Title: Towards a mid range theory of implementation An iterative grounded approach By B.V.L.Narayana, Faculty, Railway staff college, Vadodara, Gujarat, India E-mail:
[email protected] ABSTRACT Failure of implementation of strategies is ubiquitous as the phenomenon is still not well understood. This stems from the fact that it is still a neglected subject in strategy research, leading to a lack of development of theory and its subsequent cumulation to guide further research and practice. Yet its understanding holds the key to understanding of Sustained competitive advantage and strategic change. Methodologically, research on implementation has been hampered by the poor use of processual studies and the requirements of considerable time and effort at doing them. Thus a necessity exists for the development of a mid range theory of implementation which could guide research and through them practice. This paper attempts to fill this gap. Using a multiple case embedded design; a processual study of the implementation of four national programmes in three states was conducted. An iterative process of explanation grounded in data coupled with literature enfolding facilitated the development of a mid range theory. It positions the concept of resource dependency as central to process of implementation. It utilizes the concept of “Implementation organization” from public policy, “Cognitive architecture” from literature on learning, construct of “Motivation to produce” representing the fields of organizational theory and strategic management and concepts of VRIN resources and “attention theory” to develop this theory of implementation. Implementation has been shown to be the management of resource dependency of the organization, characterized by the identification of “Key resources”. The management of this requires attention of the top management to facilitate direction of the macro processes in line with the stated aim and governance of the micro processes for effective execution of the service delivery components. Thus implementation is a function of attention, direction and governance. Key words: Implementation, mid range theory, resource dependency, organisational attention, governance mechanisms
1 Electronic copy available at: http://ssrn.com/abstract=1937293
Introduction: The utility of any tool lies in its effective usage and so is the case with strategy. Strategy is the instrument through which a firm attempts to exploit opportunities available in the business environment. The performance of a firm is a function of how effective it is in converting a plan to exploit these opportunities in the business environment into action and executing it. Great strategies are worth nothing if they cannot be implemented (Okumus and Roper 1999). It can be extended to say that better to implement effectively a second grade strategy than to ruin a first class strategy by ineffective implementation. Less than 50% of formulated strategies get implemented (Mintzberg 1994; Miller 1997; Hambrick and Canella 1989). Every failure of implementation is a failure of formulation. Thus implementation is the key to performance, given an appropriate strategy. The field of Strategic management has grown in the last thirty five years developing into a discipline in its own right. Borrowing extensively from Economics and Social sciences, it is still fragmented by the presence of number of distinct schools of thought, diversity in underlying theoretical dimensions and lack of disciplined methodology. The fragmentation is due to high degree of task uncertainty and lack of coordination in research —a result of lack of uniformity and focus between the strategy field, its base disciplines and practitioners (Elfring and Voelberda 2001 pp 11). One of the main impacts of pluralism has been the neglect of use of processual studies leading to methodologically inappropriate attempts at research on implementation. The result has been a lack of a mid range theory on implementation which could guide further research. Thus there is a felt need for integration across disciplines contributing to Strategic management theory and attempt to cumulate the disparate elements of existing body of knowledge. Scholars have suggested that the first step in integrating the disparate elements of theory is to develop a set of mid range theories on critical and central phenomenon(Hambrick 1979) such as implementation, decision making, learning, alliance management, innovation etc. Work in developing mid range theories in strategy is still young. It needs to be looked at in preference so as to enable the field to develop its definitive place by developing a research and methodological philosophy suited to its area. Implementation as a concept is ideally sited to serve this purpose. It is central to the understanding of the basic question being addressed by the field “how and why are some firms able to give consistently above average performance over time?” Mid range theories are the linking pins between a grand unified theory and working hypotheses. A lack of mid range theories leads to poor inter-subjective agreement on operational definition of constructs, leading to theories with high state of abstraction and which are distant from the actual observations. These do not generate subsequent empirical studies. On the other hand, it can lead to empirical studies with little description and verification of theory (Hambrick 1979). This paper attempts to address this issue of lack of a formal theory of implementation and therefore contribute to the process of cumulation and integration of the disparate body of knowledge on strategy implementation. The paper will first quickly review the status of extant research on strategy implementation. Then it builds the case for generation of a midrange theory of implementation. This is followed by the research design and methodology followed in the empirical study conducted A detailed analysis and
2 Electronic copy available at: http://ssrn.com/abstract=1937293
discussion follows leading to the generation of a mid range theory of implementation. The paper concludes with the contributions, limitations and implications for future research. Literature Review: Implementation is conversion of strategic intent into executive action (Camillus 1981). Implementation, being a non-linear, dynamic process involving multiple variables which show causal reciprocity, takes time and effort (Hrebiniak and Joyce 2001; Farjoun 2002; Miller 1997; De Leon 1999). Processual studies are the recommended method of study for this phenomenon (Pettigrew 1997; Schofield and Sausman 2004). Implementation is still a subject of neglect in research in health care, public policy and strategic management (Noble 1999; Sinclair 2001; Narayana 2010). A recent survey of Strategic management (Hutzschenreuter and Kleindienst 2006) and Health care (Narayana 2010) literature for articles which have actually looked at the process of implementation yielded only 21 out of 991 and 48 out of 268 short listed articles respectively. Same is the status in the field of policy implementation (Saetren 2005). Research in Health care, seems to be more focused on disease specific issues or policy content issues such as health financing (Narayana 2010). Those which look at program implementation are focused on impact assessment instead of finding why such an impact resulted (process evaluations). They are also plagued by methodological issues such as small sample size, publication bias, lack of use of control groups, Non reporting of confounding factors and poor identification of statistically significant results (Oliveracruz, Hanson and Mills 2001). Domination by content research and emphasis on formulation or policy issues (Bourgeois1980; Hutzschenreuter and Kleindienst 2006; Schofield 2001; Narayana 2010) is also seen in the parent fields of Policy implementation and Strategic management, both of which influence research in health care. Despite the increasing stress on process research in recent times (Chakravarty and Doz 1992; Pettigrew et al 2002; Patton 2002; Miles and Gilson 1995) there have been very few such empirical studies. The result is there is lack of theory building and a dominant operational framework (Hrebiniak and Joyce 2001; Schofield and Sausman 2004; Narayana 2010). Desires of achieving outcomes; be it in health or any other field; require conversion of intent into action. Practioners, who actually convert such intent into action, require to be guided and educated about the process of effective implementation. The availability of a dominant operational framework which tells them of the steps to be taken in the field (Alpert 1938) requires that it be based on a sound mid range theory. .Thus a felt need for a midrange theory of implementation exists. Methodology Understanding implementation and programme performance requires identification of factors, their Operationalisation and inter-linkages at different levels of a programme and the system. It also needs to be studied, over time and in the social and economic context where such programme implementation is occurring. Non existence of a theory of implementation necessitates that a theory be generated from empirical data using an inductive approach and thus requires a qualitative processual study (Pettigrew 1997).
3 Electronic copy available at: http://ssrn.com/abstract=1937293
This paper is based on a much larger Doctoral dissertation. A multiple embedded case based processual study (Yin 2003; Pettigrew 1992; 1997) with interlinked multiple units of analysis was designed. It looked at the implementation process of select national health programmes in three states in India. The programmes were selected to capture the maximum variations in the programme characteristics. Control of Blindness (NBCP), Tuberculosis (RNTCP), Vector borne diseases (NVBDCP) and Reproductive child health (RCH) programmes were studied in the states of Gujarat, Tamil nadu and Kerala identified as exemplars based on a theoretical sampling strategy (Patton 2002). Retrospective histories of key participants numbering 161 (30 headquarters; 74 district; 47 field officials and 10 consultants) were collected for a period varying from 3 to 10 years. Secondary data was collected to substantiate and validate issues arising in the retrospective histories. Four case studies at State health system, with 11 at programme, 27 at district and 19 embedded case lets at unit level were realised. In the Case of Kerala, two cases resulted – one a historical study of the system from 1870 to 1985 and the other from 1985 to present day (2008). Using the field unit as the smallest embedded unit, an iterative process of generating explanations (Yin 2003, p122; Orton 1997; Langley 1999) for performance linking all events and referencing back to the case allowed patterns in each case to be identified. Similar patterns were developed for districts, programmes and the state health system, duly connecting the contextual factors which emerged at each level of analysis. Thus an embedded analysis emerged linking activities and events over time and across levels resulting in a context sensitive and holistic explanation (Patton 2002, p 447; Pettigrew1997). For the comparative analysis across units but within programme and across programmes, a simple framework-SPICE1 was used. Similarities and differences; Patterns; Independencies and dependencies; Discontinuities and continuities and Likely Evolution (SPICE- Dixit and Shah 2009) of the activities observed in the cases helped to generate a multiple variable, complex, casual explanation duly considering possible rival explanations (Yin 2003, p20,22,122). It then helped generate within programme, district and unit level frameworks and finally a process model or “Operational framework”. Literature enfolding (Eisenhardt 1989) enabled theoretical validation of the framework and generation of a tentative mid range theory of implementation. For this study, policy and strategy are taken as equivalent as both represent directioning activities leading to achievement of objectives. Resource is defined as tangible or intangible thing over which the organisation has control and is able to use it for its activities (Wernerfelt 1984) The Context: Health care services in India are delivered through the private and the public sector. The public sector dominates the delivery system in the rural context and is responsible for delivery of all national health programmes. In the Indian federal set up, the state 1
This framework was first used by Shri Rasik bhai shah; a retired school principal. Prof Dixit (IIM A) extended the use of this framework in various fields of business policy. I could establish E-Mail contact with Shri Shah and was explained the details and process of applying this framework on 8-12-2009. The author would like to place on record the help and contribution of Shri Rasik Shah. A Search among literature did not yield any similar framework, Except SPICE as a similar acronym is used in Software process development. The contents are totally different.
4
governments are responsible for the management of the health care system while funding is a combination of central grants and state budget allocations. The public health system is a three tired set up (Figure1 below) modelled on the primary health care system (WHR 2000) with each tier acting as a gateway for referrals. Figure 1: Structure of the public health system in India at district level Sub centre: 1 female+1 male trained worker/ 5000 population (can be reduced to 2000-3000) in tribal and hilly areas
PHC: medical officer+ paramedical staff/ 30000 population, supervise 6 sub centres
Community health centre/ 100000 populations 30 bedded hospital
The administrative set up mirrors this set up with the District as the lowest unit, followed by the state and then the central government. The central government is also the prime policy making body. The national health programmes are implemented under this set up. Programmes and Service Delivery Conditions: The National blindness control programme tackles, predominantly, loss of vision due to Cataract and refractive errors in school going children. Revised National Tuberculosis control programme attempts to control the incidence of tuberculosis through a combination of diagnosis by sputum microscopy and directly observed treatment system. National vector borne disease control programme aims to control a set of diseases caused by different pathogens but are vector transmitted such as Malaria, filariasis etc. Reproductive Child Health programme covers an entire spectrum of activities related to women and children covering the entire life cycle of health, nutrition and population such as Pregnancy and its related activities, infant and child health conditions and adolescent health including reproductive tract infections. Characteristics of the programme have a significant impact on how the implementation is to be managed (CGDEV 2007). This includes critically the structuring of service delivery components, the personnel involved and the inter-linkages between the various components in form of dependencies. This determines the coordination costs involved in implementation (Thompson 1967) and influences the choice of governance mechanisms. The quantum of coordination costs and degree of inter-dependencies is the least in Blindness control and maximum in Reproductive child health programme (See Table 1).
5
Table 1: Comparison of programme characteristics2 Characteristic
RCH
NVBDCP
RNTCP
NBCP
Issue identification
Programme, district and Unit heads
Programme heads, district chiefs
Programme heads,
Issue incorporation mechanisms Knowledge exchange mechanisms Users
Initiatives, Training
Programme, district and Unit heads Initiatives, Training
Initiatives, Training
Initiatives, Training
Formal training – institutes, field, on job MO, LT,
Formal training – institutes
MO, FHW, specialists
Formal training – field, on job MO, MHW, LT
Feed back mechanisms
Process monitoring
Focal cases monitoring
Outcome monitoring
Key resources
MO, FHW, specialists
MO, LT, MHW
Patient follow up, quality assurance MO, LT
Macro processes for direction
Budgeting and Planning; procurement and supply, recruitment and selection, training, linkages to referral units Monitoring and evaluation
Budgeting and Planning; procurement and supply, recruitment, training Monitoring ,quality assurance Provision for alternate resources,
Budgeting and Planning; management of incentive mechanisms Sourcing of technology equipment; training
Governance mechanisms for management of key resources Linkages to operational structures
Recruitment and postings; Training; linkages to referral units
Budgeting and Planning; procurement supply, recruitment; Monitoring ,evaluation Provision of alternate resources Provision of alternate resources, procurement and supply, recruitment
Provision of alternate resources, procurement and supply, Training and quality assurance
Management of incentive mechanisms
Process monitoring, supervision, referral transportation, Community needs assessment
Focal out break monitoring, vector control activities, supervision
Drug and consumables supply ; quality checks; patient categorization and follow up, supervision
Monitoring of incentives payments, enrollment of institutions
Indicators and targets
Infant Mortality Rate =85% 89 82 79 Cure rate under RNTCP Utilization of services OPD 75% 28** 22*** 28 IP 75% 40.1** 35.6*** 40.8 Rev. Budget as % of total 8% 6.2 5.5 5.5 $ Figures are for 2005 * Latest figures are for 2003 & Latest figures for 2004 ** figures are for 1995-96 *** are for 2004
GUJARAT
2006
INDIA
2001 50.67 60 202
2006
2001 1028.7 66 327
2006
28.29 477 18 64.8
81.34 69 0
89.83 545 0 75.4
2085.4 3306 2061
1780.7 12317 2842 1390
0 2 1 0
19 0 0 NA
45 5 0 0
1005 53 479 NA
1704 184 658 0
0 8 0 1
2 1 0 0
2 11 0 1
2 3 2 0
2 12 3 1
127.5 123.7 5.01 0.72$ 82
NA NA 4.9 1.09 78
102.1 99 6.1 0.98$ 86
NA NA 4.49 1.12 80
2132 2068 5.03 1.01$ 83
22 40.1 4.5
22 32.1 10
18 31.3 3.5
20 45.3 NA
19 41.7 NA
37 134
53 172
57 301
Sources: Government of India; Central bureau of Health Intelligence; Sample registration surveys; National sample surveys and TB India reports
8
Table 3: Performance of districts under select programmes for period 2004-05 to 2006-07 Name of unit Sabar kantha Kheda
Achievement RCH*
Achievement NVBDCP
Achievement RNTCP
Consistent grade A
Consistent cure and detection rates –above target Consistent cure and detection rates–above target
Kutch
Falling grade B to C
Surendra nagar Jam nagar
Consistent B grade
Mahesana
Falling grade A to B
API between 1 and 2 from 2003. Falling caseload in 2006. API 1 in 2007 High API >14 in 2004-05 and 2005-06. 0.86 In 2006-07. Falling number of cases. API 0.35 in 2007 API>12 IN 2003 and 2004. Falling API but >2.5 in 2006, 4 in 2007 High API > 5 from 2002 onwards. API of >4 in 2006; 2.2 in 2007
