Understanding the Implementation of Performance Management Interventions in the Primary Healthcare System of El Salvador. A Case Study of the Salud Mesoamerica Initiative 2015-2017
Open AccessBackground: Governments around the world are increasingly adopting performance management (PM) interventions to strengthen primary healthcare (PHC) systems. How and why these interventions work is not well understood. The purpose of this dissertation was to examine the successful implementation of team-based PM interventions in the PHC system of El Salvador under the Salud Mesoamerica Initiative (SMI) to better understand the context, processes, and organizational level implementation outcomes to inform PM intervention design, implementation, and evaluation.Methods: The dissertation research adopted a two-paper model and conducted a theory-driven, single case study using 27 key informant interviews and program related documents. A program theory (PT) was developed, and a hybrid thematic analysis approach was applied to data analysis. The first paper characterized how the implementation of team-based PM interventions contributed to PHC system performance improvements. Concept mapping and causal diagrams helped make sense of the identified relationships between processes and implementation outcomes. The second study characterized system antecedents, initial organizational conditions, and implementation context. Data was coded using the Consolidated Framework for Implementation Research. Document review allowed an understanding of the system antecedents and implementation contextual conditions. Results: The first study revealed the convergence of two processes: 1) increased social interactions and relationships among implementers that enhanced communication and created opportunities for social learning; and 2) cyclical performance monitoring that generated novel flows of information. These processes contributed to emergent outcomes, including the uptake of performance information, and their spread through time plausibly contributed to system-wide improvement in teams’ performance across the 14 SMI municipalities. Based on the findings, the PT change model was refined. The second study assessed system antecedents and initial conditions that created a favorable environment for the PM interventions. It examined key contextual factors present during implementation. It found that the confluence of program implementation and the PHC system setting pre-existing in El Salvador, contributed to the emergence of a functional PM system with the features described in paper 1. It also found ‘tipping points’ that changed system-wide performance. Based on the findings, the PT action model was refined. Discussion: This study provides insights into the implementation of PM interventions within the context of universal health coverage reforms in El Salvador. Findings illustrate the social nature of implementation processes and describe plausible pathways through which contextual factors created favorable conditions necessary for lower-order implementation program outcomes to emerge that, in turn, contributed to higher-order performance improvement across the SMI ecosystem. Among the key findings was the availability of novel performance information flows connecting actors across the SMI ecosystem. This information was, in turn, purposefully used by PHC teams and MOH decision makers to inform improvements to service planning and delivery and introduce changes to their managerial practices. This case study highlights three key leverage points to improve system performance: 1) novel flows of information; 2) creation and sustainment of policy dialogue spaces; and 3) creation and sustainment of feedback and learning spaces for PHC teams. These findings can inform future PM intervention design, implementation, and evaluation.
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