Managerial responses to challenging conditions: what strategies are applied and do they indicate everyday resilience? (drawing on ref.22)
| Experience presented | Resilience strategy Responding to disruption anticipating future uncertainty | Everyday resilience indicated by experience? | ||
| Absorptive strategies | Adaptive strategies | Transformative strategies | ||
| Kilifi PHC facility manager: tackling cash shortfalls after devolution | Facility manager works with clinic committee members to reintroduce user fees as a coping strategy for current funding shortfalls Clinic committee members support facility manager in standing up to challenge from county-level officials | Yes—local solution scaled up temporarily across county; services continue to be delivered locally No—fees imposed on poor households | ||
| Kilifi County managerial actions: supporting service provision and managing crises after devolution | SCHMT members draw on personal resources to continue work and personally defend facility managers from criticism by new county politicians County manager delays implementation of national instruction to downsize SCHMT | SCHMT secured alternative funding for supervision (from programme managers) and cholera outbreak (from NGOs) SCHMT adapted supervision process in response to funding challenges (combining monthly meetings and visits to least well-performing facilities) | Yes—sustained support for facility in charges, enabled continued service delivery and tackled outbreak No—using own funds and other resources not sustainable solutions | |
| Kilifi County hospitals’ budget prioritisation processes (see box 1) | Medical superintendent uses inclusive and deliberative processes of decision-making and priority setting, involving diverse range of actors and generating ownership of decisions made, instead of the usual hierarchical processes, with potential for spin-off influence over other areas of hospital activity | Yes—commitment to priority-setting decisions demonstrated, as well as innovative ways of tackling resource constraints and sense of duty, with gains for patient care/services No—income earning departments prioritised over others, in face of budget constraints | ||
| Sedibeng managerial actions | Individual managers find ways to cope with computer and space constraints, and manage moratorium on staff appointments | Manager secures additional resources for CHW teams, given a new opportunity | Yes—community services expanded; some degree of PHC functionality maintained No—PHC functionality not sustained or coping strategies themselves undermine service delivery | |
| Mitchell’s Plain subdistrict managers act to strengthen their relationships with facility managers | Multiple changes to routine managerial processes and activities intended to democratise meetings, support learning through doing, offer mentorship, establish new routines of proactive facility management, establish new modes of accountability—responding to imposed changes and taking advantage of new opportunities for ways of working | Yes—sustained changes in the way subdistrict managers engage facility managers; hints of service improvements at facility level But sustained change in managers’ practice fragile | ||
| Mitchell’s Plain: strengthening the HAST programme (see box 2) | New ways of working established between colleagues from different organisations working towards same goals—moving away from rule-based relationships based on organisational decrees to developing framework of relational norms and values to guide collective responses to new situations over time | Yes—continued collaborative working after some months in supporting service delivery, and spill over into other programmes | ||
CHW, community health worker; HAST, HIV/AIDS/sexually transmitted infections/tuberculosis; NGO, non-governmental organisation; SCHMT, Sub-County Health Management Team.