bottom up development case study

CASE STUDIES

This collection of case studies demonstrates examples of successful implementation of bottom-up approaches (BUA) across the globe. Each case utilizes components of BUA within the planning, decision making, and/or implementation processes. Browse through these case studies using the interactive map below, or search for specific terms to find examples relevant to your interests. Continue to the bottom of the page to submit your own.

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We are always looking to learn about others' experiences implementing bottom-up approaches in a variety of planning, decision making, and management contexts. Download the case study template here and let us know about your project. Upon review, selected cases will be featured in the Knowledge Platform's case study database.

Examining Mexico’s Water Reserves Program as an Ecosystem-Based Adaptation Instrument Using EEDS

AGWA is leading a project to develop national adaptation policy guidelines for river/water management in Mexico using Eco-Engineering Decision Scaling (EEDS). The project is designed to analyze the effects of climate change on e-flows as they relate to the CONAGUA-WWF water reserves program in Mexico. About 10 years ago, CONAGUA and WWF developed the water reserves program as a mechanism to help communities and ecosystem adjust to climate impacts together. Based on an environmental flows (eflows) framework, the water reserves allocate part of the water to maintain the ecosystem itself and to provide ongoing adaptation services, including disaster risk reduction. This project is intended to quantify and document how the water reserves ensure that farmers can keep producing food, cities can continue to provide water, and ecosystems can continue to nourish water. Through the EEDS process, AGWA and its partners will assess the role of water reserves in assisting natural and human systems as they adapt to climate change and to understand the role of water reserves as an adaptation tool for CONAGUA. Find out more about the full case study here .

Preparing for Extreme And Rare events in coastal regions (PEARL)

Observations confirm that disasters being triggered by hydro-meteorological events, interconnected and interrelated with both human activities and natural processes, are increasing the need for holistic approaches to help us understand their complexity in order to design and develop adaptive risk management approaches that minimise social and economic losses and environmental impacts and increase resilience to such events. Find out more about the full case study here .

Huasco Basin

There is uncertainty on the sustainability of multipurpose water reservoir management in the Huasco basin under climate change scenarios, requiring a stress test for the currently installed water allocation rules to the different sectors. Find out more about the full case study here .

Replacing and Renovating the IJmuiden Pumping Station in The Netherlands

How should the end of a pump's lifetime be handled in the case of the pumping station Ijmuiden? Alternatives for replacement need to be explored and tested. Find out more about the full case study here .

The Application of Collaborative Risk Informed Decision Analysis (CRIDA) to the Iolanda Water Treatment Plant in Lusaka, Zambia

MCC funded infrastructure investments require robustness for a range of uncertain futures in difficult developing environments in order to achieve intended poverty reduction objectives. This case study demonstrates the application of Collaborative Risk Informed Decision Analysis (CRIDA) at Zambia’s principal water treatment facility, The Iolanda Water Treatment Plant. Find out more about the full case study here .

Adaptation to climate change in water, sanitation and hygiene: assessing risks, appraising options in Africa

The risks to delivery of WASH results posed by climate change in Africa, drawing on three country case studies and respective DFID portfolio assessments. Find out more about the full case study here .

Water Pricing to Promote Equity, Efficiency and Sustainability in Faisalabad

A better understanding of household water use in developing countries is necessary to manage and expand water systems more effectively while analysis of pricing structure and income elasticities are crucial to devise relevant policies of subsidizing improved water supply, particularly in urban areas of developing economies. Find out more about the full case study here .

Integrating top-down and bottom-up approaches to design global change adaptation at the river basin scale

This project aims at integrating information from climate change projections, provided from a top-down modelling chain, with demand development scenarios and adaptation measures, obtain through a bottom-up approach, to define water management strategies to adapt to global change at the river basin scale. Find out more about the full case study here .

Water Infrastructure Solutions from Eco-system Services Underpinning Climate Resilient Policies and Programmes (WISE-UP to Climate)

Ecosystem services need to be linked more directly and clearly into water infrastructure development, for climate change adaptation and integration into water, food and energy security. Find out more about the full case study here .

Self-reliant Island of Dordrecht

The decision problem is whether to adopt a resilient strategy or a resistant strategy for the management of flood risk on the Island of Dordrecht. Find out more about the full case study here .

Synergy between urban development and increasing river discharges

As a consequence of climate change more extreme river floods are expected. This requires an increase of the river discharge capacity. This project seeks to find synergy between space for future extreme river discharge and present needs for urban development. Find out more about the full case study here .

Water Conservation and Access with Rainwater Harvesting Implementation

The 2005 earthquake in Pakistan destroyed water supply systems in Kashmir and KPK in addition to altering the water level due to topographical changes, causing a shortage of drinking water supply in the area. Find out more about the full case study here .

Flood and Drought Management Tools

Increasing floods and droughts due to climate change is driving a need for better planning and management of water resources at basin and local level. There is a growing sense of urgency around the need to improve resilience within river basins, and for this to become a critical part of water management plans. Find out more about the full case study here .

Climate change and anthropogenic contributions to uncertainties in hydrological modeling of sustainable water supply in Moldova

The translation of climate change projections into corresponding changes in runoff and streamflow through hydrological modeling are usually accompanied by additional uncertainties caused both by specific weaknesses encountered in hydrological models, and different external factors that cannot always be eliminated during models testing. Among such factors, the anthropogenic ones prevail. As a result, the modeling water yield from a watershed should be considered as a certain hypothetic runoff that reflects reality only for the “pristine environment”. Find out more about the full case study here .

Sustainable Development in Cambodia and the Mekong Basin

To manage tradeoffs between food, energy and water security with the primary goal of sustainable economic development in the Siphandone-Stung Treng-Kratie Landscape of the Mekong Basin. Find out more about the full case study here .

Operationalising urban climate resilience in water & sanitation systems in Metro Manila, Philippines

This project was designed to build the resilience of networked water supply and sanitation infrastructure to future climate change impacts in the large metropolitan area of Manila in the Philippines. Find out more about the full case study here .

Testing bottom-up methods to deal with uncertain sea level rise in municipalities

How can coastal municipalities plan for protecting and exploiting low lying areas close to the sea given different outcomes of future sea level rise? Find out more about the full case study here .

Collaborative Risk Informed Decision Analysis: A water security case study in the Philippines

The purpose of this study is to apply the CRIDA approach to a water supply case study in Central Cebu, the Philippines in order to evaluate the added benefits of the method for planning and design under climate change uncertainty. This work will equip practitioners and decision makers with an example of a structured process for decision making under climate uncertainty that can be scaled as needed to the problem at hand. Find out more about the full case study here .

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The Knowledge Platform is designed to promote and showcase an emerging set of approaches to water resources management that address climate change and other uncertainties — increasing the use of "bottom-up approaches" through building capacity towards implementation, informing relevant parties, engaging in discussion, and creating new networks. This is an ongoing project of the Alliance for Global Water Adaptation (AGWA) funded by the World Bank Group.

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Impact case study

Supporting bottom-up development in cities in the developing world.

We had a rich programme of collaboration and exchanges with LSE, which had real consequences for us … The research facilitated the inclusion of these peripheral actors from the favelas of our large cities in the programme of actions of the Ministry. Together we moved forward in understanding that voices and everyday life expertise are absolutely needed for inclusive social development. Brazil’s former Secretary of State for Social Development (transcribed and translated)

Research by

Professor Sandra Jovchelovitch

Department of psychological and behavioural science.

LSE research in Brazil’s favelas has demonstrated the importance of community-level actors to reduce urban social exclusion.

What was the problem?

The United Nations (UN)’s 11th Sustainable Development Goal is to “make cities inclusive, safe, resilient, and sustainable” by 2030. Stigma, violence, and social exclusion present significant barriers to achieving this.

Urban communities such as Brazil’s favelas face harsh conditions of living, including poverty, violence, and segregation. They are routinely excluded from the rest of the city and have little access to state institutions and services. How life courses are determined in these communities, and what institutional factors can engender positive, sustainable, and long-term change, are vital questions for those who live there, and for policymakers at local, national, and international levels.

What did we do?

LSE research led by Professor Sandra Jovchelovitch has investigated institutional, social, and psychological determinants of self and community development in the favelas of Rio de Janeiro. The research demonstrated that the abilities and skills of people living in poverty should be recognised and used , and they should be understood as creative innovators in leading bottom-up social development. This research builds on Professor Jovchelovitch’s work on the social psychology of public spheres, community participation, social representations, and individual and social change.

The LSE research team pioneered an inter-institutional and international research partnership bringing together universities and the United Nations Educational, Scientific and Cultural Organization (UNESCO) with the charitable foundations of the Brazilian Itaú Bank and two local favela NGOs, AfroReggae and Central Unica das Favelas (CUFA) . The favela NGOs were active contributors, holding a dual role as partners in the research and research participants.

The work provided new evidence about the institutional frameworks that shape individual and community development in the favelas. It elucidated the role of the drug trade as provider, legislator, and organiser of everyday life, offering a parallel system of behavioural codes, as well as a “professional career” for favela youth. It also showed that favela NGOs act as “parents by proxy”, competing directly with drug gangs to provide role models and opportunities for young people.

The research showed that the unique characteristics of a new type of favela-born NGO (of which AfroReggae and CUFA are examples) are vital to social development, helping to make cities resilient and sustainable. These organisations operate at multiple levels and hold multiple identities – as social movements, entrepreneurs, artists, activists, and social workers. Their members are local people who share other residents’ experiences of growing up and living in a favela community.

In contrast to “mainstream” aid programmes, bottom-up organisations do not come from outside and do not withdraw once their objectives have been fulfilled. They take a three-pronged strategy involving: i) a combined focus on the individual and community; ii) use of the arts to reinvent social representations of themselves and their future; and iii) action on internal city borders through innovative partnerships with business, government, and international organisations. Favela NGOs act as a “stand-in” for myriad institutions including the state and even the private sector. They support the development of skills, organise employment, and promote a new set of positive representations of the favelas, of favela-dwellers, and of the city. LSE researchers defined these provisions as “psychosocial scaffoldings” – actions and structures supporting human development at individual and social levels, which become key sources of resilience.

This has important implications both for the theoretical understanding of the sociological foundations of human development, and for the development of social policy. The research evidence strongly supports the inclusion of bottom-up local NGOs as partners in designing and implementing public policy. From this research LSE, UNESCO, and the favela organisations produced a toolkit of concepts and methods for implementing bottom-up social development.

What happened?

This novel research partnership supported sustained interactions between favela residents, NGO leaders, academic, governmental, and international organisations. Its findings highlighted the contribution of community-level actors to making cities safe and inclusive, and provided new tools to help realise this goal.

UNESCO was a key partner and the research has influenced its work – and many of its partners in turn. UNESCO has used the toolkit, which was published in Spanish , Portuguese, and English, to incorporate bottom-up models of social development and the knowledge of disenfranchised citizens into its activities. This has included interventions with national governments and participation in UN meetings particularly in Latin America but also, increasingly, the Middle East.

The work has also helped to promote a new, shared understanding within Brazil of the value of incorporating citizens’ knowledge into policymaking. It catalysed the Brazilian government to initiate joint platforms to better include favela citizens and grassroots organisations in policy formulation and debate. In 2015, Brazil’s Department for Social Development and Fight Against Hunger worked with UNESCO, the Brazilian Mission at the UN, and favela organisation CUFA on a new policy on urban poverty and development. This was launched at the Economic and Social Council Chamber of the UN in New York. Here CUFA was representing previously marginalised voices in high-level policy discussions.

The research itself has also directly supported capacity-building among community organisations in Brazil. Grassroots NGOs’ participation provided new opportunities for these groups to meet and speak to policymakers, urban planners, governments, and other NGOs in the global South (and, indeed, the global North, with CUFA subsequently establishing offices in New York and Madrid). As CUFA’s CEO, Celso Athayde , explained:

"From the moment we have a partnership of this kind … we are seen in a different way. We start to have more power, more space to speak, and to be heard in a different way."

The tools, opportunities, and vocabulary provided by the research were used by Athayde to set up a new organisation, Favela Holding, which has pulled together 25 companies to support the development of favelas and their residents; its operations now employ some 2,000 people, many of them favela-dwellers.

Favela residents who participated in the research also reported significantly improved understanding and a more positive image of themselves and their neighbourhoods. In a workshop , 98 per cent of participants considered the work to have been useful to them and 91 per cent expected to be able to use the knowledge gained from the research. According to Athayde, this has helped favela inhabitants demand more from those who should support them:

"These contributions to increased capacity and enhanced self-esteem among research participants make an important wider contribution to the inclusivity, resilience, safety, and sustainability of the communities in which they live and work."

Impact case study

Supporting bottom-up development in cities in the developing world.

We had a rich programme of collaboration and exchanges with LSE, which had real consequences for us … The research facilitated the inclusion of these peripheral actors from the favelas of our large cities in the programme of actions of the Ministry. Together we moved forward in understanding that voices and everyday life expertise are absolutely needed for inclusive social development. Brazil’s former Secretary of State for Social Development (transcribed and translated)

Research by

Professor Sandra Jovchelovitch

Department of psychological and behavioural science.

LSE research in Brazil’s favelas has demonstrated the importance of community-level actors to reduce urban social exclusion.

What was the problem?

What did we do?

What happened?

"From the moment we have a partnership of this kind … we are seen in a different way. We start to have more power, more space to speak, and to be heard in a different way."

"These contributions to increased capacity and enhanced self-esteem among research participants make an important wider contribution to the inclusivity, resilience, safety, and sustainability of the communities in which they live and work."

Bottom Up Development in Mumbai

Toilet blocks that were provided by the city government charged individual prices for each use, which made them too expensive for families. The city toilets were badly designed, without running water, and government employees failed to clean them.

SPARC is an Indian NGO that works with communities in Mumbai to build new toilet blocks, connected to city sewers and water supplies. The local community helps to construct the toilet black and families from the community can then purchase monthly permits to use it for a very cheap price- about 25p.
Once they have a permit, they can use the toilet block as many times as they want during the month.
The SPARC toilet blocks have electric lights, making them safer to use at night, and separate toilets for children.

In the past 5 years, SPARC has provided 800 community toilet blocks, each containing 8 toilets.

Advantages and Disadvantages

This project has responded directly to community needs and has involved the community in providing solutions, however, it can take time to gain permits.

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BMC Public Health

Bottom-up innovation for health management capacity development: a qualitative case study in a South African health district

Marsha orgill.

1 Health Policy and Systems Division, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa

Bruno Marchal

2 Institute of Tropical Medicine Antwerp, Antwerpen, Belgium

Maylene Shung-King

Lwazikazi sikuza.

3 Independent, Cape Town, South Africa

Lucy Gilson

4 London School of Hygiene and Tropical Medicine, London, UK

Associated Data

The datasets generated and/or analysed during the current study are not publicly available as we did not receive consent from participants to share the full transcripts.

As part of health system strengthening in South Africa (2012–2017) a new district health manager, taking a bottom-up approach, developed a suite of innovations to improve the processes of monthly district management team meetings, and the practices of managers and NGO partners attending them. Understanding capacity as a property of the health system rather than only of individuals, the research explored the mechanisms triggered in context to produce outputs, including the initial sensemaking by the district manager, the subsequent sensegiving and sensemaking in the team and how these homegrown innovations interacted with existing social processes and norms within the system.

We conducted a realist evaluation, adopting the case study design, over a two-year period (2013–2015) in the district of focus. The initial programme theory was developed from 10 senior manager interviews and a literature review. To understand the processes and mechanisms triggered in the local context and identify outputs, we conducted 15 interviews with managers in the management team and seven with non-state actors. These were supplemented by researcher notes based on time spent in the district. Thematic analysis was conducted using the Context-Mechanism-Outcome configuration alongside theoretical constructs.

The new district manager drew on systems thinking, tacit and experiential knowledge to design bottom-up innovations. Capacity was triggered through micro-practices of sensemaking and sensegiving which included using sticks (positional authority, enforcement of policies, over-coding), intentionally providing justifications for change and setting the scene (a new agenda, distributed leadership). These micro-practices in themselves, and by managers engaging with them, triggered a generative process of buy-in and motivation which influenced managers and partners to participate in new practices within a routine meeting.

District managers are well placed to design local capacity development innovations and must draw on systems thinking, tacit and experiential knowledge to enable relevant ‘bottom-up’ capacity development in district health systems. By drawing on soft skills and the policy resources (hardware) of the system they can influence motivation and buy-in to improve management practices. From a systems perspective, we argue that capacity development can be conceived of as part of the daily activity of managing within routine spaces.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10546-w.

Decentralisation debates have a long history in the health sector in low- and middle-income countries (LMICs) [ 1 ]. The rationales for decentralising decision-making authority include better coordination of disparate activities, improved use of local knowledge, and strengthening accountability - with the intention to improve the equity, responsiveness, efficiency and quality of health services [ 2 – 4 ]. Over time, the district health system (DHS) has become understood as an important decentralised foundation for a well-functioning and primary health care (PHC)-oriented system [ 5 , 6 ]. The DHS “ consists of a large variety of interrelated elements that contribute to health in homes, schools, workplaces, and communities, through the health and other related sectors … . Its component elements need to be well coordinated by an officer assigned to this function in order to draw together all these elements and institutions into a fully comprehensive range of promotive, preventive, curative and rehabilitative health activities. ” [ 7 ].

Many agree that the management and leadership capacity of the lead ‘officer’ (and her/his team) to steward the DHS is a key cross-functional ingredient for strong health systems functioning [ 7 – 20 ]. District managers (DMs) and their district management teams (DMTs) are the middle managers who “ work at the boundaries between senior management and the rest of the workforce ” [ 21 ]. They must conduct both ‘sensemaking’ around top-down policies and the changing environment, as well as ‘sensegiving’ to a variety of actors in the district in order to direct change [ 22 ]. They are responsible for improving and sustaining organizational performance over time, ‘managing’ the internal activities of the organization and ‘leading’ the staff and external partners in the face of increasingly complex conditions [ 23 ]. From a bottom-up perspective, they often shape policy [ 24 ].

However, across settings, capacity to manage the DHS is often found to be weak and in need of strengthening [ 8 , 16 , 25 – 28 ]. The attention paid to strengthening such capacity has resulted in the development of many managerial competency frameworks [ 29 – 32 ] and the delineation of the 12 practices of managers, grouped as (1) leading, (2) managing and (3) governing [ 13 ]. Over time, as the DHS has come to be recognised as a complex adaptive system (CAS) [ 33 – 35 ], understanding of the competencies and capabilities that district managers need has further evolved [ 10 , 36 – 39 ]. Capacity development efforts have moved beyond the traditional focus on administrative management and health professional practice training. Instead, they have come to consider the leadership skills needed to manage complex systems and intersections with the organisational environment, including both harder (budgeting, planning, monitoring etc.) and softer competencies (communication, trust building, networking etc.) [ 19 , 20 , 36 , 37 , 40 – 44 ]. The recognition of the health system as a CAS also demands different ways of managing and measuring capacity development interventions. A systems perspective looks beyond the black box of the intervention, to consider the how and why of capacity development, understanding it as a process of system learning [ 40 , 45 ]. Baser and Morgan [ 46 ], for example, bring a CAS perspective to capacity, moving beyond linear understandings. They define capacity development as an “ emergent combination of individual competencies, collective capabilities, assets and relationships that enables a human system to create value ”.

There are several calls for further research on management and leadership capacity in the DHS. These identify as important: the role and capacity of middle managers in bridging policy and practice; how management practices become part of organisational routines; how capacity development interventions ‘work’ for managers in diverse settings; better knowledge on complex leadership and strategic management of the health workforce; and operational research on how to develop capacity in decentralised systems [ 8 , 16 , 20 , 37 , 47 – 49 ].

This paper presents insights from a realist evaluation in one South African district that illuminates how district managers design bottom-up innovations to improve management practices in meetings through simple but profound acts of sensemaking and sensegiving. It provides lessons that can inform thinking on the approaches needed to develop DHS management capacity. Bottom-up policy implementation theory tells us that managers make meaning of top-down reforms based on the conditions in which they work and that they use their own experience, discretion and tacit knowledge to transform policy into practice [ 11 , 50 – 52 ]. Making meaning of and interpreting top-down instructions is an act of sensemaking [ 22 , 53 ]. Sensemaking has to do with the way managers understand, interpret and create sense for themselves based on the information surrounding strategic change [ 53 ].

The local setting: DHS in South Africa

Pre-1994, the health system of South Africa was fragmented along racial and geographic lines. During the apartheid era, deliberate differences in the allocation of funding, infrastructure and human resources between areas and levels of care resulted in inequitable access to health care by the population – and interprovincial and urban-rural inequalities persist today [ 54 ]. In 1994, the new African National Congress government faced the massive task of reducing fragmentation – eventually consolidating the health system into one National Department of Health and nine Provincial departments of Health [ 54 ]. A new Health Plan for post-apartheid South Africa (1994) laid the basis for the introduction of a district-based PHC system in South Africa [ 55 ]. The primary purpose of the new DHS was to involve local people in decision making, to take account of local needs, to overcome inefficiencies in service delivery and to shift from “ administering health services towards improving health and quality of care at the local level” [ 56 ]. South Africa now has 53 health districts spread across its provinces, each led by a district manager who is supported by a district management team [ 56 ], comprised of members with different capacities and authorities [ 15 ]. Table 1 shows the responsibilities of district management teams in South Africa.

District Management Team core responsibilities in South Africa

Source: [ 57 ]

The DHS in South Africa has achieved successes over the years, but there is still need for improvement in developing the capacity of DMTs to distribute and manage resources [ 15 , 58 , 59 ]. In 2012, the National Department of Health introduced a range of innovations under the banner of ‘National Health Insurance (NHI) piloting’. These innovations focused on strengthening the public health system in preparation for major health financing reforms [ 60 , 61 ]. Eleven NHI district pilot sites were selected in 2011 on the basis of their underperformance in health outcomes relative to other districts in the country [ 62 ]. The innovations proposed/introduced centred on re-engineering the PHC platform and included a call to strengthen the capacity of management in the DHS at all levels [ 63 ]. Among the many top-down capacity development initiatives introduced was a hospital revitalisation strategy focused on Hospital CEO capacity. In addition, as identified in our previous research, some district managers used their discretion to develop bottom-up innovations to strengthen management [ 24 , 61 , 64 ].

Bottom-up innovation

We followed the emergence of such bottom-up innovation for 2 years in two districts to understand the ‘how’ and ‘why’ of capacity from a systems perspective. We present results from one district in this paper. Realist evaluation starts from a programme theory (see Methods). Here, we briefly introduce the key elements of the programme theory, expanding on it in the methods section.

In a district with some of the worst comparative health outcomes in the country which was piloting reforms linked to national health insurance (NHI), a new DM sought to institutionalise functional systems, explicitly focusing capacity development efforts toward improving practices within the routine extended district management monthly meetings. This is a core meeting space for oversight and planning in the district which includes senior managers and invited partners.

The suite of inter-linked innovation

The DM worked with a combination of existing resources to address challenges within the management team meeting. He designed a suite of bottom-up innovations, understood as “… the introduction of new elements into a public service – in the form of new knowledge, a new organisation, and/or new management or processual skills. It represents discontinuity with the past. ” [ 65 ]. These innovations included: introducing a new meeting agenda that focused on all the health system building blocks; developing job descriptions for former hospital chief executive officers (CEOs) who were sent to work in the district office ‘without a portfolio’; inviting non-governmental organisation (NGO) partners to the meeting to foster shared vision and accountability; enforcement of the Health Management and Information Systems (HMIS) policy to promote information use by managers; and efforts to focus on solutions in meetings not only problems.

We conducted a realist evaluation over a two-year period (2013–2015) in one health district. This study followed the realist evaluation cycle (Fig. 1 ).

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Object name is 12889_2021_10546_Fig1_HTML.jpg

The realist evaluation cycle [ 66 ]

To contribute to an evolving understanding of how to develop management capacity in district health systems.

Research question

What mechanisms for change are triggered when bottom-up innovations to develop management capacity emerge in the district context and how do these homegrown innovations interact with the existing social processes and norms? What outputs and outcomes emerge?

Eliciting the programme theory (PT)

To elicit the PT, we drew on (1) theories of bottom-up innovation and capacity development and (2) exploratory research to elicit the assumptions of key actors who designed the bottom-up innovations in the local context. The full programme theory is presented in Additional file 1 .

We have articulated the first part of the programme theory in the background section of the paper, considering theory on bottom-up implementation and a description of the innovation. Here we further elaborate the mechanisms, outputs and outcomes of this programme theory.

Hypothesized mechanisms

In times of change, managers, like the new DM, need to challenge the existing ways of working that drive individual and collective action [ 67 ]. Managers first engage in sensemaking but must also sensegive to their staff to get them to buy into and enact the innovations in practice, a step that forms part of and precedes an innovation adoption decision. Sensemaking and sensegiving are “ complementary and reciprocal processes ” [ 53 ]. “ Sensegiving is concerned with their [managers’] attempts to influence the outcomes, to communicate their thoughts about the change to others, and to gain their support ” [ 53 ]. Innovation recipients also work through a series of their own sensemaking cycles before the adoption decision [ 68 ]. It is this cog in the wheel of change we seek to explore - the cycles of sensemaking that precede the adoption decision. Rouleau and Balagon [ 69 ] identify two strategic discursive competencies of managers. First, ‘performing the conversation’, which includes crafting and diffusing messages in order to influence others, using the right words, the appropriate metaphors and symbols – in ways that speak to the demands and interests of others. Second, ‘setting the scene’, which is about bringing the right people and alliances together; this includes mobilising networks as well as drawing on others for influence and legitimacy, “…. knowing how to set up the arena in which the conversations are to be performed”. Table 2 outlines the micro-practices entailed by these competencies that are “ embedded in tacit knowledge and social contexts ” [ 53 ]. These include the notions of carrots, sticks and sermons that are borrowed from political science theory, where they are used to categorise policy instruments for behavioural change [ 70 ]. Action, participating in the activity, is another key ingredient for sensemaking [ 67 ].

Four micro practices of strategic sensemaking and sensegiving

Source: [ 53 , 70 ]

We hypothesize that the reciprocal processes of sensemaking and sensegiving will kick-start a generative process of buy-in for new management practices by members of the extended district management team, including senior managers in the district and some NGO partners.

Proximal outputs

The ouputs envisioned by the new DM included a well-structured meeting with an agenda that focused on core business; improved use of information by managers for decision making; sharing of solutions by managers; NGO services aligned to the district health plan; and a correct skills mix in the DMT. We only assess outputs in this study. These proximal outputs serve as improvements on the journey to full capacity.

The new DM wanted to develop the capacity of the management team by improving the practices and processes of the managers in the monthly DMT meeting. We see capacity development as a continuous process, not a time-bound, discrete intervention. Capacity development is “ the process of enhancing, improving and unleashing capacity; it is a form of change which focuses on improvements ” (Baser and Morgan, 2008, pg. 3). Capacity as the long term outcome in the programme theory is understood as an “ emergent combination of individual competencies, collective capabilities, assets and relationships that enables a human system to create value ” [ 46 ].

While we do not measure long-term outcomes, the Baser and Morgan [ 46 ] view on capacity enables us to think about capacity as a phenomena that emerges over time, and that includes a set of interdependent collective capabilities (Table 3 ) that are needed within complex systems. We anticipate that capacity will emerge over time in the district as a result of the suite of inter-connected innovations.

Five interdependent collective capabilities that emerge and work together to harness capacity in a system

Directly from source: [ 71 ]

Study design

We employed a realist evaluation (RE) approach, which is method neutral and allows study designs to be chosen based on their capacity to test the initial programme theory. RE not only assesses outcomes, but explicitly seeks to understand the processes involved in achieving the observed outputs and outcomes [ 12 , 72 , 73 ]. It is the combination of intervention inputs together with mechanisms triggered in context that brings about change. Mechanisms are “ not variable [s] but an account of the behaviour and interrelationships of the processes that are responsible for the change ” [ 72 ]. Programmes ‘don’t work’, it is people that make them work [ 72 ]. Mechanisms are a combination of resources and reasoning, “ intervention resources are introduced into a context, in a way that enhances a change in reasoning ” [ 74 ]. Resources (material, emotional, social, encouragement, etc.) and reasoning alter the behaviour of participants in specific contexts, which then leads to outcomes. As the study design, we adopted the case study design [ 75 ] as it allows to study a phenomenon in context as it is being shaped and re-shaped.

This study was approved by the University of Cape Town Human Research Ethics Committee (479/2011 and sub study 746/2015).

Definition of the case and of the unit of analysis

We adopted a single case study design to “ determine whether the propositions [in our programme theory] are correct or whether some alternative set of explanations might be more relevant ” [ 75 ]. The context is the district and the case is defined as ‘the introduction of bottom-up capacity development innovations targeted at the district management team’ to improve processes for managing the district.

Site selection

We purposively selected a health district to which we had access given the larger project in which this work was nested, 1 and which had a district management team in place. The new DM was willing to grant us access to himself and his staff and had clear ideas on what he was planning to do to strengthen management.

Data collection

The first author collected data within the period 2013–2015, monitoring reforms in the district pilot site, keeping researcher notes and capturing key reflections on the district’s context. The process of eliciting the initial programme theory from managers in 2013 contributed to a rich understanding of the context (the interview guide is shown as Additional file 2 ). We drafted the PT and then member-checked it with the new DM in an additional in-depth interview. To test the PT and to understand the processes and mechanisms underlying the introduction and adoption of the innovations, the first author conducted in-depth interviews with 15 senior managers in the district (all of whom were part of the extended DMT) and 7 major non-state actors (some of whom participated in the extended DMT meetings). The same interview guide was used in the second round of interviews, which focused solely on the bottom-up innovations that had been identified. Based on what we had learned, we developed an additional interview guide for NGO partners (see Additional file 3 ). Researcher notes on context were used to further interpret findings.

Data analysis

In realist evaluation, the context-mechanism-outcome (CMO) configuration is used as the main structure for analysis [ 72 , 74 ]. The transcripts were coded using principles of thematic analysis. Deductive codes included actors, mechanisms (both resources and reasoning, including the micro practices of sensemaking and sensegiving), contexts, processes and emergent outputs and outcomes, as well as elements of the innovation itself [ 76 ]. “ People who study sensemaking pay a lot of attention to talk, discourse, and conversation because that is how a great deal of social contact is mediated ” [ 67 ]. The process also included looking inductively for any new ideas that emerged in the data.

In the analysis, we moved back and forth between the empirical data and key theoretical concepts. We deepened the analysis by searching for patterns and conjecturing various CMO configurations, moving between the micro-practices within the meeting space and the interaction with the context. Finally, plausible CMO configurations were tested by triangulating a variety of sources of data including researcher notes and observations, and by validation with co-researchers within the project. Interim findings in this paper were presented to some of the senior managers as part of the larger project feedback session in 2016, and the final conclusions of this paper were presented in 2019 to the District Manager who had led the innovation to member-check the analysis.

Synthesis and comparison of CMO findings with the programme theory

At the end of the analysis phase, we reflected on our findings against the original PT, considering the data, the theoretical literature and the original PT. In this process, we engaged in peer debriefing across the three authors to discuss what we had found beyond the original assumptions captured in the PT.

Results section

In this section, we describe the general context of the district, the innovations to strengthen management practices, key outputs achieved in the 18-month period November 2013 to April 2015 and finally, we consider the mechanisms triggered in context that generated outputs. The results are summarised in table format in Additional file 4 .

Context and actors

The health district both under-performed relative to the rest of the country in terms of health outcomes and suffered from human and infrastructural under-resourcing as a result of apartheid legacies [ 77 ]. The district is considered rural: it is hard to attract staff to work in it and at times there are poor working relationships between the district and the Provincial government.

In November 2013 a new DM with 29 years’ experience in the South African health system (public and private sector) arrived to lead the district. The new DM worked with a core district management team (DMT) who met every Monday morning. There was also an extended DMT (including the core managers as well as hospital, programme, sub-district managers and other invited guests; in total 24 managers at that time) who met once a month to report, plan and prioritise for the district. There were critical vacancies in the DMT, and three hospital CEOs who had to leave their hospital posts 2 were sent to work within the district office with no specific portfolio. The DM reflected that stability was needed. Being an NHI pilot district expected to implement several new service delivery reforms made the challenges more complex:

“I think the preparation for NHI relies heavily on innovation and in order to innovate properly, you need a stable system. This is an extremely unstable system, so you have got to innovate and stabilise at the same time, which I think adds a lot to the complexity of what we do ( The new DM, 09/09/2014).

The extended monthly DMT meeting needed to change, as it was a space mainly used for complaining. The use of information by hospital and sub-district managers for problem diagnosis, decision making, and accountability needed to be improved:

“I think that there were lots of meetings, or there are lots of meetings that happen, but not lots of structured meetings. Not lots of minutes and not lots of agendas, so you cannot go to a meeting and you sit there the whole day and you don’t have something tangible to show …. We get a lot of whining sessions, but they actually don’t help at all …. That is more the approach than to listen, because you can spend ninety percent of your time listening to or whining, and then only ten percent looking at solutions, whereas we would like to reverse that … It is about looking at the indicators and asking: “Why we are doing well or why we are doing badly? … It has worked before and it is kind of standard practice in functional systems. I am sure it will work” (The new DM, 19/02/2014).

The information manager (IM) was carrying the burden of information preparation and presentation for the meeting. She had a sense that managers were afraid of working with numbers and this resulted in a general culture of avoidance and deferring queries back to her:

“… because even things that they can do themselves, they will also say: “No give it to [the] information person.” … They would make it a big deal when it comes to compilation of other reports. Anything that is computer-related, they associate it with anything that relates to numbers. They will just give it to someone to add it in … they don’t want to use numbers” (Manager 1, 09/09/2013).

The IM already had a huge workload, including managing all the aggregate information, quality-checking data and being responsive to information requests in the district. Additional data capturers had been sent to the district as it was an NHI pilot site, but they did not have the skills to do the work required. In the past, reports had sometimes been generated but the problems managers raised in them were at times not acted upon reducing motivation to produce new reports.

There were also many NGO partners operating in the district, but it was not clear whether they were well aligned with the service delivery priorities in the district health plan (DHP). The new DM felt there was neither a shared vision with all partners, nor an established decision-making platform where decisions could be taken consultatively with stakeholders.

The suite of inter-linked innovations to develop management capacity

The suite of inter-linked innovations introduced in the extended DMT monthly management meetings to improve capacity were:

(1a) The introduction of a new agenda that focused on the core functions of the district (‘services’, ‘corporate governance’ and ‘quality’, with time allocated for each item), and the introduction of a routine procedure to support decision making - whereby managers had to produce reports, covering core indicators for reading, which were distributed before the meeting. Additional file 5 presents an overview of key agenda items.
(1b) An explicit effort to institutionalise the engagement with and application of information by all managers, backed up by the DM’s purposeful enforcement of the national District Health Management and Information Systems (DHMIS) policy. Linked to this, the DM also established the routine procedure that managers must first investigate problems by collecting information on the ground before bringing them to the monthly meeting, and be ready to discuss solutions and progress (or lack thereof).
(1c) The routine procedure that NGO partners in the district would attend the extended district management meeting in order to support coordination and accountability, as well as discuss their activities directly with the DM.
(1d) Defining job descriptions for the ex-hospital CEOs newly posted to the district office describing their purpose in the team; as well as attempts to fill critical management vacancies in the team.

By 2015, 18 months after the new DM’s appointment, senior managers and district partners who attended the monthly meetings confirmed that the innovations had resulted in an emerging set of improved management practices.

A new extended DMT agenda with a structured format was being routinely applied, managers had to present on core system issues and meetings were being time-managed.

"Yes, we present but we are being given a chance, we are being informed earlier on that you are expected to present in such-and-such a DMT because of the time schedule and there are a lot of them here. So, it doesn’t become possible for us all to report. For instance, there’s a lot of, the NHLS, there’s pharmaceutical, there’s the information officer who gives a summary report for the activities that happened in the districts. Then we input or respond; when you haven’t done well, you indicate what causes the deviations from targets and how are you going to improve on those things. And if we don’t present the actual status ourselves, it appears". (Manager 7, 02/10/ 2015).

Already by the end of 2014, at least 15 managers were preparing and submitting reports to the DM, who then decided both what would be discussed in the meeting and which reports would be circulated in preparation.

“so what we are trying to do now is have a structured agenda, not a reactive agenda, a structured agenda where you have reports that you prepare and then the line management people that attend have to interact with those reports ” (The new DM, 19/02/2014).

The hospital managers and sub-district managers as line managers were expected to read the reports to empower themselves. Nonetheless, getting managers to engage with information in the reports was not easy. The DM identified two challenges: he was not fully satisfied with the make-up of the reports and not all managers had read the reports as needed before coming to meetings;

“ because progressively we are going to start making decisions based on that and if they don’t read those reports … …. we are now at the point where we are kind of saying read your emails, read your reports etcetera ” (The new DM, 19/09/2014)

The application of information for decision making was now part of managers’ performance contracts as per the Health Management and Information Systems (HMIS) Policy. There was an improved use of information to diagnose problems, monitor progress and support forward planning in the extended DMT meetings by sub-district managers. The IM and another manager in the DMT confirmed that, in 2015, service delivery information was being presented and discussed in the meeting and that managers had to account for targets. This process remained in place after our final evaluation period.

“ We continued with what [the new DM] has started. We look into the indicators and the performance of the district, the subdistrict and the hospital CEOs, they do make some presentations so that we are able to identify gaps and formalise some strategies to work around the gaps - we’re still continuing. ” (Manager 6, 17/05/ 2015).

While problems were still brought to meetings, there was a proactive effort to identify solutions in the meeting:

"So now, at least people, even though not everybody, but some are able to say, okay, we have got a challenge of transport – how about if management could talk with [the] municipality so that we can join vehicles together when they are going to ward A, maybe we got to ward A, all of them. Starting from that integrated planning there." (Manager 8, 24/03/2015) .

"I have to get assistance from the people who are actually doing the immunisations, what was the problem? Were there vaccines that were not available, for instance; or was there something that made them not be able to come to the facility?" (Manager 7, 02/10/2015).

Improved capability to relate and partner with othersStaff of the large NGOs in the district met with the new DM personally to report on their district activities, and subsequently, a growing number of NGOs were reported to attend extended DMT meetings to present and discuss their progress. However, we primarily observed interactions with representatives of two large NGOs that had been present in the district for more than 5 years, had their own funding and were actively implementing health programmes and/or were directly engaged with senior management in the district toward health system strengthening. These NGOs also participated in developing the DHP to ensure shared planning and vision.

“ Yes, I was part of that stakeholders [mapping] meeting and we all [NGO partners] presented the work that we are doing, the challenges and the successes that we have had. And on a monthly basis we used to give him our progress reports in the DMT meetings ” (NGO partner 1, 18/05/2015).

" …. they [NGOs] are actually invited to make inputs [into the DHP] and also to look at the priorities of the district when they are going to be doing that. So their plans must actually be part of what the district plan is " (Manager 4, 1/10/2015).

" Ja [yes], I think mainly it’s [NGO partner 1 & 2] who are attending those district management meetings, though it’s continuously growing in terms of who is attending those meetings. " (Manager 4, 1/10/2015).

An NGO partner who had been part of the DMT meetings before 2013 (when the new DM arrived) noted that as partners had to present on their activities when attending the meetings, accountability amongst NGOs improved (NGO partner 2a, 2/10/2015).

The new DM filled at least two key senior management posts that had been critical vacancies: an HIV/AIDS, STI and TB (HAST) manager and a quality assurance manager. Also, the hospital CEOs who had been redirected to the district office were given clear job roles 3 linked to their competencies and the needs of the DMT.

Mechanisms for change

Initial sensemaking by the dm.

The arrival and initial sensemaking by the DM were both a trigger and a mechanism in improving management practices in the DMT meeting.

“Look, when I first got here, we went through quite a long process of saying: “What is the ideal organogram that is needed at district level? What are the ideal processes needed at district level to ensure that we are able to have a strong management team that can take us into the NHI?” Therefore, I think it does depend a lot on what people we’ve got. I think there needs to be a standardisation of processes, because the way I am doing things, it is pretty similar to the way they do it in the [previous Province he worked in], but chatting to my colleagues from other provinces, it is not the same and I think there needs to be a standardisation of the management processes. There should be some space in between for us to express our individuality and so on, but essentially there needs to be an improvement in the standardisation” (The new DM, 09/09/2013).

The new DM drew on his personal resources, including tacit knowledge and experience in the public and private health system in another province to design the suite of inter-connected innovations. He did not believe that more resources would by themselves improve district performance and instead judged that inefficiencies in the public sector could be dealt with through system improvements. The new DM explained where the idea for the structured agenda came from:

“My little thing to keep me focused, there is a thing called the district management accountability framework, which over the …. five years, … that I was a manager in [Province X], we progressively developed a series of things that need to be in place for a health system to be functional. So, we documented you know, the governance, management, leadership … as I was saying, those things are the pillars of … what is it … [the] WHO building blocks, but having lived through the … development of it, I understand it in a particular way. It is ... management, governance, leadership, it is service delivery, it is critical support functions, and it is quality. Now … and below that, I can see the headings … and that is the agenda for the DMT (The new DM, 09/09/2013).

“So, I think the vision comes from … a lot of the vision comes from what I have seen in reality in [Province X]. A lot of the vision [also] comes from what I have seen in reality in the private sector” (The new DM, 9/09/2014).

Introducing a new agenda in the extended DMT meeting: sensemaking and sensegiving as reciprocal processes

The DM ‘disciplined’ the DMT meeting space as part of sensegiving to others – as shown in Table Table2, 2 , “ discipline comes from a meticulous organisation of gestures, words and objects that permits optimal use of space, bodies, and thought ” [ 53 ]. He employed tacit and experiential knowledge of meetings and agendas to structure proceedings in the space, the information managers summarised the comparative data and time was allocated for managers to speak to their performance, reinforcing accountability.

The DM translated and framed the need for a new agenda by drawing on familiar organisational-cultural codes of the health system, including discourses such as ‘core business of health’, ‘patient care related’, ‘indicators’ and ‘PHC’ and ‘performance’ – which can be seen as the careful crafting of ‘normative sermons’.

" You know, when he came, there was much more focus around the core business in meetings, than to simply discuss how much money we have spent around HR, around that, and so on. Remember, we are having this business of being the Department of Health, so everything must be patient care-related. Now once you talk the performance indicators, you talk PHC, hospital indicators, that’s fundamental – because we can say our department is existing not because of various other things but because of the performance. I would say in relation to that I'm still very much pleased " (Manager 2, 25/03/2015).

"Maybe one will be saying because I was really always close to this office and having that advantage of knowing why there is this initiative, why we should change – I would say starting from you say the nature of our agenda items in the DMT.” (Manager 2, 25/03/2015).

The DM over-coded, drawing on familiar organisational socio-cultural codes as a ‘stick’, noting that the ‘auditor general’ (a powerful figure in the bureaucracy) can check up on the use of information and the focus on performance in meetings by looking at the agenda, effectively using hardware of the system as a stick linked to accountability.

"T he DMT meetings might have been held every month, but if in the minutes and the agenda, there’s no … .. agenda items around the information or data management, then you cannot say you are discussing your performance – because it’s not showing in the agenda and minutes. So, that’s what [the new DM] emphasised all the time. " (Manager 1, 09/09/2013).

The new approach to meetings encouraged active participation by senior managers, whilst simultaneously facilitating their buy-in to the new practices through the process of ‘doing’. Managers appreciated that they were no longer tired in meetings because of long drawn-out processes. Increased participation provided more ingredients for sensemaking and sensegiving, which triggered the motivation and self-efficacy of managers.

"Yes, because before the subdistrict managers were presenting, the CEOs were presenting – so when the last one is presenting, you are no more listening. It’s already four o’clock, so you are tired. So the way he did it – it’s for the information manager to present comparing the subdistricts, not for subdistricts, for [sub-district A] to present, then one for sub-district B to present, because at the end, you won’t be able to see how do they work comparing them, and where to give assistance. The way he did it is for the information manager to present and show us which subdistricts doesn’t perform well in what. That has really helped us. Like they are also doing it today in preparation of the DMT on Thursday." (Manager 8, 24/03/2015) .

These actions were complemented by the preparation and pre-reading of reports, which reinforced the use of information and, together with the requirement to present problems with potential solutions, fed into a more structured agenda.

Embedding the use of information for problem diagnosis and problem solving: sensegiving and sensemaking as a social process

The DM used his positional authority and employed over-coding, drawing on the professional codes of the bureaucracy [public policy], to create shared meaning around information use for decision making. The National Health Management and Information Systems policy (policy hardware) also served as a ‘stick’. The new DM enforced it to justify why managers must use information and monitor performance in their daily practice. Information use also formed part of their performance contracts as per the policy. He matched this with a sermon approach, taking the time to visit managers at facilities, together with the Information Manager (IM). The latter had institutional memory given her working history in the district and was familiar with policies and staff; she also reinforced that they ‘must’ comply with government policy.

" They [the managers] were fine because we were also emphasising to them that it’s not any person’s choice, because it’s a policy issue which, though we were trained on it, but in terms of implementation, you were not implementing it as expected. But now, that [was coming from] from the district manager" when [the new DM] went around.” (Manager 1, 09/09/2013)

Including the IM in his visits was symbolic in ‘setting the scene’ as the IM legitimated discussions, was always highly motivated for change (despite not having had the authority to enforce improved information practices) and knew the content of the HMIS in detail. To improve information use and accountability in the DMT meeting, the new DM drew on his positional authority and introduced a requirement that the sub-district manager ‘sign-off’ data from the facilities before sending it to the district office.

“They [sub-district managers] are more responsive, especially when it comes to the variances that we are showing them, because they are the only people that should tell us the reason as to why it is like this.” (Manager 1, 09/09/2013).

The planning manager, identified as exceptional by the DM, was tasked with reviewing all the data from facilities to identify any obvious discrepancies. The DM then employed ‘sticks’ to reinforce the importance of data by writing letters to each facility manager or sub-district manager, saying either 1) your data was late, 2) your data was not complete, 3) your data is not believable in the following areas (…).

However, the information management changes had not yet impacted at the facility level, the planning manager has picked up similar challenges again:

“ So, she is now … she has given me the second month’s letter, and it is almost identical to the first month’s letter. ” (The new DM, 19/09/2014).

Sensemaking and sensegiving for information use was also reinforced by the working environment. Some managers had been permanently appointed to their positions during the tenure of the new DM. The IM felt ‘being permanent’ supported responsiveness and accountability in the meeting, as when managers are in ‘acting’ positions, it is easier for them to say they are ‘only acting’, avoiding accountability.

Since NHI piloting began, additional resources for performance monitoring were introduced by the National government and the Provincial government, including templates for monitoring and evaluation and sets of preparatory activities for meetings. All managers in the DMT had been given computers and 3G data cards. The IM was hopeful that the new technology would enable better practices by the managers. She felt she needed to be released from the dependence of managers on her for information:

“Yes, because in those pivot tables [shown on the computers], all the indicators for various programmes, they are there. So the managers even [can] now compare quarters to look at the performance of sub-district A versus [B] sub-district … to see areas that are alarming and as well as for them to be able to act up on the data that they see and it’s also assisting me as information manager, even if I am not there. (Manager 1, 09/09/2013).

However, there were still challenges to using information for decision making in the DMT, including some managers’ lack of trust in the data. The DM tried to address these reservations by using an example of a project where data had successfully been collected and verified to illustrate that it is possible to change practice and get good data.

He also used his positional authority (system hardware) to encourage managers to present proposed solutions, based on insights from the ‘ground’, in the meeting,

"Ja, people were focussing on challenges. Really their focus was specific to challenges. Like they are doing now, [they] don’t have vehicles to reach area 1, so at the end what he was saying is “when you have got a challenge, come up with a proposed solution”. It mustn’t be just a challenge being thrown because you need to think what is it that can help you to change." (Manager 8, 24/03/2015) .

However, it was not always easy to make people focus on solutions. Doctors’ accommodation was one intractable problem that seemingly had no solution:

“ So, people started getting a little bit edgy. They said “what is the point of telling this guy that we have got a problem, because he actually can’t do anything about it”, you know and it is that kind of a … situation ” (new DM, 19/09/2014)

When a problem was resolved, the team were asked to share lessons in order to generate collective learning and thus contribute to the collective capabilities of the team.

Sensegiving to NGOS: crafting and managing key relationships to attract resources and support

In 2013, the new DM used his positional authority to host a stakeholder meeting for NGOs to present to him what they were doing in the district, what progress they were making and to remind them of their role as supporters in the district. They were told they would be invited to the extended DMT monthly meetings to present on their work to ensure objectives and progress would be aligned to district goals – effectively reinforcing ‘the disciplining of the space’. His actions were supported by many managers in the DMT:

“They [NGOS] don’t have priorities; it’s the district that has priorities – they are here to support the district to achieve the set targets on those specific priorities.” (Manager 5, 1/10/2015).

“Everybody had a voice. Everybody had a voice, all the partners had a voice. We felt part of the plan, and so we were prepared or we managed to own the plan." (NGO partner 1, 18/05/2015).

"As a partner we have to compromise. ( … ) As a partner we have to be flexible all the time, because we are here to respond to the needs of the DoH. So, if you are not doing that, then the relationship between yourself and the DoH might turn a little bit sour; so you have to ensure that you’re flexible all the time." (NGO partner 1, 18/05/2015).

“ No, he was not a difficult person because he had the best interests of the department at heart ” (NGO Partner 2b, 18/06/2015).

“ We are actually more explicit to them, and said “if you don’t talk to us, then we write to your funder, saying that you are not helping us, then they can send the money somewhere else”, because everybody comes and they think the answer is training. ” (The new DM, 19/09/2014).

“ Really, it started working. He invited partners, even the partner that we didn’t like a lot, Partner XXXX. So, we felt that these are the people that normally write negatively about the department of health – then why are they here now? But the way he explained it ... because they were part of the meeting and they know what is happening, they have inputted in relation into what is supposed to be changed. … It really worked; I think it really worked, because otherwise we didn’t like the idea, but we saw that as fruitful. ” (Manager 8, 23/05/2015).

“[The planning manager] ensures that we plan with our partners; we do reviews with our partners." (Manager 6, 17/05/2015).

The DM also used familiar professional codes and discourse to encourage NGOs to understand that they had to participate in the development of the District Health Plan. This helped to create shared meaning about the importance of shared vision and accountability in the district:

" Firstly, [the new DM] told us that what he needs is a consolidated plan for the DoH and for the partners as well. As partners, we have our own operational plans that talk to the objectives and the targets that have been set up by our funders, and there are certain indicators that we need to focus on. Same applies to the DoH, because they have got some indicators that they need to focus on. So, [the new DM] said “with all your plans that you have, they need to be integrated into our master-plan so that we can have one plan that we are going to support and implement as district [X]. So we found that very valuable because with all the plans that we had, we had an opportunity to express our concerns and maybe the needs that we might have as partners for the kind of support that we are expecting from the DoH. " (NGO partner 1, 18/05/2015).

Other mechanisms in context that facilitated sensemaking and sensegiving included the ongoing work of a large NGO specifically placed in the district to provide technical support to the district as an NHI pilot site. Some donor-funded projects also intentionally and actively sought to build working relationships between themselves and members of the management team (e.g. a UNICEF project).

An NGO partner noted that strong partnerships are built on good relationships:

“ Make good relationships with people, be flexible and try and understand the other’s opinions. Don’t be a know it all - acknowledge we learn from them and then learn from us. Be yourself and present yourself as you are. ” (NGO Partner 2b, 18/06/2015).

Despite the improvements experienced, persistent ongoing challenges for partner NGOs in the district included their limited power to hold staff in the sub-districts they supported accountable, where, for example, staff showed lack of urgency.

The number and distribution of managers in the team: negotiation as sensegiving

To fill a critical vacancy (in this case a quality assurance manager) in the DMT, the DM used his positional authority and negotiated within his resource envelope rather than pushing the Provincial government for more money:

“ I have weighed up the benefit of one post above the other one, and said I am giving you [the Provincial government] the money for a quality assurance manager, … I have got a TB manager that resigned, and I said TB and HIV should actually be under the same deputy director. So, I am taking that TB money and that is quality assurance money. ” (The new DM, 19/09/2014).

This approach of prioritising among management posts was contested as some senior managers felt that posts at the same level simply could not be ranked (e.g. occupational health and safety against an HIV manager). But, using his positional authority, the new DM asked managers to rank their posts from 1 to 10 in order to create shared meaning. Using his implicit knowledge, he tried to create sense for others and diffuse meanings around the change – to influence and convince recipients to adopt change. Whilst acknowledging the reluctance of managers to do the ranking and his own discomfort in ranking posts he believed were all important, he noted that it had to be done given budget shortages.

“But you … as a leader and manager, you have to make tough decisions” (The new DM, 19/09/2014).

The DM noted some said he did not push the Province hard enough for more resources, but he drew on his knowledge resources to arrive at a decision:

“ I come from a different school of thought, but I mean to be fair, there are people that say I don’t argue enough for more resources and that is based on … I attended a course on efficiency and so on and he [the lecturer] said the worst thing that you can do for a dysfunctional system is to throw money into it … It makes it more dysfunctional. So, I have been … when Province says I am not giving you money, I say okay. ” (The new DM, 19/09/2014).

For the Hospital CEOs deployed to the DMT without portfolio, the DM considered their skill set and then wrote each 1 a role description for a portfolio of work where they could use their skills, purposefully enhancing the collective capabilities of managers within the DMT in the process. In this, he drew on a common cultural code in the workplace of having a ‘job description’ to facilitate a sense of collective purpose.

"He couldn’t get formal job descriptions because job descriptions come from the provincial office ..[but] … he looked at those who were additional to the establishment and then from there, he managed to allocate them in areas where he was seeing that there are gaps … So, from there, you will be able now to come with what you are supposed to be doing. " (Manager 8, 24/03/2015).

Did practices continue over time?

The DM who designed the innovations left the district in late 2014, but his successor as DM continued with the innovations in 2015. This new DM reflected that they drew on the courage instilled by the previous DM when applying for the leadership position, as well as recent leadership training. We asked if the changes in the use of information introduced by the previous DM was making things better:

Yes, it does because that’s what we are continuing even with …. , we continued with what [the previous DM] has started. We look into the indicators and the performance of the district, the subdistrict and the hospital CEOs, they do make some presentations so that we are able to identify gaps and formalise some strategies to work around the gaps - we’re still continuing. (Manager 6, 17/05/2015).

In 2015, the new DM also confirmed that the Planning Manager continued to ensure that planning and review processes continued with partners. Similarly, the Hospital CEOs deployed to the DMT without portfolio continued to work within clear role descriptions to ensure they functioned as an effective part of the team:

"Then I am able to allocate them to those areas. So, they’re kind of busy there, because once you don’t utilise one, he becomes demotivated and feels as if he’s worthless. But now, we are utilising them fully." (Manager 6, 17/05/2015).

Nonetheless, the new DM was not naïve about the broader contextual challenges faced in leading the district in 2015, including key leadership vacancies in the hospitals (and in the district more broadly) and challenges related to clinical governance in some hospitals:

" So, there are those kind of weaknesses that affect the progress and stability in the district " (Manager 6, 17/05/2015).

" So, another weakness is you see there’s a lot of staff turnover in the whole district, especially clinical people, professionals, the nurses. Because you will appoint a hospital manager; while you’re appointing this one, the other one says I'm resigning, I'm going. So it’s those kind of things that are threats now – I've done the weakness, the threats " (Manager 6, 17/05/2015).

More positively, the new DM mentioned that a new key NHI liaison official had been appointed at the Provincial government, which helped them stay on top of NHI processes in the district.

Amidst challenging contextual conditions and the implementation of top-down NHI piloting, this paper illustrates how a new district manager drew on systems thinking together with tacit and experiential knowledge to design bottom-up innovations to improve management capacity in monthly management meetings. The innovations, together with the agency of the DM, triggered simple but profound micro-practices of sensegiving and social sensemaking among other DMT members. In turn, these triggered a further, generative process of buy-in and motivation among managers and partners to engage in improved management practices in their monthly meeting, unleashing and harnessing capacity in this routine structure (the meeting).

The research thus highlights (1) the individual competency for systems thinking needed by those in sub-national management positions, who must develop capacity bottom-up to manage district functioning; (2) the mechanisms of sensegiving and social sensemaking that trigger motivation and buy-in of district-level managers and NGO partners and (3) bottom-up capacity development as an emergent process in the daily routines of the DHS. These points are discussed further below.

The competency for complex sensemaking

The DM’s competency for sensemaking in context was a key factor underlying the design of the bottom-up innovation in the experience reported here. Sensemaking has to do with the way managers understand, interpret and create sense for themselves [ 11 , 53 , 69 ]. Managers may adopt a linear or a complex frame to drive sensemaking and interpretation in context [ 40 ]. The DM applied systems thinking, for instance, when targeting a routine structure (the meeting) that brought managers and partners together to work across health system functions and silos to manage the district collectively. Systems thinking is an approach to problem solving that views problems as part of a wider dynamic system, “ demanding a deeper understanding of the linkages, relationships, interactions and behaviours among the elements that characterise the entire system ” [ 78 ]. Other experiences of capacity development offer insights on how to build capacity for systems thinking. In Ghana, a study of a programme to develop leadership capacity found that teaching systems thinking only as a tool rather than embracing it as an embedded practice failed to develop the new mental models needed [ 79 ]. System leaders need to develop and apply three key capabilities: “ their understanding of the system that shapes the challenge they seek to address; their ability to catalyse and support collective action among relevant stakeholders; and their ability to listen, learn and lead through coordination with and empowerment of others ” [ 80 ]. The systems thinking competency demonstrated by the DM was informed and complemented by his formal training, as well as his tacit and experiential knowledge of the health system. Together, these individual competencies allowed the DM to design a suite of bottom-up inter-connected innovations to build the capacity of the extended DMT. The DM’s individual competencies thus also contributed to the growing capacity of the DMT.

While we did not measure long-term outcomes, we argue that the outputs observed in this case study are likely to contribute to building capacity in the management team over the long-term, defined as an “ emergent combination of individual competencies, collective capabilities, assets and relationships that enables a human system to create value ” [ 46 ]. In their research, Baser and Morgan [ 46 ] found that capacity emerges out of multiple relationship and that capacity has both technical, organisational and social aspects – which cannot be addressed through exclusively functional interventions. They note that some are sceptical of taking a system approach to capacity development given that the operational implications can be challenging. However, the operational guidance they offer those supporting capacity development includes: (1) given that the future is largely unknowable in complex systems, settle for ‘good enough’ and allow for exploration in the early stages of capacity development; and (2) as “capacity cannot be assembled like a machine”, focus on emergence and opportunities and promote self-organisation for capacity [ 46 ].

Sensegiving and social sensemaking

Recognising the DHS as a CAS informed our approach to investigating capacity development, and required us to look at the software of the system (knowledge, relationships, norms, communication), the intersection with hardware (positional authority, public policy documents) and how together they serve as sensegiving tools that drive an ongoing process of capacity development [ 9 , 46 , 81 ]. “Sensegiving is concerned with ... [managers’] attempts to influence the outcomes, to communicate … thoughts about the change to others, and to gain their support ” [ 53 ]. The micro practice of sensegiving included the use of sticks, such as the DM drawing on positional authority to shape accountability in the meeting, and enforcement of the HMIS policy, and over-coding using discursive symbols, such as ‘the auditor general’. To trigger the motivation of managers and partners, the DM also employed sermons, created shared meaning by taking time to justify and translate the need for new management practices, including visiting managers in their workplace, gave voice to partners in meetings and employed relevant discursive symbols (performance, core business). He also disciplined the space by using an agenda to systematise the processes in the meeting and further drew on distributed leadership to create an environment that reinforced the overall goal [ 53 ]. As these experiences demonstrate, complexity-sensitive managers adopt a contingency approach to leadership, balancing transactional, transformational and distributed leadership styles based on the needs of the situation and problem, adapting leadership practices to fit context [ 37 ]. A study on the daily management practices of sub-district managers in South Africa found, for example, that improving practices in daily routines, such as facilitation styles in meetings, minute taking, etc. required a set a software skills to nurture and engender “ relationships of constructive accountability … that support persistent and adaptive problem solving aimed at enhancing service delivery and patient care ” [ 41 ]. We posit, then, that software skills are critical aspects to be considered when designing and evaluating capacity development innovations.

Sensegiving was strengthened by the DMT members’ proximity to change (working alongside the DM), as well as by their engagement with new practices. In other words, ‘doing’ triggered appreciation for the new practices leading to motivation and renewed self-efficacy in managers and partners - and it triggered a generative process of buy-in. Actions also provide raw ingredients for sensemaking by generating stimuli or cues … “ action serves as fodder for new sensemaking while providing feedback on the sense that was already made ” [ 67 ]. Sensegiving and sensemaking are “ complementary and reciprocal processes ” - staff will go through a series of cycles of sensemaking before making a decision to adopt an innovation [ 53 , 68 ]. Sensemaking is not only an individual act, it is also a social process that is ongoing and recurrent in organisations and that is influenced by contextual factors [ 67 ]. In our study, the introduction of NHI piloting came with additional technology to support information use, training on information use in facilities and the placement of the large NGO in the district to provide technical support. These other efforts to build capacity in the context complemented the new DM’s suite of inter-connected innovations.

The outputs of these processes are the emergent practices and processes within a routine meeting structure that reflect improved DMT capacity.

Proximal outputs and emergent capacity development

Taking a CAS or systems perspective on capacity development in this research has enabled us to look beyond the “input – blackbox - output” model of capacity development [ 46 ]. It has allowed us to identify how a space between the health system building blocks/functions, the monthly management meeting, itself shaped by history and context, emerged as a site of innovation and anchor for capacity development within the DHS.

While there are growing efforts to understand how to develop district/health management capacity through CD interventions and courses from outside districts [ 79 , 82 , 83 ], we posit that from a bottom-up perspective, capacity development can be seen as an everyday act of managing. This may refocus attention to the challenging role of daily managing critical vacancies, developing support systems, holding well-functioning meetings for better planning, establishing clear role descriptions and knowledge of one’s role in a DMT [ 84 , 85 ]. We argue that bottom-up capacity development initiatives anchored in daily routines have the potential to circumvent some of the challenges identified in external, top-down CD initiatives. These include finding time in busy schedules to attend training, additional resources needed to convene new activities, the duplication of existing structures and/or processes in a district and the limited understanding of capacity development as a bounded project that is finished when the project is over or the convenors leave [ 49 , 79 ]. Homegrown CD activities allow for longer time frames and can potentially deepen local actor ownership and voluntary commitment to CD strategies, both of which are necessary for sustained capacity [ 71 ]. We acknowledge that this type of workplace-based capacity development can work in combination with other, and external, forms of training and learning, such as classroom-based learning or e-learning combining theory and practice [ 86 – 90 ]. We also note that some of the general challenges facing innovation in the public service include risk-averse attitudes, coordination problems, opposition to innovation in general and the doubts of stakeholders. To deal with the unexpected challenges likely to arise in implementation, slack should be built into the innovation process [ 65 , 91 ].

Gilson et al. [ 92 ] present a rare empirical example of bottom-up capacity development. They worked with local managers to implement and co-create an intervention to improve governance at the sub-district level. The intervention focused in part on the management of meetings and decision making and included rotating the meeting chair, positive rounds and managing time proactively. Challenges faced included senior managers not taking the time to ensure meetings were managed productively and an initial unwillingness of meeting participants to make decisions. These authors note that “ institutionalizing the new principles and practices intended to nurture collective problem-solving and collective responsibility for service improvement [takes] time” [ 92 ]. They did, however, find that intervening in the existing meeting structures created emergent and positive changes such as building supportive relationships across organisational silos, as well as improved collective decision making and sensemaking in management meetings. They argue, as we do here, that managers at the local level must be given the flexibility to experiment, whilst nurturing relational leadership skills and distributional leadership can improve the practice of decision making [ 92 ].

Finally, we argue that building the capacity of the ‘structures’ (e.g. meetings, organisational processes) that hold the district health system are critical for developing capacity and unleashing the tools, skills and infrastructure in the system at large. Structural capacity includes decision making fora where inter-sectoral discussions occur and corporate decisions are made, records are kept and individuals are called to account for non-performance [ 93 ]. We call for more research to build our understanding of the challenges and opportunities for building the capacity of managers from the bottom-up in the district health system.

Limitations

Improving district management team functioning is part of the long chain of proximal and distal outcomes needed to improve the capacity of district management teams towards improved responsiveness, equity and health outcomes. This research only provides insight into one cog of this wheel – that is, the social processes of sensemaking and sensegiving and their interaction with the hardware of the system needed to motivate change. We were also only able to observe short term outputs. Additional longitudinal research is needed to understand how bottom-up innovations are institutionalised over the long term and the consequences for long term health goals. Finally, we did not reflect here on all the challenges faced by the new DM when introducing the changes; these will be considered in a subsequent cross case analysis.

We argue that local managers are well placed to design CD innovations and must draw on tacit and experiential knowledge and system thinking capacities in thinking ‘bottom-up’. As their commitment and motivation are required to engage in CD processes, senior managers with power must draw on both their individual software competencies and the hardware resources of the system to influence motivation for capacity development. The act of managing is an everyday process, and we posit that CD can, thus, be conceived of as an everyday act of managing in routine structures while simultaneously building structural capacity in routine organisational processes. We recommend that further research is undertaken to understand bottom-up capacity development from a systems perspective, as well as CD interventions targeted at system ‘structures’ and organisational processes.

Acknowledgements

Marsha Orgill would like to acknowledge the National Research Foundation (NRF|98227) in South Africa, the African Doctoral Dissertation Research Fellowship (ADDRF) and the CHESAI consortium in the Western Cape, South Africa. All provided contributions to writing time.

Abbreviations

Authors’ contributions.

MO developed and conceptualised the paper. MO developed data collection and data analysis tools, collected, coded, analysed data and wrote the manuscript. LG and BM contributed to the conceptualisation of the paper and provided critical commentary in the writing process. MSK collected data and provided comments on drafts, LS enabled communication with the fieldwork site and participated in data collection. All authors have read and approved the manuscript.

Primary research funding was received from the European Commission’s Seventh Framework Programme (FP7-CP-FP-SICA, grant agreement number 261349) (UCT).

Availability of data and materials

Declarations.

Research ethics was approved by the University of Cape Town Human Research Ethics Committee (reference number 479/2011). We received written consent from participants in this study.

Not applicable.

No competing interests to declare.

et al., 2019).

2 As part of another innovation in the district some hospital managers were being replaced in their current job due to new job requirements, they were not removed from the payroll or from the district.

3 These were not new formal posts on the organogram but rather a description of the duties they were expected to fulfil.

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Exdecel A Revision Home > Global Development > Strategies to reduce uneven development > What are the differences between top-down and bottom-up development projects?

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International strategies to address uneven development

What are the differences between top-down and bottom-up development projects?

Advantages and disadvantages of top-down development projects

Advantages and disadvantages of bottom-up development projects

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Top-down strategies – these are usually large-scale development projects occurring through the actions of governments and transnational corporations (TNCs). They are usually expensive and require countries to borrow money.

Bottom-up strategies – these are usually small-scale development projects aimed at the poorest communities through the actions of non-government organisations (NGOs). They are usually less expensive due to their smaller sale.

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Published on 26.4.2024 in Vol 11 (2024)

Exploring the Role of Complexity in Health Care Technology Bottom-Up Innovations: Multiple-Case Study Using the Nonadoption, Abandonment, Scale-Up, Spread, and Sustainability Complexity Assessment Tool

Authors of this article:

Original Paper

Ulla Hellstrand Tang 1, 2 * , PhD ;
Frida Smith 3, 4 * , PhD ;
Ulla Leyla Karilampi 5 , PhD ;
Andreas Gremyr 5, 6 , PhD

1 Department of Prosthetics and Orthotics, Sahlgrenska University Hospital, Gothenburg, Sweden

2 Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden

3 Regional Cancer Centre West, Gothenburg, Sweden

4 Department of Technology Management and Economics, Collaborative Plattform for Healthcare Improvement, Chalmers University of Technology, Gothenburg, Sweden

5 Department of Schizophrenia Spectrum Disorders, Sahlgrenska University Hospital, Gothenburg, Sweden

6 Jönköping Academy for Improvement of Health and Welfare, School of Health and Welfare, Jönköping University, Jönköping, Sweden

*these authors contributed equally

Corresponding Author:

Ulla Hellstrand Tang, PhD

Department of Prosthetics and Orthotics, Sahlgrenska University Hospital

Falkenbergsgatan 3

Gothenburg, SE-412 85

Phone: 46 706397913

Fax:46 31408162

Email: [email protected]

Background: New digital technology presents new challenges to health care on multiple levels. There are calls for further research that considers the complex factors related to digital innovations in complex health care settings to bridge the gap when moving from linear, logistic research to embracing and testing the concept of complexity. The nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) framework was developed to help study complexity in digital innovations.

Objective: This study aims to investigate the role of complexity in the development and deployment of innovations by retrospectively assessing challenges to 4 digital health care innovations initiated from the bottom up.

Methods: A multicase retrospective, deductive, and explorative analysis using the NASSS complexity assessment tool LONG was conducted. In total, 4 bottom-up innovations developed in Region Västra Götaland in Sweden were explored and compared to identify unique and shared complexity-related challenges.

Results: The analysis resulted in joint insights and individual learning. Overall, the complexity was mostly found outside the actual innovation; more specifically, it related to the organization’s readiness to integrate new innovations, how to manage and maintain innovations, and how to finance them. The NASSS framework sheds light on various perspectives that can either facilitate or hinder the adoption, scale-up, and spread of technological innovations. In the domain of condition or diagnosis, a well-informed understanding of the complexity related to the condition or illness (diabetes, cancer, bipolar disorders, and schizophrenia disorders) is of great importance for the innovation. The value proposition needs to be clearly described early to enable an understanding of costs and outcomes. The questions in the NASSS complexity assessment tool LONG were sometimes difficult to comprehend, not only from a language perspective but also due to a lack of understanding of the surrounding organization’s system and its setting.

Conclusions: Even when bottom-up innovations arise within the same support organization, the complexity can vary based on the developmental phase and the unique characteristics of each project. Identifying, defining, and understanding complexity may not solve the issues but substantially improves the prospects for successful deployment. Successful innovation within complex organizations necessitates an adaptive leadership and structures to surmount cultural resistance and organizational impediments. A rigid, linear, and stepwise approach risks disregarding interconnected variables and dependencies, leading to suboptimal outcomes. Success lies in embracing the complexity with its uncertainty, nurturing creativity, and adopting a nonlinear methodology that accommodates the iterative nature of innovation processes within complex organizations.

Introduction

Why is it so difficult to develop and spread new innovative technologies in health care.

There has been an increasing focus on innovation and the role of new technologies (eg, electronic health records, smartphones, and health applications) in health care. However, developing new technologies comes with significant challenges. Studies show that technology projects in health care, particularly large and complex projects, have a high rate of failure and seldom produce the anticipated results [ 1 - 5 ]. Bottom-up innovations in health care are innovations for service delivery that have been developed “from the ground up,” often focusing on preventive patient-centered care, typically driven forward by small interdisciplinary groups of professionals and patients [ 6 - 9 ]. As a result, they may not be captured by existing metrics, thus being “invisible” to senior management and policy makers [ 10 ].

The challenges when it comes to developing and making use of innovations, such as spreading or implementing new ways of working [ 11 ], have been described by many, often as a “knowledge translation or production problem” [ 12 ]. Braithwaite et al [ 13 ] compared the traditionally dominant linear and causal thinking that characterizes early implementation science and the evidence-based medicine paradigm with features such as those in systems thinking. The linear approach applies simple, orderly processes with cumulative sequences of stages to produce results building on a knowledge of the way things work, making use of predictable relationships between causes and effects. This has helped generate many successes in the past, not least in health care, but it tends to increase rigidity and fail when applied in more complex and messy systems where things change dynamically and are therefore unpredictable [ 13 ]. Instead, systems thinking and the related complexity science recognize system characteristics in building an understanding of how best to move forward.

To drive change in a predictable “simple” system where causes and effects are known, a linear, stepwise approach has a greater chance of success. However, complex systems are not only dynamic but also are often described as adaptive (as in complex adaptive systems) in that they are constituted of agents and artifacts that communicate and learn from each other and the surrounding environment, creating opportunities to learn from experience, self-organize, and evolve, making them less predictable systems [ 14 ].

Even though the linear approach has previously dominated implementation and development initiatives in health care, many researchers point to the necessity to apply systems thinking and complexity science when developing health care through the innovative use of new technologies, as exemplified in the study by Greenhalgh and Papoutsi [ 2 ]. As the concept of stepwise, linear cause and effect is not sufficient when studying complex systems that evolve in ways that are impossible to predict, it is relevant to use the knowledge of complex systems when understanding and studying health services [ 15 ]. Complex systems are defined by (1) intricate intertwined processes, (2) interconnectivity between systems, (3) interconnectivity between levels within systems, and (4) interconnectivity between actors and elements, giving complex systems different properties from those of less complex systems [ 1 ]. In short, a complex system does not work linearly but dynamically, with fundamentally different logics [ 16 ], and needs to be addressed and understood accordingly during innovation and implementation. If not, there is a risk that new technology and innovations will further increase the complexity rather than actually supporting the needs and demands for an improved health care system [ 17 ].

The Challenges

A total of 4 bottom-up innovators found that there was a need to gain insights into the complexity involved in developing and executing bottom-up innovations in a complex health care organization. All 4 innovators had met with hindrances preventing them from moving forward with their innovations. It was necessary to pause and retrospectively try to comprehend the underlying reasons for the stagnation in the 4 cases in question.

Project representatives, all health care professionals, joined forces to identify challenges by assessing project complexity to increase an understanding of the role of complexity and find ways to explore and assess it. As they all worked within the same regional system, it was crucial to involve regional stakeholders (support functions) during the learning process.

The aim of this study was to investigate the role of complexity in the development and deployment of innovations by retrospectively assessing the challenges to 4 digital health care innovations initiated from the bottom up.

This section describes the theoretical framework that underlies our methodological approach, the settings, and the 4 cases under study, as well as the procedure.

Theoretical Framework

An impressive amount of knowledge related to the diffusion of innovations and their implementation in health care by the start of the new millennium is summarized in the extensive review by Greenhalgh et al [ 11 ] from 2004. It builds partly on the ideas by Rogers [ 18 ] that innovations have characteristics that will affect their diffusion, as well as affect other domains (eg, the readiness of the system for change, the implementation process, the adopter, and the external wider [sociopolitical] context). As innovations in health care were increasingly associated with new technologies, a new review was conducted by Robert et al [ 19 ] in 2010, adding more recent data and focusing on the adoption and assimilation of new technologies into health care.

This, along with the high failure rate of health care technology innovation projects, inspired Greenhalgh and colleagues to deepen their knowledge of the diffusion of innovations, with an emphasis on health technology projects. Building on previous work, reviewing the literature, and using empirical studies of technology implementation, they elaborated on and explained domains of importance. This resulted in the nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) framework ( Figure 1 [ 20 ], published under Creative Commons Attribution 4.0 International License, CC BY).

The NASSS framework was developed into a complexity assessment tool (NASSS-complexity assessment tool [NASSS-CAT]) [ 20 ] to help assess the complexity of health technology projects before, during, or after they were finished.

Design and Methodological Approach

A multicase retrospective, deductive, and explorative analysis using the NASSS-CAT LONG was conducted [ 15 , 21 ]. The process of analysis is shown in Figure 2 and is described at the end of the Methods section. The complexities of 4 bottom-up innovations developed in Region Västra Götaland (VGR) in Sweden were explored. The NASSS-CAT LONG consists of 2 parts divided into 7 domains ( Figure 1 ). First, one is asked to describe the project and its potential messiness in their own words. Writing this narrative can help surface interdependencies and tricky issues of the project, hence revealing complexity. Second, one answers the questions related to the domain to help them estimate key areas of complexity. One can define whether the question is complex or not complex, whether they do not know, or whether it is not applicable. The total score of orange boxes ticked tells one how complex a certain domain is for their project. In part 2, one is guided through prompts to help them plan for and manage complexity by reducing it where possible and responding to it if or where it cannot be reduced. The questions can be answered by different people who will provide the needed insights into the domain and the project under evaluation.

The 4 bottom-up innovators were from different parts of the organization in the VGR [ 22 ]. All of them had unique experiences of their own departments of the VGR and the surrounding supporting systems, such as the IT departments, purchasing departments, and legal offices. Although all 4 worked in specialized care, the care flow for each of the relevant diagnoses spanned specialized care, primary care, and municipal care.

The VGR is a region on the western coast of Sweden with a total population of 1.8 million. For several years, there has been a push for increasing the development of innovative solutions to the challenges faced by, for example, the public health care system. This has been implemented through the formation of an Innovation Platform (IPF) that develops processes and supportive structures as well as approving funds to help innovative ideas thrive. The mission of the IPF is to contribute to a sustainable innovation system that promotes innovation in health care and ensures that collaboration between academia and business fulfills the needs of patients within the health care system.

In total, 4 bottom-up innovators in the VGR pioneering eHealth and clinical research united in 2019 after realizing that there were barriers to their separate innovations due to an organizational lack of an innovation framework and to inexperience in developing, testing, implementing, and maintaining digital innovations. One author, familiar with the NASSS framework, encouraged the others to explore complexity in innovation. Together, they adapted the NASSS-CAT to identify unique and shared complexities in their innovations. Concurrently, at the same network meeting, representatives from the IPF wanted to be a part of the study, exchanging insights on how to identify and manage complexities in the innovation process.

Ethical Considerations

Because no personal data were collected, no ethics approval was needed. All participants agreed, orally, to take part. No sensitive personal information was collected, and no patients participated in the workshops. The IPF, the regional support resource for innovations in health care, read and commented on the Swedish report before publication.

The 4 Bottom-Up Innovations

Each innovation is presented in the following sections and in Multimedia Appendix 1 [ 15 , 20 , 23 - 38 ]. The cases are heterogeneous with regard to intended user, phase in the innovation process, and place of implementation (locally, regionally, and nationally). Despite their differences, they all existed in the same environment, framed by the regulations of the VGR and its support system for innovation.

Case 1: The D-Foot

The lifetime risk of developing diabetic foot ulcers (DFUs) is as high as 34% for patients with diabetes [ 23 ]. It is a burden for the patient and for health care with regard to costs. With prompt prevention, the prevalence of DFUs can be halved [ 24 ].

The D-Foot is a digital decision support system designed for preventing DFUs. It conducts early screening and provides treatment recommendations based on a risk grade (ranging from 1=no risk to 4=ongoing foot ulcers) [ 25 , 26 ]. The risk grade is automatically generated through a series of structured foot assessments and patient surveys [ 27 ]. A printable report of foot assessments, risk grade, and recommendations is generated. The innovation’s reliability and usability have previously been reported and assessed as good [ 27 , 28 ]. The innovator’s intention was that the D-Foot would serve as a tool in the national effort to implement a person-centered and seamless care chain for preventing foot ulcers in people living with diabetes [ 25 , 26 ].

The seamless care chain consists of (1) an annual foot examination, (2) a podiatry intervention, (3) the provision of appropriate footwear for at-risk patients, and (4) treatment in a multidisciplinary team for patients with active DFUs [ 25 , 39 ]. The D-Foot was developed as an easy-to-use digital tool to support foot examinations for individuals diagnosed with diabetes, primarily targeting prosthetic and orthotic specialist care [ 27 , 28 , 40 ]. The goal was to implement the D-Foot nationally, expecting early prevention of DFUs, improved quality of life for affected individuals [ 29 , 41 ], and reduced health care costs [ 42 ].

Version 1.0 of the D-Foot software was developed from 2011 to 2016 by an expert group comprising certified prosthetists and orthotists, patient representatives, and orthopedic surgeons in the VGR [ 27 ]. Initially, it underwent regional testing with positive results. Thereafter, continuous improvements have been made based on users’ comments [ 28 ]. Not yet executed is the request from users for integration between the D-Foot and the major medical record system [ 28 ].

Case 2: The MoodMapper

Bipolar disorder, often diagnosed in early adulthood, typically necessitates lifelong treatment. It leads to undesirable mood swings affecting daily functioning. Mood episodes vary from extreme “highs” (manic episodes) to severe “lows” (depressive episodes) lasting for days or weeks. Even with proper treatment, mood fluctuations can occur. Collaborative communication between patients and health care providers enhances treatment effectiveness. Moreover, the early detection of behavior changes is of the utmost importance in the successful treatment of bipolar disorder.

The aim of this innovation was to determine whether smartphone use data are a reliable source for studying changes in the digital behavioral patterns of individuals with bipolar disorder by exploring correlations between different parameters of smartphone use data.

The MoodMapper is a mobile app that, through real-time data collection, can provide valuable insights into a patient’s smartphone use. The ambition was, after pilot-testing, to study and evaluate the connection between mobile-generated passive data and documented changes in the patient’s mental well-being, with the goal of making it easier for both patients and health care professionals to monitor the progression of the patient’s condition and make decisions regarding prevention and care.

Case 3: The Digi-Do

Radiation therapy (RT) is a common treatment after breast cancer surgery. The high-technology environment and unfamiliar nature of RT can affect the patient’s experience of the treatment. Misconceptions or a lack of knowledge related to RT processes can increase levels of anxiety and enhance feelings of being unprepared at the beginning of the treatment. Moreover, the waiting time is often fairly long. Cancer care involves several, often independent clinics. Even if the clinical pathway is clearly described, transitions and information exchange can be problematic. RT is only provided at the university hospital in the region, with long distances and long waiting times for many patients.

The Digi-Do tool consists of two separate mobile apps: (1) an app providing a guided digital tour of the RT department, where the patient can familiarize themselves with the department by using virtual reality glasses; and (2) an app with additional information, including questions and answers, practical information, and short animated films about the RT process. The design of both apps was developed in a co-design process with patients and staff [ 43 ]. The primary aim of the researcher or innovator was to evaluate whether a digital information tool with virtual reality technology and preparatory information was able to reduce distress and enhance the self-efficacy and health literacy of patients with breast cancer before, during, and after RT. A secondary aim was to explore whether the digital information tool increased patient flow while maintaining or improving the quality of care [ 44 ].

Case 4: A Point-of-Care Dashboard for Schizophrenia Care (the PoC Dashboard)

The Department of Schizophrenia Spectrum Disorders at Sahlgrenska University Hospital delivers specialized care for people with psychotic disorders in the metropolitan Gothenburg area (with a population of approximately 600,000 people) in Sweden. Schizophrenia is the most common diagnosis among the approximately 3000 patients who receive care at the department’s 7 outpatient units. Approximately 20% of these patients also need acute inpatient care at 1 of the department’s 4 wards each year.

With the aim of supporting patient coproduction of health, a digital dashboard was developed to be jointly reviewed at the point of care by patients and case managers and psychiatrists to support evaluation and planning, outcome questionnaires, and patients’ care plans [ 45 ]. The dashboard was developed between 2016 and 2018 and was piloted at 2 outpatient units with approximately 400 patients for 18 months. The dashboard is one of several connected applications and displays for visualizing data fed by multiple systems to support, for example, planning, management, and triage and includes a unit-level overview of quality indicators to identify patients at risk. The dashboard project also served as a case in the development of the NASSS-CAT [ 20 ].

Study Procedure

This study followed an iterative process, including analyses, discussions, and seminars ( Figure 2 ).

As we used the NASSS-CAT, the analysis was deemed to be of an exploratory, deductive nature. First, an individual assessment of each case was made, and then the 4 cases were compared to find similarities. However, while using the NASSS-CAT in each of the 4 cases, the innovators had discussions about how to interpret the questions in the 7 domains. An additional method, namely, constant comparative analysis (CCA), was chosen as it is appropriate in collaborative projects to facilitate and identify agreements and disagreements [ 46 , 47 ] ( Multimedia Appendix 2 ). After agreeing on how to interpret the questions, members of the IPF were invited to complete the analysis in a workshop.

In total, 4 bottom-up innovators had individually experienced complexities during their respective innovation processes from 2010 to 2019.

The 4 innovators got together and started the study in January 2020 by learning how to use the NASSS framework based on the work by Greenhalgh et al [ 15 ]. Support was available as one of the authors had been involved in the development of the NASSS-CAT [ 20 ].
The innovators identified complexities in their individual projects using the NASSS-CAT [ 20 ] in 2020.
During >30 one-hour meetings using the NASSS-CAT and taking minutes, the innovators identified, compared, and discussed similarities and differences regarding complexities in their respective innovations. A CCA was included in the process and is described in Multimedia Appendix 2 .
A seminar was held in April 2020 with one of the bottom-up innovators and the IPF presenting the concept of complexity and the NASSS framework.
In October 2020, another seminar was held with the 4 innovators and staff members from the IPF to discuss the domains of the NASSS-CAT, illustrated by examples and findings from the assessment of the 4 bottom-up innovations. The participants from the IPF discussed and reflected on experiences of complexities. The seminar was recorded and summarized in a report in collaboration with a representative from the IPF [ 48 ].
The authors were commissioned to write a report (in Swedish) for the IPF exploring and summarizing the NASSS framework and complexity with examples from the bottom-up innovations [ 48 ].
The insights gained into the role of complexities from the entire aforementioned process were discussed and summarized and are presented in this paper.

In this retrospective exploration of the role of complexity in 4 bottom-up health care innovations in a Swedish region, both similarities and differences emerged among the 4 cases when using the NASSS-CAT ( Multimedia Appendix 3 ). The findings for each domain are described in the following sections.

Complexity Domain 1: The Illness or Condition

This domain has no or low complexity when the illness is well known and an assessment can result in a well-defined diagnosis and when there is, furthermore, knowledge and know-how regarding how to treat the condition successfully. Complexity can be related to conditions with less known causes, a high prevalence of multimorbidity, and challenging sociocultural factors (eg, language barriers). In our study, the cases that addressed mental illness (PoC Dashboard and MoodMapper) and diabetes (D-Foot) had more complexity related to the actual illnesses than the case aiming to prepare women before RT for breast cancer (Digi-Do) [ 49 , 50 ]. Both bipolar disorder and schizophrenia are strongly connected with comorbidity and lifestyle-related conditions, and even though national guidelines exist, there is no simple pathway to treat those conditions. The third case (D-Foot) involved diabetes, also an illness defined as complex due to the patient being treated in various institutions and with several lifestyle factors influencing the outcome of the treatment [ 39 ].

Complexity Domain 2: The Technology (or Other Innovations)

An innovation is less complex if it is well known, ready, and easy to use and has a clear supply model, well-defined ownership regarding its intellectual properties, and low or no dependency on other systems. For the actual technologies under study, similarities regarding complexities revolved around interdependencies with other IT systems, ranging from local to regional and even national systems. Even if the technology already existed (D-Foot) or if new software was developed to create a better overview of data in several existing systems (PoC Dashboard), it was difficult to develop the innovation so that it enabled adoption beyond the local settings. Regulations regarding software used as a medical device [ 30 ] sometimes prevailed over the simple adaptations for different target groups. “Fireproof” walls exist between organizations (eg, municipal care, primary care, and specialist care), and different versions of the regional information systems, being related to ownership, budget, and management, make it less clear whether and how new technologies can be bought, adapted, and used in a local setting. In contrast, the Digi-Do app does not require any interaction with existing IT systems and was not deemed to be a medical technical device. The MoodMapper app, on the other hand, is complex as it aims to interact with both patients and health care staff, requiring interaction with medical electronic health records as well as ensuring a very high level of security to safeguard the patients’ integrity [ 51 ]. The need for supply chains included both purchasing and procurement and clinical implementation, the latter involving questions regarding intellectual properties (is the owner the bottom-up innovator or is it the region?), ownership management (which regulation steers the region when managing a medical device owned by the region?), and updates and maintenance of the eHealth tools (which department in the VGR is responsible for updates and maintenance of the innovations?). All the cases had run into or expected to run into severe complexity when planning to launch their innovations. It was clear that complexity regarding supply chains had not been considered by either the innovator or the VGR when intending to expand from a local level to a regional or national one. An example of the complex challenges related to the spread and maintenance of one of the eHealth tools, the D-Foot, is presented in the following paragraphs.

Regulations regarding funding and ownership made it difficult to implement a supply chain outside the local region as each of Sweden’s 21 regions has its own procurement processes. Since the start, the D-Foot project had been aiming for national spread. In 2017, the IPF approved funding with the aim of testing, Conformité Européenne (CE) marking, and thereafter implementing the D-Foot first in the VGR at the department of prosthetics and orthotics and then nationally. At the same time, several departments of prosthetics and orthotics in other regions were interested in using the D-Foot as soon as the CE marking was finalized. However, in June 2017, an official at the VGR decided that the region was only able to allow the D-Foot to be used within the region (Article 5.5 in the Regulation [European Union] 2017/745) [ 30 ]. Following this decision, national spread was impossible. The bottom-up innovator continued to have a dialogue with the IPF seeking a solution for national spread. In 2020, an opportunity for national spread arose by registering the D-Foot as a national medical information system (NMI) at the Medical Products Agency. An NMI is an information system developed for joint use at nationwide, regional, or municipal level in Sweden.

Thus, the D-Foot transitioned from being a “self-manufactured medical device” to becoming an NMI registered with the Swedish Medical Products Agency in 2020. However, the NMI registration was withdrawn by the VGR in 2021 due to new regulations from the Swedish Medical Products Agency [ 52 ]. The D-Foot remains a separate software program not integrated into the standard medical record system in the VGR. As a result, one option remained for national spread, namely, to CE mark the D-Foot, a procedure that was not as yet allowed or tested in the region.

Complexity Domain 3: The Value Proposition (Costs and Benefits of the Technology)

Complexity in this domain arises when determining the value provided by the innovation to developers, users (patients, staff, and health care systems), and the broader health care ecosystem. Despite their origin as bottom-up innovations aimed at improving care, the complexities of demonstrating supply-side value in terms of business models and monetary benefits were challenging. Key questions included defining improved value, decision-making processes, the inclusion of nonmonetary values, and the extent of evaluation required: what is regarded as improved value? Who decides? Is it only monetary or other types of value as well? How much does the innovation need to be evaluated and how?

The Digi-Do has a defined regional vision and has faced challenges in quantifying value, especially regarding soft values such as reduced distress and increased health literacy and self-efficacy. The Digi-Do aims to optimize the use of waiting time before RT, adding value by reducing waiting times and queues. Furthermore, the innovation aims to create value for patients by delivering information in a novel, accessible format, potentially improving health literacy even for those with language difficulties or cognitive impairments. It also extends benefits to the patient’s social network, enhancing support and knowledge and reducing distress among family and friends affected by the patient’s cancer diagnosis. By using the often idle waiting time for meaningful preparation, the innovation may foster a sense of control and inclusion, diminishing distress and worry. Well-prepared patients may navigate the system more efficiently, potentially reducing waiting times for information dissemination.

The evaluation of the outcomes in this specific project is still ongoing through an unpublished randomized controlled trial [ 44 ], but so far, the qualitative results show a high level of acceptance of and positivity toward the tool. Nevertheless, there needs to be a discussion about how to endorse a more pragmatic evaluation of both effectiveness and process outcomes [ 53 ].

If successful, this approach could be adapted for other health care domains, although commercialization is not the project’s primary goal. Measuring soft values has proved challenging as they might not directly impact traditional health care outcomes. The other cases faced similar difficulties in pinpointing the exact stages in which costs and values could be calculated.

Enhancing foot health can improve the quality of life of patients and reduce health care costs associated with treating DFUs and amputations. Objective risk assessment by using the D-Foot precedes interventions, aligning with the vision of providing equal, high-quality care to citizens. Early interventions in the prevention process (D-Foot) might require more resources within primary care but were expected to be cost-effective in the long term due to a reduction in specialist care following fewer ulcer treatments and amputations [ 31 , 42 ]. In terms of quality of life and cost reduction, the value proposition needs further evaluation over a longer period relying on data related to care costs for at-risk patient groups. The D-Foot database contains valuable information on risk groups and foot status, serving as a data source for audits and evaluations to optimize foot care. It could also function as a quality registry, potentially becoming the new diabetic foot register in Sweden.

The MoodMapper aims to provide a more objective risk analysis and early interventions, potentially preventing hospitalization. In the examples of innovations (MoodMapper and PoC Dashboard) designed to prevent relapses in severe mental illness by coordinating data or even by asking patients to send and react to data, the need for hospital care could be reduced. However, this area is as yet unexplored.

The value proposition of the PoC Dashboard remains uncertain. Case managers and patients find the technology useful based on preliminary data. Local testing and piloting suggest perceived effectiveness, although the degree of cost-effectiveness is still unknown. The dashboard streamlines administrative tasks for staff, offering an overview of patients’ progress and risks while facilitating collaborative care planning. However, the technology’s potential as a commercial product is uncertain, mainly because it is integrated with older systems. Additional uncertainties involve the IT department’s role in dashboard maintenance and associated costs.

Complexity Domain 4: The Intended Adopters of the Innovation and Technology

Complexity in this domain is higher when adopting the innovation, necessitating changes in routines, roles, and identities. Innovations that support existing routines with minimal disruption are associated with lower complexity, and all 4 cases required either behavior changes by patients or modifications to work routines for health care staff. For example, the PoC Dashboard simplified patient overview and reduced administrative work for staff, thus positively impacting daily tasks [ 54 ].

However, transferring the D-Foot to primary care posed challenges as different health care professionals (podiatrists, nurses, and physicians) with varying roles and routines questioned its added value. The MoodMapper required patients to trust the handling of their behavioral data, which could be challenging for those with symptoms of paranoia.

Complexity Domain 5: The Organization Implementing the Technology

Complexity in this domain pertains to the efforts required to plan, implement, and monitor the innovation’s adoption, as well as to the organization’s overall capacity for innovation. Challenges included a lack of clear pathways for support, making it necessary to find the right individuals at the right levels for consultations. Different organizational levels faced varying complexities, and despite a desire for innovation, built-in regulations sometimes hindered dissemination. For instance, regulatory obstacles prevented the national spread of the D-Foot.

Complexity Domain 6: The External Context for Innovation

Complexity in this domain is influenced by the political, sociotechnical, and regulatory context, as well as by stakeholder groups and interorganizational networking. In Sweden, despite a national Vision for eHealth by 2025 [ 55 ], the existence of 21 independent regions creates complexity in decision-making for local, regional, and national development and for the implementation of digital health care innovations. For instance, there is a national initiative from the government to improve cancer care, but the regions are self-governed in terms of budget and implementation. This means that, even if the regional cancer center had a national assignment to improve cancer care generally and the RT process in the local region specifically, it has no mandate to implement the Digi-Do without the approval of the RT department at each separate regional hospital.

Furthermore, if an innovation needs to be integrated with the IT systems, such as in the other 3 cases, national initiatives can be ruled out by regional procurement, management supply chains, and European regulations regarding medical devices [ 30 ]. If regional support and the management of supply chains only permit regional use, there will be no dissemination, and thus, bottom-up innovations risk becoming only local or, at worst, experiencing the “death of innovations” after the initial project phase.

Complexity Domain 7: Emergence Over Time

Complexities were identified in all 4 cases ( Multimedia Appendix 3 ). When summarizing the complexities from domains 1 to 6, all the authors concluded that the complexities were likely to increase in the coming 3 to 5 years, probably due to advances in technology, unexpected events such as pandemics, international conflicts, and new regulations and standards. In the coming years, a new regional medical record system, Millennium, is planned to be implemented. For small bottom-up innovators, it is not yet clear how the implementation of Millennium will affect their innovations [ 37 ].

Principal Findings

In this study, we conducted a retrospective, deductive, and exploratory analysis of 4 cases using the NASSS-CAT LONG. We intended to explore whether there were shared or individual challenges related to bottom-up innovation projects in the same health care region. The analysis itself was complex, but it resulted in both common and individual learning, and all but one case have moved forward, partly due to new insights gained that have made progress possible. By applying the NASSS-CAT in various projects, the authors learned several lessons, the most important of which are described in the following sections. After that, we discuss and reflect on the methodology and the need or suggestions for further research. Finally, we briefly present how the cases have developed since the analysis.

The Innovation Versus the System

As proposed by Rogers [ 18 ], the properties of the innovation affect its probability of diffusion within and beyond the organization. Through this study, we have become aware of the need to understand the “system” in which we are working to develop and adopt innovations and make effective use of those innovations. The NASSS framework sheds light on various perspectives that can either facilitate or hinder the adoption, scale-up, and spread of technological innovations. Before our projects, none of us had fully considered all these perspectives. During this study, complexity was found and highlighted, involving many issues related to the organization or system rather than the specific innovation itself. Multiple regulations must be considered, and regional procurement [ 56 ], management of supply chains, and European regulations regarding medical devices [ 30 ] can hinder the spread of innovation. A lack of necessary interorganizational networking further complicates matters.

Linear Logic Versus Dynamic Complex Processes

By applying the NASSS framework, we discovered how the innovation process and the training we had all had in evidence-based medicine and the research process were geared toward a linear process rather than embracing complexity. We also discovered that the complexity was mostly found outside the actual innovation and related more to the system that the innovation was supposed to live in and to regulations and legislation. More specifically, it related to the organization’s willingness to integrate new innovations and to questions regarding how to manage, maintain, and finance innovations.

Developing and deploying new bottom-up innovations in health care involves multiple logics [ 57 ]. Initially, we attempted to approach this in a traditional linear fashion with sequential steps from idea to widespread adoption. However, we quickly realized that this linear approach did not align with the reality of navigating the complexities of health care innovation. Instead of a straightforward innovation journey, it often felt like traversing a dense jungle, making it challenging, if not impossible, to gain a comprehensive overview of the landscape, identify opportunities, and predict the appropriate course of action.

Complex environments often require creative and dynamic thinking; in contrast, a linear approach may stifle the ability to respond to unexpected challenges or opportunities. Innovation is inherently uncertain and unpredictable [ 58 ]. It often involves trial and error, experimentation, and the willingness to explore unconventional ideas. A rigid stepwise approach may not accommodate the iterative and nonlinear nature of the innovation process. Complex organizations involve numerous interconnected variables and dependencies. A linear approach may overlook these interconnections, leading to suboptimal solutions or unintended consequences. Innovation often requires a holistic understanding of the organization’s ecosystem. This understanding is hindered if established cultures in the complex organizations are resistant to change [ 57 ]. A nonlinear approach may face resistance from employees or departments unwilling to deviate from established norms.

Successful innovation requires addressing cultural and organizational barriers, which may not fit neatly into a linear plan. Finally, complex organizations require adaptive leadership that can navigate ambiguity and inspire a culture of continuous improvement [ 59 ]. These are important findings as innovation, particularly in the realm of new technologies, is often seen as a potential solution to address the challenges facing health care. Calls for innovation and new ways of working have come from various sources, including governments, health care organizations, and life sciences clusters. However, the high failure rate of health care technology projects suggests that there may be deficiencies in the structure, resources, and knowledge needed for success [ 60 ]. Furthermore, there is a risk of simplifying the complex innovation process by building a support system that is linear. The linear and stepwise approach (first do this, then do that) is counterproductive. While a linear approach may work in certain situations, the nature of innovation in complex organizations demands a more flexible, adaptive, and nonlinear methodology. Embracing uncertainty, fostering creativity, and adapting to change are critical elements that a rigid stepwise approach may not adequately address in the context of complex organizational innovation [ 58 ].

For all 4 cases, questions arose related to value and costs. Will there be an initial or a recurrent cost for the product, or will the cost be related to a new service that entails new tasks for staff? There is an advantage in specifying both costs and values, as well as the effect of the innovation on other resources, early in the innovation process. Therefore, health-economy analyses are needed, but they are difficult to design and perform as some innovations focus on increasing soft values that are difficult to translate into monetary variables.

Indeed, evaluating the values—different kinds of values and on different levels—of health care innovation is complex. While clinical testing can demonstrate its usefulness to end users, it is often difficult to determine whether the outcomes involve soft values (eg, reduced distress and improved health literacy and self-efficacy) or hard, monetary values [ 14 ]. Furthermore, the distribution of costs and value resulting from an innovation can be intricate, making it hard to assess. Questions arise about the initial and recurrent costs and whether they relate to the product or to new services that require additional staff tasks. Early in the innovation process, there is a need to specify both costs and values, be they monetary or qualitative. Clearly describing and anchoring a value proposition, whether it involves soft or hard values, with stakeholders early in the process is crucial for understanding costs and outcomes. However, finding effective ways to evaluate an innovation before it is ready for large-scale testing can be challenging. Similarly, value and costs stemming from an innovation can be distributed across the organization or organizations in ways that are difficult to assess. Calculating the health costs of improving care processes that involve many actors in a complex organization such as the VGR is complicated [ 61 ]. More pragmatic evaluations of both effectiveness and process outcomes are needed and can help show the effect from different angles [ 53 ].

For all cases dealt with in this study, the value proposition in terms of quality of life and cost reduction needs further evaluation over a longer period relying on data related to care costs for at-risk patient groups. The D-Foot database contains valuable information on risk groups and foot status, serving as a data source for audits and evaluations to optimize foot care. It could also function as a quality registry, a new diabetic foot register in Sweden. In the MoodMapper, the users comprise patients; their clinical teams; and, occasionally, relatives or caregivers. A published study highlights the value of implementing and receiving psychological relapse prevention for these groups, leading to improved understanding of bipolar disorder [ 62 ] that might, in turn, lead to enhanced working relationships and better condition management. However, the evidence is not consistent, and further studies are needed [ 61 ]. Moreover, for patients with bipolar disorders, having some of their behavioral patterns (such as step count and estimated sleep) automatically monitored meant that there needed to be a great deal of trust in how data are handled, something that might be difficult for patients experiencing symptoms of paranoia.

Co-Design and Coproduction

Involving users both directly and indirectly at an early stage of the development process is highly beneficial, particularly because what benefits one person may pose challenges for another, thereby creating complexity. Although there are several examples of how coproduction is useful in the innovation process, the existence of complexity must not be neglected in the co-design.

Bottom-up innovations in care encompass a wide spectrum of patient-centric approaches, empowering individuals and communities to actively participate in projects aiming to support well-being. These innovations, driven by the challenges that health care faces, range from self-management tools [ 62 - 64 ] and patient support networks to community-driven health programs [ 6 - 8 , 10 , 59 - 61 , 65 - 67 ]. They appear with different approaches, such as lean production [ 9 ] and Six Sigma [ 68 ]. Coproduction can enhance the 3 Rs in research—reach, rigor, and relevance [ 69 ]—by ensuring that the right needs are addressed and that the innovation is practical for both patients and staff.

Enthusiastic innovators and staff should be engaged early in the process, along with representatives from patient organizations or individuals with relevant experience. There is a strong movement toward involving patients in health care improvement, and genuine engagement is necessary for truly bottom-up innovation involvement [ 70 ] as it can lead to more radical solutions or suggestions when used correctly [ 71 ]. If a technological innovation is too demanding or unfamiliar for users, it is unlikely to be accepted. Piloting with stakeholders is crucial for assessing practicality [ 59 ], and using input from stakeholders in the right phase can increase the possibility of finding radical suggestions, as well as saving time for both parties (developers and patients) [ 71 ]. We support the idea that coproduction incorporating the multifaceted aspects of complexity is necessary in the evaluation of success in the implementation of bottom-up innovations [ 4 ].

Methodological Considerations

Performing a retrospective, deductive analysis as a case study [ 21 ] with 4 cases with differences regarding where they were in the innovation process and with different technical solutions was challenging, but it provided multiple valuable insights. The authors found that, before using the NASSS-CAT, users need to be familiar with the NASSS framework [ 15 ]. The NASSS-CAT appeared deceptively easy at first, but it was more difficult to use and more time-consuming than expected. A need for a way to track how we could jointly understand and agree on the meaning of the NASSS-CAT by using CCA became apparent during the work, leading to a common language being agreed upon and a consensus being reached on how to interpret the terminology used in the NASSS-CAT. During the CCA, discussions about how to interpret the questions in the 7 domains of the NASSS-CAT took place in cycles, and thus, it was a continuous learning process. As intended by the method [ 46 , 47 ], finding disagreements and negotiating led to a higher degree of understanding not just of the instrument but also of the concept of complexity. The 4 innovators contributed multiple perspectives based on their own cases and discussed their different understandings of the narratives, the domain questions, and the subquestions. As the authors used a nontranslated version of the NASSS-CAT and are native speakers of Swedish and not English, the CCA helped them understand the questions in the NASSS-CAT. Therefore, the use of CCA statements and negotiations on how to interpret the questions in the NASSS-CAT facilitated the analysis and helped create a common language within the group.

The NASSS framework was developed through a detailed review of the existing literature and clinical cases [ 15 , 20 ], but to our knowledge, the tools (NASSS-CAT) have so far been sparsely tested for their ability to unveil complexity in bottom-up projects in public health care. Going from commonly used methods for quality improvement (eg, using the Plan-Do-Study-Act method [ 72 ] to incorporate complexity assessment) shows promising results. A recent study used the framework and tool combined with the Plan-Do-Study-Act cycles of improvement to plan and evaluate digital services for patients in Sweden [ 73 ]. Similar to our retrospective analysis, that study identified several elements of complexity, explaining a gap among the capacity of adopters, the organization, the wider system, and how intended users valued the service. This gap hindered the innovations from integrating new services into routine care effectively [ 73 ]. Similarly to us, these authors found the tool and framework helpful in that they allowed for deeper insights into the project compared to only following method, approach, or cycles or other tools or models for innovation. It seems that, even if complexity is revealed early in the process, this still does not solve the problems. However, if people working with innovation or in supporting innovation become more aware of complex elements, issues might be easier to anticipate or even deal with earlier. Such awareness can thereby help explain obstacles and prevent failure, hence enabling more successful innovation projects in health care, as presented by Greenhalgh et al [ 15 ].

Strengths and Limitations

The strength of this study lies in the 4 different cases representing both somatic and psychiatric care and the innovators’ long experience in both health care and eHealth. The diversity of innovations presented and the different departments that each of the innovators worked in contribute to a broad overview of shared experiences. None of the innovators had worked together before this study. The fact that all cases came from the same region with the same support function strengthens our results by showing that (1) knowledge of complexity needs to be improved in such systems and (2) the project itself contains complexity in different domains even if we found several common problems. Therefore, the study increased the understanding of the role of complexity, not only in the studied bottom-up innovations but also in the system in which the innovations took place, through prolonged engagement [ 50 ]. This study was strengthened by the support of one of the authors, who was involved in the development of the NASSS-CAT [ 20 ], but despite this, it appears that adaptation to the setting (geographic and cultural) is crucial.

The retrospective NASSS-CAT analysis of 3 of the 4 cases was mainly performed by the respective innovators without direct input from stakeholders involved in each of the cases. This meant that only 1 perspective from the many actors involved in each of the projects was put forward. The rationale for this was that each innovator had already faced and, therefore, was acquainted with the diverse complexities addressed in all 7 domains. However, other perspectives might have further improved the analysis. The PoC Dashboard project was assessed regarding complexity in a workshop with stakeholders and discussed with management [ 54 ].

Even though the NASSS-CAT tools have been used previously [ 74 ], more testing in clinical bottom-up innovation cases is needed to scrutinize their utility in a Swedish setting and to learn from the experiences originating from 4 different cases that used the tools.

Use and Usefulness of the NASSS-CAT

In this section, experiences of the use and utility of the NASSS-CAT are presented. At the start, the 4 bottom-up innovators were naïve and expected the NASSS-CAT [ 20 ] to be easy to comprehend and use as they identified complexities in their own innovations. As mentioned previously, by using the CCA interpretations from multiple perspectives (the 4 cases), a shared understanding and language regarding how to interpret the questions in the NASSS-CAT was established. The results from the CCA revealed that each of the 4 innovators needed to clarify or consider a number of points in their own NASSS-CAT analysis while assessing complexities in each of the domains. The most important issues were as follows:

To define the time frame and the scope that the innovator is assessing.
To define the intended users and adopters at the time of the studied project.
To rethink the way in which the value proposition can be measured.
To consider that questions in the NASSS-CAT regarding ownership; supply chains; and use and spread at the local, regional, national, and international level belong to both “Domain 5: organization” and “Domain 2: technology.”

Moving Forward in Supporting Bottom-Up Innovation

This study explored insights from the NASSS framework, revealing that the adoption and dissemination of technological innovations are influenced by organizational and systemic factors rather than by the innovations themselves. The success of bottom-up innovators in navigating complexities emphasizes common challenges across innovations. The NASSS framework has illuminated various perspectives that can either facilitate or impede the adoption, scale-up, and dissemination of technological innovations.

The 4 bottom-up innovators managed to navigate through the complexities within the innovative system, uncovering overarching challenges that unified their respective innovations. However, it is essential to recognize that the NASSS-CAT cannot be used as a linear checklist. Existing support systems, while aiming to foster innovation, may unintentionally follow a linear approach rather than embracing frameworks suitable for complex interventions, such as the Medical Research Council guidance [ 75 ]. To better support health care innovators, a “midway filter system” is needed, which offers profound insights into innovation within complex systems. Implementing such a filter between top-down and bottom-up approaches would facilitate bidirectional knowledge transfer. It would enable clinical insights, ideas, and innovations to be discussed in harmony with the regulatory framework, ultimately leading to improved and equitable health care as envisioned by Tierney et al [ 10 ], who found that localized, regional, and flexible innovations can shape care in the future [ 10 ]. Incentives to connect bottom-up initiatives with a top-down vision at a national level in building systems for digital innovation and health IT are presented by Sheik et al [ 67 ] from the United Kingdom. We share their vision to improve usability and interoperability and integrate bottom-up with top-down resources.

Our study, similarly to the research by Batalden and Davidoff [ 76 ], discusses the complexities of integrating grassroots idea innovations into established health care systems. Batalden and Davidoff [ 76 ] highlight the need for organizational changes and a shift in culture to recognize the value of patient-driven innovations and effectively incorporate them into clinical practice.

Future studies should consider a translation project of the NASSS framework from English into Swedish. This would facilitate the framework’s use in a Swedish context, similar to the translations of health-related quality of life questionnaires, which follow guidelines to ensure validity in terms of language and culture [ 53 ]. In addition, an evaluation is recommended alongside updates to the NASSS-CAT. Some subquestions may benefit from further splitting, such as assessing the likelihood of technology obsolescence or the measurement of alternative ways to evaluate innovation. It is crucial to involve relevant stakeholders in these changes. Cultural adaptation should receive significant emphasis to provide a language that is relevant to the Swedish context. We also suggest that future studies explore similarities and differences regarding the existence of complexities when bottom-up innovations are developed and implemented in other regions. Finally, we consider making a follow-up prospective evaluation of our 4 innovations. By doing this, we can possibly review the impact of this study on the long-term outcomes of each innovation using the NASSS-CAT LONG.

The Progress of the 4 Cases

The insights gained from our exploration of the existence of complexities in innovation processes led to some of the presented innovations being appreciated in the VGR. The Digi-Do and the D-Foot have gradually, during the study, been acknowledged as important in building future care with digital tools. The VGR has granted the innovator of the D-Foot the legal rights to be spread nationally and internationally and to be implemented and scaled up to prevent DFUs through early screening.

The Digi-Do has been evaluated, and the results show a positive effect on the users, indicating reduced levels of distress and an improved sense of preparedness [ 43 , 77 ]. Hence, the difficulties in evaluating soft values have been successfully dealt with. Since the analysis presented in this paper, the intellectual properties have been transferred to the VGR together with the RT department, and updated versions of the Digi-Do are underway.

Learnings from the complexity assessment of the PoC Dashboard [ 54 ] helped address the challenges differently by going for a simpler technical solution with less dependencies on other information systems and focusing on core features such as supporting patients and health care professionals in the planning and evaluation of care. This was done by adapting Dialog+, which is both a tool to measure and monitor patient-reported outcome measures and patient-reported experience measures and a solutions-focused methodology, to fit Swedish psychiatric care [ 78 ]. It has since then been piloted and tested for >4 different patient groups in mental health care settings and is being implemented as part of routine psychosis care. The MoodMapper is not an active innovation project in Sweden. However, it is used internationally in research to map behavior changes in mental disorders [ 79 , 80 ].

Conclusions

The NASSS framework increased the bottom-up innovators’ understanding of the role of complexity in their innovations. The analysis provided valuable insights by identifying and bringing attention to complexities, particularly within the broader system, albeit requiring a deep understanding. This study enriched our comprehension of the pervasive role of complexity in bottom-up innovations within public health care and shed light on the practical utility of the NASSS-CAT. Early use of a validated tool aids in identifying complexities and pinpointing the domains in which these complexities exist. Importantly, even when bottom-up innovations arise within the same support organization, the complexity can vary based on the developmental phase and the unique characteristics of each project. Identifying, defining, and understanding complexity may not solve the issues but substantially improves the prospects for successful innovation implementation provided the right expertise is available to support the process.

Successful innovation within complex organizational structures necessitates a comprehensive understanding and an adaptive leadership to surmount cultural resistance and organizational impediments. A rigid, linear, and stepwise approach risks disregarding interconnected variables and dependencies, leading to suboptimal outcomes. Success lies in embracing the complexity with its uncertainty, nurturing creativity, and adopting a nonlinear methodology that accommodates the iterative nature of innovation processes within complex organizations.

Acknowledgments

The authors are most grateful for the collaboration with the Innovation Platform in Region Västra Götaland. They would also like to acknowledge the Regional Cancer Centre West, the Department of Prosthetics and Orthotics at Sahlgrenska University Hospital, and the Department of Schizophrenia Spectrum Disorders at Sahlgrenska University Hospital for their support.

Data Availability

The data sets generated during and analyzed during this study are available from the corresponding author on reasonable request.

Conflicts of Interest

None declared.

Description of each of the 4 cases of bottom-up innovations in Swedish health care, including a presentation of how the innovations relate to the 7 domains of the nonadoption, abandonment, scale-up, spread, and sustainability complexity assessment tool.

A constant comparative analysis of how to interpret the 7 domains of the nonadoption, abandonment, scale-up, spread, and sustainability complexity assessment tool.

Complexities in the 4 bottom-up innovations assessed using the nonadoption, abandonment, scale-up, spread, and sustainability complexity assessment tool.

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Abbreviations

Edited by A Kushniruk; submitted 18.07.23; peer-reviewed by M Aanestad, J Wells; comments to author 20.11.23; revised version received 24.02.24; accepted 02.03.24; published 26.04.24.

©Ulla Hellstrand Tang, Frida Smith, Ulla Leyla Karilampi, Andreas Gremyr. Originally published in JMIR Human Factors (https://humanfactors.jmir.org), 26.04.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Human Factors, is properly cited. The complete bibliographic information, a link to the original publication on https://humanfactors.jmir.org, as well as this copyright and license information must be included.

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Case Studies on Bottom-up Approaches
This collection of case studies demonstrates examples of successful implementation of bottom-up approaches (BUA) across the globe. Each case utilizes components of BUA within the planning, decision making, and/or implementation processes. Browse through these case studies using the interactive map below, or search for specific terms to find ...
Top Down & Bottom up Approaches
Example Case Study: Bottom Up Approach - Peru. Bottom-up development schemes are relatively low cost; Usually organised by NGOs and/or local people; They target the poorest communities and involve local people at all stages; Use appropriate technology which can be maintained and used by local people;
Bottom Up Development
Adapt Assessment. Exam-specific revision content for every subject. Unlimited past paper questions on every topic. Personalised, examiner feedback on your answers. Everything you need to know about Bottom Up Development for the GCSE Geography B Edexcel exam, totally free, with assessment questions, text & videos.
Top-down Paternalism Versus Bottom-up Community Development: A Case
An alternative bottom-up community development process is proposed based on the principles such as social inclusion, participation and empowerment. ... Mendes P. (2018). Community as a spray-on solution: A case study of community engagement within the income management programme in Australia. Community Development Journal, 53(2), 210-227 ...
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The Bottom-Up Development Model as a GovernanceInstrument for the Rural Areas. The Cases of Four Local Action Groups (LAGs) in the United Kingdom and in Italy ... case studies are summarized in ...
Are Bottom-Up Approaches in Development More Effective than Top-Down
This article analyzes both the top-down and bottom-up approaches of development interventions in the Global South with reference to historical backgrounds and particular case studies.
Supporting bottom-up development in cities in the developing world
This has important implications both for the theoretical understanding of the sociological foundations of human development, and for the development of social policy. The research evidence strongly supports the inclusion of bottom-up local NGOs as partners in designing and implementing public policy.
Supporting bottom-up development in cities in the developing world
The United Nations (UN)'s 11th Sustainable Development Goal is to "make cities inclusive, safe, resilient, and sustainable" by 2030. Stigma, violence, and social exclusion present significant barriers to achieving this. Urban communities such as Brazil's favelas face harsh conditions of living, including poverty, violence, and segregation.
Who Should Be at the Top of Bottom-Up Development? A Case-Study of the
It is widely acknowledged that top-down support is essential for bottom-up participatory projects to be effectively implemented at scale. However, which level of government, national or sub-national, should be given the responsibility to implement such projects is an open question, with wide variations in practice. This paper analyses qualitative and quantitative data from a natural experiment ...
[PDF] Who Should Be at the Top of Bottom-Up Development? A Case-Study
Abstract It is widely acknowledged that top-down support is essential for bottom-up participatory projects to be effectively implemented at scale. However, which level of government, national or sub-national, should be given the responsibility to implement such projects is an open question, with wide variations in practice. This paper analyses qualitative and quantitative data from a natural ...
(PDF) 'Bottom-up' Approaches in Governance and Adaptation for
The book also includes case studies from India and Bangladesh, which show that community-level factors such as social and cultural capital are key to the success of sustainable development efforts ...
Who Should Be at the Top of Bottom-Up Development? A Case Study of the
It is widely acknowledged that top-down support is essential for bottom-up participatory projects to be effectively implemented at scale. However, which level of government, national or sub-national, should be given the responsibility to implement such projects is an open question, with wide variations in practice.
Full article: Identifying the merits of bottom-up urban development
Our subject is a complex, contemporary phenomenon, which is why we chose for a multiple case study approach (Yin, Citation 2014). The main units of analysis (i.e. cases) are former industrial areas undergoing transformative changes given organic development ambitions, in which bottom-up initiatives have emerged in recent years.
Bottom Up Development in Mumbai
Evaluate the success of the SPARC project. Your answer should include: Time / Permits / 800 / Toilets. Click to reveal answer. Everything you need to know about Bottom Up Development in Mumbai for the GCSE Geography B Edexcel exam, totally free, with assessment questions, text & videos.
Bottom-up innovation for health management capacity development: a
Bottom-up innovation for health management capacity development: a qualitative case study in a South African health district. Marsha Orgill, 1 Bruno Marchal, 2 Maylene Shung-King, 1 Lwazikazi Sikuza, 3 and Lucy Gilson 1, 4 ... We recommend that further research is undertaken to understand bottom-up capacity development from a systems ...
Bottom-up community development: reality or rhetoric? the example of
Bottom-up community development 23 1 The case study focused on the Kingsmead Kabin, a community project on the Kingsmead Estate, situated in one of the most disadvantaged wards in England and Wales (Office of the Deputy Prime Minister, 2004a). Opened in 1939 and adjacent to Hackney Marsh, during the 1990's the
Theory and Practice of Community Development: a Case Study from the
The top-down approach has roots in Victorian benevolent paternalism, while the bottom-up approach is associated with radical neighborhood action. Community development is considered in the context of current British government initiatives aimed at addressing social exclusion1 and health improvement targets.
Top-down bottom-up strategic green building development framework: Case
These case studies were selected based on three different types of building: hospitals, shopping malls, and office buildings. The building's names were treated confidentially, per the request of the building managers. For the green buildings, case study 1 was a state development head office located in the heart of the administrative centre.
Who Should Be at the Top of Bottom-Up Development?: A Case Study of the
It is widely acknowledged that top-down support is essential for bottom-up participatory projects to be effectively implemented at scale. However, which level of government, national or sub-national, should be given the responsibility to implement such projects is an open question, with wide variations in practice.
'Bottom-up' Approaches in Governance and Adaptation for Sustainable
Books. 'Bottom-up' Approaches in Governance and Adaptation for Sustainable Development: Case Studies from India and Bangladesh. Pradip Swarnakar, Stephen Zavestoski, Binay Kumar Pattnaik. SAGE Publications, Jun 23, 2017 - Science - 368 pages. This book analyzes how governance and climate change adaptation - both integral to sustainable ...
Bottom-up innovation for health management capacity development: a
Background As part of health system strengthening in South Africa (2012-2017) a new district health manager, taking a bottom-up approach, developed a suite of innovations to improve the processes of monthly district management team meetings, and the practices of managers and NGO partners attending them. Understanding capacity as a property of the health system rather than only of individuals ...
What are the differences between top-down and bottom-up development
Bottom-up strategies - these are usually small-scale development projects aimed at the poorest communities through the actions of non-government organisations (NGOs). They are usually less expensive due to their smaller sale.
PDF Bottom-up innovation for health management capacity development: a
Methods: We conducted a realist evaluation, adopting the case study design, over a two-year period (2013-2015) in the district of focus. The initial programme theory was developed from 10 senior manager interviews and a ... tacit and experiential knowledge to enable relevant 'bottom-up' capacity development in district health systems. By ...
Sustainability
Using Lhasa, Tibet, as a case study, the coupling and coordination relationships among the three systems were analysed to explore the impact of tourism behaviour on sustainable tourism development. Utilising panel data from 2010 to 2020, the carbon emissions of tourism activities were calculated using a bottom-up approach.
Exploring the Role of Complexity in Health Care Technology Bottom-Up
Background: New digital technology presents new challenges to health care on multiple levels. There are calls for further research that considers the complex factors related to digital innovations in complex health care settings to bridge the gap when moving from linear, logistic research to embracing and testing the concept of complexity. The nonadoption, abandonment, scale-up, spread, and ...

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Impact case study

Professor Sandra Jovchelovitch

What was the problem?

What did we do?

What happened?

Related content

Impact case study

Professor Sandra Jovchelovitch

What was the problem?

What did we do?

What happened?

Related content

Bottom Up Development in Mumbai

Advantages and Disadvantages

Bottom-up innovation for health management capacity development: a qualitative case study in a South African health district

Bruno Marchal

Maylene Shung-King

Lucy Gilson

Associated Data

Supplementary Information

The local setting: DHS in South Africa

Bottom-up innovation

The suite of inter-linked innovation

Research question

Eliciting the programme theory (PT)

Hypothesized mechanisms

Proximal outputs

Study design

Definition of the case and of the unit of analysis

Site selection

Data collection

Data analysis

Synthesis and comparison of CMO findings with the programme theory

Results section

Context and actors

The suite of inter-linked innovations to develop management capacity

Mechanisms for change

Introducing a new agenda in the extended DMT meeting: sensemaking and sensegiving as reciprocal processes

Embedding the use of information for problem diagnosis and problem solving: sensegiving and sensemaking as a social process

Sensegiving to NGOS: crafting and managing key relationships to attract resources and support

The number and distribution of managers in the team: negotiation as sensegiving

Did practices continue over time?

The competency for complex sensemaking

Sensegiving and social sensemaking

Proximal outputs and emergent capacity development

Limitations

Acknowledgements

Abbreviations

Availability of data and materials

Publication: Who Should Be at the Top of Bottom-Up Development?: A Case Study of the National Rural Livelihoods Mission in Rajasthan, India

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GCSE | Edexcel A Revision | Global Development | What strategies address uneven development?

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What are the differences between top-down and bottom-up development projects?

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Exploring the Role of Complexity in Health Care Technology Bottom-Up Innovations: Multiple-Case Study Using the Nonadoption, Abandonment, Scale-Up, Spread, and Sustainability Complexity Assessment Tool

Original Paper

Corresponding Author:

Introduction

The Challenges

Theoretical Framework

Design and Methodological Approach

Ethical Considerations

The 4 Bottom-Up Innovations

Case 1: The D-Foot

Case 2: The MoodMapper

Case 3: The Digi-Do

Case 4: A Point-of-Care Dashboard for Schizophrenia Care (the PoC Dashboard)

Study Procedure