Whole-system change: case study of factors facilitating early implementation of a primary health care reform in a South African province
Whole-system interventions are those that entail system wide changes in goals, service delivery arrangements and relationships between actors, requiring approaches to implementation that go beyond projects or programmes.
Drawing on concepts from complexity theory, this paper describes the catalysts to implementation of a whole-system intervention in the North West Province of South Africa. This province was an early adopter of a national primary health care (PHC) strategy that included the establishment of PHC outreach teams based on generalist community health workers. We interviewed a cross section of provincial actors, from senior to frontline, observed processes and reviewed secondary data, to construct a descriptive-explanatory case study of early implementation of the PHC outreach team strategy and the factors facilitating this in the province.
Implementation of the PHC outreach team strategy was characterised by the following features: 1) A favourable provincial context of a well established district and sub-district health system and long standing values in support of PHC; 2) The forging of a collective vision for the new strategy that built on prior history and values and that led to distributed leadership and ownership of the new policy; 3) An implementation strategy that ensured alignment of systems (information, human resources) and appropriate sequencing of activities (planning, training, piloting, household campaigns); 4) The privileging of ‘community dialogues’ and local manager participation in the early phases; 5) The establishment of special implementation structures: a PHC Task Team (chaired by a senior provincial manager) to enable feedback and ensure accountability, and an NGO partnership that provided flexible support for implementation.
These features resonate with the deliberative, multi-level and context sensitive approaches described as the “simple rules” of successful PHC system change in other settings. Although implementation was not without tensions and weaknesses, particularly at the front-line of the PHC system, the case study highlights how a collective vision can facilitate commitment to and engagement with new policy in complex organisational environments. Successful adoption does not, however, guarantee sustained implementation at scale, and we consider the challenges to further implementation.
Because system wide interventions involve many players and sub-systems in complex webs of interaction (both formal and informal), the pathways and impacts of these interventions are inherently unpredictable. Complexity theory suggests, however, that most complex systems have a few key rules underpinning them . In their review of Canadian experiences with primary health care reforms, Best et al.  identified five “simple rules” of successful large-system transformation.
A mix of designated (formal) leadership with distributed leadership in the change process
The presence of feedback loops
Paying attention to past system history
Engaging front line/powerful providers
Engaging end-users (families and communities)
The “simple rules” emphasize the need for collective or distributed leadership in the change process, and are therefore not only driven by top managers of organisations. Actors at the coal-face of systems, often the actual implementers of policy, may have very different interests and perspectives than their managers. Referred to as “street level bureaucrats” , they are faced with the immediate consequences – sometimes unanticipated – of new initiatives, and have to reconcile the demands from the top with the reality of resource constraints in the service delivery environment. They are able to exercise discretionary power in either accommodating or resisting policy initiatives and in shaping them in ways that fit with their every day realities. A political perspective on implementation, therefore, would see it as inherently contested and a negotiated combination of top down implementation with bottom up reactions and accommodations . As implied by Best et al.  processes that explicitly seek to engage the frontline create the spaces for this negotiation.