How to work with intangible software in public health systems: some experiences from India

Abstract

This commentary focuses on “intangible software”, defined as the range of ideas, norms, values and issues of power or trust that affect the performance of health systems. While the need to work with intangible software within health systems is increasingly being recognized, the practical hows of doing so have been given less attention. In this commentary, we, a team of researchers and implementers from India, have tried to deliberate on these hows through a practice lens. We engage with four questions of current relevance to intangible software in the field of health policy and systems research (HPSR): (1) Is it possible to rewire intangible software in health systems? (2) What approaches have been attempted in the Indian public health system to rewire intangibles? (3) Have such approaches been evaluated? (4) What practical lessons can we offer from our experience on rewiring intangibles? From our perspective, approaches to rewiring intangible software recognize that people in health systems are capable of visioning, thinking, adapting to and leading change. These approaches attempt to challenge the often-unchallenged power hierarchies in health systems by allowing people to engage deeply with widely accepted norms and routinized actions. In this commentary, we have reported on such approaches from India under six categories: approaches intended to enable visioning and leading; approaches targeted at engaging with evidence better; approaches intended to help health workers navigate contextual complexities; approaches intended to build the cultural competence; approaches that recognize and reward performance; and approaches targeted at enabling collaborative work and breaking power hierarchies. Our collective experiences suggest that intangible software interventions work best when they are codesigned with various stakeholders, are contextually adapted in an iterative manner and are implemented in conjunction with structural improvements. Also, such interventions require long-term investments. Based on our experiences, we highlight the need for the following: (1) fostering more dialogue on this category of interventions among all stakeholders for cross-learning; (2) evaluating and publishing evidence on such interventions in nonconventional ways, with a focus on participatory learning; and (3) building ecosystems that allow experiential learnings on such interventions to be shared.

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

“…The predominant focus on workforce capability in particular, for example, by enhancing individuals’ skills through training or provision of decision support, is very rarely accompanied by efforts to tackle the major and persistent problems of serious workforce shortages (capacity). Although poor management and leadership are often retrospectively identified as causes of intervention failure it is surprisingly uncommon for interventions to include deliberate efforts to improve organisational relationships or other elements of ‘intangible software’ 49. As we emphasise, it is also critical for intervention designs to go beyond even these three core resources.…”

“…Although poor management and leadership are often retrospectively identified as causes of intervention failure it is surprisingly uncommon for interventions to include deliberate efforts to improve organisational relationships or other elements of ‘intangible software’. 49 As we emphasise, it is also critical for intervention designs to go beyond even these three core resources.…”

Strengthening implementation of integrated care for small and nutritionally at-risk infants under six months: pre-trial feasibility study

“…People are at the heart of systems, the “intangible software” that make, shape and break implementation success (Trisha Greenhalgh & Chrysanthi Papoutsi, 2018; Ramani et al, 2022). Our study emphasised that the micro-context of the personal relationship between health workers and mothers may be critical and influential to implementation strength and quality (Carl R. May et al, 2018).…”

“…Unpacking the nature and influence of research levers we use, as well as individual and systems reactions and responses during implementation, will be important to capture through RCT evaluation, to identify 'nugget' mechanisms of action and any "re-wiring" that happens (Ramani et al, 2022), to contextualise findings, inform transferability and bridge the evidence to practice gap (Harvey et al, 2023).…”

Addressing Disparities in Pediatric Congenital Heart Disease: A Call for Equitable Health Care

“…Participatory learning and action techniques have demonstrated their effectiveness in increasing community engagement with health systems, especially in lower‐middle‐income countries. 94 By actively participating in the learning and decision‐making process, individuals from low‐SES groups become more informed and are better equipped to advocate for themselves. Participatory learning and action techniques also offer a platform for voicing their concerns, bridging the gap between their circumstances and the health care system.…”