Table 1

Managerial responses to challenging conditions: what strategies are applied and do they indicate everyday resilience? (drawing on ref.22)

Experience presentedResilience strategy
Responding to disruption anticipating future uncertainty
Everyday resilience indicated by experience?
Absorptive strategiesAdaptive strategiesTransformative strategies
Kilifi PHC facility manager: tackling cash shortfalls after devolutionFacility 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 devolutionSCHMT 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)
Yessustained support for facility in charges, enabled continued service delivery and tackled outbreak
Nousing 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 activityYescommitment to priority-setting decisions demonstrated, as well as innovative ways of tackling resource constraints and sense of duty, with gains for patient care/services
Noincome earning departments prioritised over others, in face of budget constraints
Sedibeng managerial actionsIndividual managers find ways to cope with computer and space constraints, and manage moratorium on staff appointmentsManager secures additional resources for CHW teams, given a new opportunityYescommunity services expanded; some degree of PHC functionality maintained
NoPHC functionality not sustained or coping strategies themselves undermine service delivery
Mitchell’s Plain subdistrict managers act to strengthen their relationships with facility managersMultiple 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 accountabilityresponding to imposed changes and taking advantage of new opportunities for ways of workingYessustained 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 goalsmoving 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 timeYescontinued 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.