultations;
discussions provided evidence in the wider system.
document factors external to the and good accessibility of top Tdh
relation to the perceptions, in-depth
6 | London School of Hygene & Tropical Medicine 7
Introduction
Realistic Evaluation
researcher is to first theorise possible Formulation of our MRT in the analysis the a limited number
C+M=O configurations and to explore of key interventions of IeDA, select-
the ways in which real-life experience We formulated our MRT on the basis ed according to the intervention
reflect and differ from these theories. of an explorative study of the pilot theory of change and the opinion of
Here evaluation outcomes are districts where IeDA was first test- main stakeholders: tablets and REC
focused on refined theories of action ed. During that study, interviewees availability, IMCI/REC training, super-
based on understandings gained indicated the importance of the vision and the sequencing of these
from empirical research. characteristics of the innovation as activities. (Bonell, Fletcher et al. 2012,
a driver for use and the importance Moore, Audrey et al. 2015).
Focusing on the realist dimensions of the facility setting as a physical Dose delivered is about identifying
enables us to examine the particular and organisational structure. We also the activities and material most and
significance of ‘mechanism’ and found indications that the perception least successfully delivered at all
‘context’ more closely. Specifically, by communities was a determinant levels.
it directs us to identify the specific factor that influenced health provid- Dose received is defined in the
mechanisms, defined as specific ways ers’ behaviour to adopt and use IeDA. present study as the number of par-
© Tdh-Ollivier-Girard
of introducing IeDA, that might be A second source of inspiration is ticipants to trainings, the number of
activated by the prospect of use of the realist synthesis of 36 peer- healthcare (HCW) workers effectively
REC and the contexts in which these reviewed papers we conducted on supervised and those taking part in
mechanisms might apply. the factors influencing the use of the Quality Improvement activities,
electronic Computer-based Decision and the REC utilisation rates.
The evaluation environment we are
SystemS (eCDSS). It highlighted the Mixed methods: embedded quantitative approaches alone; The mechanisms triggered are
working in is one in which relatively
interrelation between the properties Reach of IeDA is estimated through (iv) MM encourages collaboration determined together with the way in
little is known about ‘what works realistic evaluation
of the innovation itself with the the rate of HCW having been invited between researchers from various which they produce the outcomes
in what circumstances’ in relation
organisational environment. The to trainings, the rate of healthcare The realistic evaluation approach is disciplines; (v) MM is pragmatic as in each of these specific contexts.
to the use of the REC and more
contextual factors that influenced facilities supervised and the average defined by Pawson and Tilley (1997) it opens the possibilities of methods This leads to the definition of a
generally the use of electronic
negatively the use of eCDSS were: technical issues disrupting REC as a series of principles and theories. (Johnson, Burke et al. 2007, Bergman theory detailing which mechanisms
computer-based decision support
financial incentives; competing utilization. To analyse recruitment, However, the authors do not provide 2008, Teddlie and Tashakkori 2011, of the program work in which
systems. Therefore, a core task for
programmes; previous knowledge we gathered information about the any guidance on how to translate Denzin 2012). context to produce which outcomes
the research is to draw on existing
and use of IT; high clinician turnover; actions conducted to create and these principles into research and for whom. An MM approach is
data to theorise what seem to be MM research can have four different
link of eCDSS to an ordering system; maintain adherence and participation methods (Rycroft-Malone, Fontenla appropriate for realistic evaluations.
likely ‘change mechanisms’ and to objectives (Creswell and Plano Clark
and individual patient preferences to IeDA activities and use of REC. et al. 2010). Indeed, they advocate for This evaluation is concerned with
use the empirical study to explore 2007):
for treatment. The complexity, methodological pluralism and the use providing an overall understanding
the presence or otherwise of these
lack of a relative advantage, and of mixed methods. of the nature of the theory-of-change
C+M configurations, to examine 1. triangulation: the objective of
the nature of their interaction and
incompatibility of eCDSS with Context evaluation MM is to generate additional
model and how it actually operates. A
workflow, current practice and beliefs Using more than one research quantitative and qualitative approach
their consequences, both in terms The context evaluation aimed to method can generate a more and complementary evidence
of clinicians was associated with low is required to explore the research
of outcomes but also in terms of document factors external to the accurate analysis of the phenomena on the same topic using
use of eCDSS. Trialability and change questions and deal simultaneously
facilitating greater awareness of intervention that may have acted being studied (Morse 2003). Mixed different methods to better
valence did not influence eCDSS use. with the inductive and deductive
sustainability issues. Our aim is to as moderators of implementation methods (MM) research is defined capture phenomena;
theoretical drives (Marchal, Westhorp
make use of the early ‘demonstration and outcomes (Pawson and Tilley as “the combination of quantitative 2. embedded: one data set
et al. 2013).
projects’ (cases where we know provides the main set of
the REC has been successfully
Implementation evaluation 1997), i.e. as facilitators or barriers to and qualitative approaches that
evidence (e.g. quantitative
IeDA implementation and affecting provide a better understanding Quantitative data and qualitative
used) to help us define the various The implementation evaluation aimed REC use (Moore, Audrey et al. 2015). of research problems than either data) and the second set (e.g. data are collected concurrently:
C+M configurations and test these to document how the implementation In particular, we payed attention approach alone” (Creswell and Plano qualitative data) complements quantitative numerical data is
hypotheses through case studies of IeDA was organised and achieved, to potential unanticipated factors. Clark 2007). The advantages of MM the first one; collected from questionnaires and
carefully selected. and how the intervention was re- Social, political, resources and have been extensively described in 3. explanatory: qualitative clinical observation and qualitative
ceived. This implementation evalua- logistical factors were screened and the literature and be summarized as data contributes to provide data (text data, transcripts and
The emerging findings are compiled explanations to initial results
tion focused on fidelity, dose deliv- added throughout the study. Various follows: (i) MM gives the opportunity memos) from open-ended questions
as conjectural CMOCs that indicate collected with quantitative
ered (completeness), dose received sources of information were used: of mitigating the limitations of included in semi-directed interviews,
how the intervention led to particular methods;
(exposure), reach (participation rate) individual interviews and document both quantitative and qualitative focus group discussions, documents
outcomes in which context and by 4. exploratory: the results of
and recruitment (Saunders, Evans et review (project documents as well as research; (ii) combining quantitative review and observations. In this
which mechanism. Their fit with the the qualitative method help
al. 2005). national policy documents). with qualitative research enables research, qualitative and quantitative
data is checked to ensure internal elaborate the questions and
Fidelity is about comparing what the researcher to study phenomena methods are mixed throughout all
validity. The retained CMOCs are then tools for the quantitative
happened in practice in the four from different perspectives using phases of the project from the design
compared with the MRT, which in method that follows.
districts to what was planned in IeDA different paradigms; (iii) MM helps stage through data collection to data
turn is modified if necessary (Barnes,
project documents (Moore, Audrey answer questions that cannot interpretation.
Matka et al. 2003).
et al. 2015). We decided to prioritise be answered by qualitative or
12 | London School of Hygene & Tropical Medicine 13
The sampling procedure was chosen Table 1: Number and profile of individuals interviewed during the realistic
generalisation” (Yin 2003 p. 32). In according to the objectives of the evaluation
Healthcare workers Patients
real-life contexts, qualitative research study: generating theories and
Coges MoH and, more particularly, case study concepts rather than generalising Profile Number
Outcomes findings to a wider population.
methodologies are known to be Healthcare workers 92
appropriate for understanding and Therefore, a purposive rather than a
probabilistic sampling method was Health district officers 16
District Management team
Results
The management vision Table 2: Number of healthcare workers trained on IMCI/REC in four districts
sometimes to use their own money to the single symptom expressed by the des DOnnées Sanitaires; District centre but we needed to move around was that the REC would increase
cover internet costs. carer. Health Information System 2 (DHIS2), furniture.” (Healthcare worker) the physical distance between the
which will be a critical key to scaling patient and the healthcare worker. In
The REC is, above all, an eCDSS “The REC pushes us to be more “At the start, we through that the REC
up. fact, we observed in several centres
tool that guides healthcare workers scrupulous. So it takes more time was asking for drugs that we do not that one agent moves away from his/
in their clinical decisions and help and mothers complain about it”. In the eyes of the community, the have in stock. We then realised that her desk to sit down next to the child
them respect the recommended IMCI (Healthcare worker) REC has generated indirect benefits. these drugs were part of the essential in order to consult the child and ask
protocol. Step-by-step decisions the Tdh provided solar kits to ensure list of medicine. We had to order questions to the carer. The healthcare
The REC is described by many inter-
clinicians need to make throughout autonomous supply of energy for the them.” (Drug stock manager) workers noticed the satisfaction of
viewees as a living entity with its own
the course of the consultation are running of the tablet. The community the community in this new approach
autonomy and decision power. As a In terms of team organisation, health
guided by the software that forces made direct link between the and feel a gain of trust from the
result, the “machine”, brings its own staff realised that the use of REC was
the consultant to follow each step introduction of the REC with supply of community. The acceptance of the
independent opinion on the top of the easier with several health agents
of the protocol in order to be able electricity at the health centre, which REC by the community cannot be
healthcare worker’s opinion. involved with an efficient use of
complete the consultation. The brings security around the health better assessed when it is missing:
software developed for the project centre during the night. several personnel. For example, one
“It is the REC that help quickly find when the REC is not functioning
uses conditional logic where the agent stays in the waiting room and
the right products that are needed or out of battery, the community
following questions and steps depend “This tool is great since it was take basic measures (weight and
to treat my child when he is sick.” notice it, ask for explanations and
on the answers previously registered brought. Power is not in the village size). When possible, two agents
(Mother) demand the use of the REC during
by the healthcare worker and no skip but light and the machine are here. manage the consultation as a team.
consultation time.
option where every variable needs to The night guard can now sit down in One person close to the child
“The machine gives more information
be recorded to enable the healthcare advantage of having access to the the light and even if a patient comes and a second person guiding the The strict adherence to the
than the nurse”. (Father)
worker to progress to the next step. medical history of patients. Access during the night, there is light. It is consultation with the tablet through IMCI protocol also means that
The district officers as well as the In a sense, the presence of the REC to the medical history of the child is great.” (healthcare worker) each step of the IMCI protocol and the prescription of drugs is not
healthcare workers recognised that is reassuring for the community as it probably the most visible function recording data on the tablet. In other systematic, which contrasts with
the tool is well designed and enables is a way to guarantee and triangulate from the perspective of the carer. health centres, usually large health current practice in Burkina Faso
the healthcare workers to directly the diagnosis provided by a nurse. To Compatibility centres, the consultation of children is where each patient expects to receive
go further, it is as if the community “Once they [the nurses] type the conducted in one room in parallel to
have access to the protocol without a prescription of drugs. This change
name of the child, they can see a lot In terms of compatibility, we consultations for adults in a second
searching for the right information. had more trust in the REC viewed as of practice puts a lot of pressure on
of information as they already can tell investigated the compatibility with room. We observed that the outreach
generating a non-biased opinion: healthcare workers and requires from
the age”. (Mother) the infrastructure, the use of IMCI, health agents were mobilised for
“When using the REC, we have them perseverance and conviction.
“To me it is like a machine. It is a the health team and the relationship consultations, often in charge of
to follow each step [of the IMCI “When the child is here, you click
computer. This will diminish the patient/clinician. the triage and measuring weight “The person expects to be prescribed
protocol], which means we are to here to see past treatments. You can
screen all the potential problems errors. When I see some work done and size of the children outside the drugs like in the old times. This was
see when he came and what reason. In terms of infrastructure, the REC,
of the child, even the ones not with a machine, I have no fear. I consultation room. We observed routine practice during consultations.
With the registry, it is very difficult. which consists of a tablet, does not
mentioned by the carer. The REC respect this work.” (Father) several times the involvement of People are used to drugs. For people
And we change registry all the time create any specific challenge for the
pushes us to ask the right questions.” one member of the health centre who are illiterate, you explain but they
“In the REC, there is no lie”. (Father) as soon as the pages are finished. health centres, whatever their size.
(healthcare worker) management committee when staff will go to another facility to ask for
But here, even one year later, you see More than being seen as an obstacle,
are overstretched. drugs. It is about trust between us
“I think that it is in the REC that the everything.” (Healthcare worker) the REC actually highlights in each
“If you directly register the child in and the patient.” (Healthcare worker)
healthcare workers see the diseases facility the minimum equipment There are situations when the use
the REC, it [the REC] provides the Another important function of the
of the child. Every time you come and drugs required to run child of REC was challenged by the
classification, the medicine you REC is the centralisation and sharing
back to the health centre, they find consultations according to IMCI population: when the agent was on
need to prescribe, even the dose. So
the information inside the machine”. of data (including monthly reports). standards. The introduction of
Complexity
no need anymore to search in the his/her own and during the malaria
(Father) The patient registry is saved on the the REC systematically generates
documents [i.e. IMCI paper protocol]. season. Complexity of REC was one of the
tablet, saved on a cloud and shared amongst the health team an
So to me, it is much easier like this: main concerns from the national
Another advantage of the REC is with district and national authorities. inventory of equipment missing or not “If I take months such as September-
you ask questions, record the answer policy makers considering the limited
the capacity to generate a patient functioning and the list of essential October-November, when the waiting
and this is finished. You get the “At the end of each week, data are level of computer literacy of their staff
registry and even the medical history medicine. For example, in many health room is full of patients, people are
treatment and the prescription. Huge sent to the district – very quickly at primary health care level. It appears
of the child. The information from the centres, after the IMCI training and vomiting, people are on the floor with
advantage!” (healthcare worker) – from the tablets without leaving that the use of the tool is perceived
previous consultation are recorded in the introduction of REC, we observed fever, it is very challenging when staff
the health centre. We can say that as being easy to understand after
the patient file. The paper-based filing the creation of oral rehydration is limited. The population would insult
The community really perceived a what we save is time.” (Townhall initial training. We have also observed
previously used could not make this therapy (ORT) corners with plastic us if we are slow.” (healthcare worker)
change in the way consultations employee) that new comers in a health centre
task possible. Thanks to the patient containers and oral rehydration
are delivered. The fact that the IMCI are immediately trained by their peers
history function, the healthcare solution (ORS). In terms of patient/clinician
protocol is followed step-by-step The negotiations between the MoH on how to conduct consultation
worker can refine his/her consultation relationship, the REC introduced a
takes more time than only focusing on and Tdh focus on adapting the REC with the REC and use the tablet.
and ask further questions to the carer. “IMCI requires a consultation room new way of interacting with patients.
database to the national health All healthcare workers trained on
This function is well appreciated by dedicated to child consultations, One concern at the start of the project
database, ENDOS (Entrepôt National REC recognise the importance of
the community who understands the which was possible in our health
20 | London School of Hygene & Tropical Medicine 21
coaching following the training and worker complaining about the For the district health team, the “For example, in terms of respiratory practice and behaviour change. A services provided. Even most Heads
after practising in order to be able to innovation was not excluded from introduction of the REC does not infections, to check whether a child real support system was put in place of the health centres have a sense
ask questions, understand some of the intervention but on the contrary, only mean the introduction of a new has a stridor, you can click on the engaging each level of the health that it is their responsibility to monitor
the troubleshooting methods when their concerns were embraced by the technology but is really rather seen as REC to watch a short video with a system in the implementation and the quality of the consultations
the software or tablet has issues and coaches in order to build their skills the scaling up of the IMCI strategy. specific case of stridor. The REC promotion of quality of care practices. performed by their team. This
verify they are doing the correct tasks. and later n their confidence. provides a few more extra details on This required the involvement of a integration of the governance system
“We have to say that before we what information we need to check wide range of actors ranging from to the lowest level of the health
The feedback loops established One limitation of the current version introduced the REC, even if some IMCI to confirm a stridor. They are plenty of national actors from all levels and system is a real achievement and
by Tdh to understand users’ of REC is the absence of correction training took place at some point, details provided.” (Healthcare worker) sectors of the health system (different contribution towards the routinisation
perspectives is also well valued as function. The information cannot be there were only two health centres departments at MoH including family of the REC at the primary health care
after each software version healthcare changed as soon as the section is [out of 28] that were using IMCI and Another new management practice medicine, statistics and information) system of Burkina Faso.
workers can see the improvements validated. This lack of flexibility makes within the health centre, only nurse introduced by IeDA is team work. and international donors and United
made compared to the previous in typing mistakes very unforgiven and had been trained in IMCI and tried to The utilisation of the REC is more Nations agencies as well non- “I keep an eye on the ones who use
order to facilitate their work. The may lead to incorrect diagnosis. used it during consultations. So you efficient when two staff are involved governmental organisations and civil REC and when I go around, I select
healthcare workers really understand can imagine the proportion of children to conduct consultations. In several society organisations and individuals the patients already consulted and
that they are the key players in this consulted with IMCI was quite low. health centres, we even observed (opinion leaders, religious leaders). check whether their name is recorded
project and that their voice and views Observability After the introduction of REC, which that peer support was organised in Many of these actors were involved or not. If they are not registered, I
are recorded and analysed to improve was preceded by an IMCI training order to enhance individuals practice and engaged at each stage of the call the agent and explain that all
the usability of the tool. In terms of observability (i.e. the for all agents, I can say that now all and knowledge. Peer support was the patients need to be registered.”
project to share views on the next
possibility for the users to perceive CSPS use IMCI during consultations suggested by the Quality Assurance (Head of health centre)
steps of the implementation and
The utilisation of REC becomes visible benefits), interviewees and more than one agent per health activities and coaches as an approach scaling-up of IeDA. The recognition
very complex when the system listed quite a few aspects. First, the centre.” (District Officer) to enhance quality. “The person who leads the
of everybody’s voice created an
breakdowns. It happened that healthcare workers realised that the consultation has to provide his
atmosphere of mutual support and
in the middle of the consultation, use of REC lead to a more rational “It is really a positive change because The IeDA is seen by the health personal details, which helps identify
trust within health centres and
the software froze or the system prescription of medicine and with the REC it is really the IMCI district officers as the introduction who is in charge of the consultation,
between health centre staff and
shut down deleting all information reduced over-prescription, which is strategy that is rolled out, which of a quality of care approach at so we know the proportion of
district health teams. There is general
registered during the consultation. usually the result from community means that we introduce the IMCI primary health care level. The IeDA consultations performed by nurses, as
perception that the IeDA has been
We also observed that in some pressure. The presence of the tablet form during every consultation.” project through higher adherence they are the ones who supposed to do
implemented with genuine will from
health centres, nurses were using the provides vis-à-vis the community (District Officer) to IMCI promotes a comprehensive it. And when there are problems, we
health staff to make it work.
paper registry as they had serious arguments and a rationale for the assessment of the child health, can identify which person has difficult
issues with the battery of the tablet. healthcare worker for not prescribing The REC is also a dynamic tool, which moving away from a classification conduct correct consultations.”
“The culture of performance and
The point here is to highlight that drugs when not necessary (for evolves with the policies and can based on the most visible and (District Officer)
quality needs to start from the
the introduction has become so example when the child has a simple support the dissemination of new apparent symptoms. institutional level. We need to be
much part of routine practice that cough). policies at reduced cost. For example,
able to support the institutional level,
its absence due to a breakdown is during the course of the project in “With IeDA, it helps screen more
which means the national, district and
noticed by the healthcare workers On the other hand, the healthcare 2016, a revised version of the national comprehensively the health
health centre levels.” (Tdh)
and disrupts the organisation of worker through the use of REC IMCI protocol was introduced conditions of the child. It helps
consultations. has a better understanding of and by MoH. The protocol was then change the practice of health agents. The behaviour of health workers
adherence to the IMCI protocol as supposed to be rolled out by the MoH, Sometimes, there are consultations is also influenced by the new
skipping steps are impossible with which requires dissemination of the when, maybe. We don’t take enough accountability system introduced
Testability REC. The healthcare workers have document and ideally refreshers for all time to consult the child or ask all the de facto by the REC. Indeed, every
the feeling that they really follow the health staff. With the REC, a revision right questions to the mum. But with healthcare worker needs to log in
In terms of testability, we observed in IMCI protocol as they should do. As a of the protocol in the software and that [REC], as everything is indicated, every time they use the REC. The
a few health centres some resistance result, healthcare workers feel more the upload of the revised protocol we have to follow each step and this information officer at the district level
from heads of facilities. It was mainly confident in their own classification on each tablet were the only tasks contributes to improve the behaviour can easily retrieve this information in
due to the lack of self-confidence and prescription. necessary to a full roll out of the of healthcare workers. So this is a case of problem. This is a significant
and literacy on using tablets and revised protocol. great advantage for us.” (District change in the Burkinabe public
softwares. The coaching played a “Without the REC, there are many Officer) service culture as for the first time this
key role in accompanying individuals questions we used to forget. But here, From the perspective of the
information can be used to identify
who had some reluctance in using all the questions are listed and you healthcare workers, nurses or nurse “When you see on the walls the ideas
malpractice (if needed).
REC and building their confidence. cannot skip any of them. So to me, I assistants, the REC also represents of changes and the solutions. You
Coaches did not consider resistance think that we better manage patients. a tool supporting continuous can see a weekly programme and the The high level of commitment from
as an exceptional event but rather For example, when a child comes development through the eLearning indicators displayed.” (Head of health a wide range of actors generated
assumed that resistance was the with a simple malaria, you can without tools. Indeed, in 2017 were introduced district) more legitimacy for the project and
norm. As a result, any healthcare the REC forget to identify anaemia.” online training modules with short created a devolution of powers and
(Healthcare worker) demonstration videos. The quality of care approach
responsibilities within the health
promoted by MoH and Tdh goes
system to monitor the quality of the
beyond the improvement of individual
22 | London School of Hygene & Tropical Medicine 23
Analysis
assurance sessions are built around and no disruption of availability of (including community and policy This study offers interesting insights on how the introduction of one computer-based decision
specific concrete issues experienced the tablet are considered as essential makers support), which can be
by the health centre team and context elements in the three
support tool combined with management support practices created new work practices.
translated by peer support and
elaborate realist solutions and action configurations. district authorities support, and
points, which achievement depends availability of support services Lessons for policy and to a stronger organisational culture motivation. Assessing the exact
on how the members will work as responding to software or practice (Granovetter 1973, Eisenberger, contribution of a set of management
a team. In turn, it stimulates the The new MRT hardware issues. The supportive Hutchinson et al. 1986). Finally, a practices to overall performance
feeling of perceived organisational environment is based on reciprocity This project reinforces the point balanced management approach is virtually impossible. What realist
system and team mechanism. The Our analysis identified three that in a successful diffusion of
and acknowledges individual is costly, especially in management evaluation can do is to stimulate the
leadership and management style CMO configurations that indicate innovations (such as in the case of
contributions to the wider system. time (supervision, dialog, problem- researcher to describe a detailed
introduced by Tdh is perceived by causal pathways between sets of IeDA), it is necessary to combine
Conditions for such environment solving sessions). It requires picture of the causal web that
health centre staff to be effective and management practices and use the introduction of technology
to be promoted by a leadership reasonable financial resources and includes the multiple determinants
supportive. In ensuring that all staff of REC and we modified the MRT with support and management
that creates a decentralised a management capability to deal and to categorise these as
have access to improved working accordingly: mechanisms. It also shows that in
decision space where initiatives are not only with administration but intervention, underlying mechanism
environment, their work tools are respected. management of healthcare workers, also with the less tangible issues of and context. In our case, we argue
The adoption of a computer-based
repaired, and their requests listened it is important to mix different relationships, organisation culture that open dialog, training and support
decision support tool by health The introduction of the innovation
contributes to create reciprocity and management practices. It also and motivation of staff. services are essential, but we don’t
staff at primary health care will be is combined with a multiplicity of
organisational commitment. This is in important to highlight that managers’ know which among these sets is the
enhanced by having a leadership management practices including
turn contributes to good performance attitude plays a great place in the most important and in which setting.
focusing on building wide consensus role distribution, team work, problem
in terms of utilisation of the tablet
from surrounding stakeholders (local solving approach and task monitoring
success of the intervention: open Methodological lessons
and adherence to the IMCI protocol. dialog and respect are crucial The MRT is used in realist evaluation
and national authorities) on the (hard) and training, supervision,
dimensions. This is aligned with the We used a realist evaluation to clarify key findings. An MRT cannot
The third CMO configuration can be benefits of using such an innovation support and recognition (soft).
findings from other studies. approach as we see health facilities cover all possible explanations of
formulated as after creating strong and having a wide of actors fully and
as primarily being social entities. change. A realist evaluator does
truly engaged in the directions the Based on the mechanism of
consensus at all levels on the benefits Regarding the mechanisms, our Pawson argues that realist evaluation not pretend to provide the ultimate
project could take. This necessitates perceived organisational support,
of using REC (C3), sustaining the findings relate to the analysis of is well suited to investigate change evidence that the intervention
a system promoting flows of such combinations lead to a
use of REC as routine practice (O3) Evans and Davis (2005) who situated in such social system (Pawson and works. Rather, the MRT aims at
information between all levels of the reorganisation of the health team
requires introducing the notion the underlying mechanisms of high Tilley 1997). However, appealing as it enlightening the decision-maker, a
health system where transparency of and the distribution of roles before
of individual responsibility and commitment management at the level is, realist evaluation poses a number process of utilisation of research that
information is valued. and during the consultation, and
accountability (M3). The members of of the internal social structure of the of challenges for the researcher. may be the most frequent in case
positive atmosphere that includes
the health centre, the primary users of The introduction of such innovation organisation. Such practices improve of social research. In such cases, a
recognition of each team member, The most critical issue is the
the REC, have the feeling of belonging needs to occur in an environment knowledge, practice and skills but pragmatic position should be taken
organisational commitment and attribution paradox. In complex
to a system that is wider than their flexible enough to provide space also exert effects at the level of whereby one tries to refine the MRT
sense of belonging. Every new comer systems, the behaviour of people
health centre and contributing to to staff make decisions on the relationships between team members as much as practically possible
starting in the health centre or the is determined by many interlinked
a bigger enterprise than their own distribution of clearly-defined tasks but also with line managers (in this with the explicit aim of providing
district are fully integrated into factors. Health professionals act
district. This is the result of early within the team in order to better case, the district health managers). options for improvement or scaling
this new organisational culture and under influence of their professional
and ongoing engagement with a adapt their work to the new situation. Weak ties are strengthened, up rather than reaching a perfect
benefit from the same support and norms, social pressure, management
wide range of actors ranging from On the other hand, the innovation, reciprocity is established and understanding of the intervention as
recognition. interventions and their intrinsic
national and district authorities to REC, needs to be flexible enough shared mental models contribute such.
opinion leaders at community level to take into account the constant Conditions for such management
(Yukl 1999). REC users feel strong changing policy environment and the changes to work include open dialog
and wide consensus on the necessity emerging needs and requests from at all levels of the system, a minimum
of testing and using REC – a unique its users. of resources to cover the support
message sent by a multiplicity of services and supervision and regular
key stakeholders influencing the The REC is adopted when perceived
discussions focusing on solving
environment of healthcare workers. by users and district managers as
problems faced by health centre
The introduction of the notion of being encompassed within a broader
teams.
individual accountability in public quality improvement strategy
services through personal login where health staff is sensitised to
on the software also contributed the importance of quality and their
to enhance a sense of individual capacity to address quality issues at
responsibility and contribution to the their own level.
wider system. The introduction of the REC needs
to be accompanied by a supportive
In terms of context, availability of
atmosphere and environment
well-trained staff in IMCI and REC
26 | London School of Hygene & Tropical Medicine 27
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