The diffusion of managerial practices in performance perspective: a review of transfer models in health systems

INTRODUCTION

For several decades, public organisations landscape is changing with globalization which has imposed market orientation and public service performance according to new public management (NPM) orientations. In this context, managerial practices (MP) frequently developed in private sector are increasingly adopted by public organizations to improve their performance. MP, especially contracting practices related to financial incentives, good governance, and participatory management practices, are then transferred in different domains and at different levels.^1,2 Overall, the NPM has imposed its orientations in public services of both developed and developing countries. In this review, we are interested in health systems of developing countries (HSDC). We focus our analysis on the transfer models of managerial practices (TMMP).

In recent years, HSDC have been implementing reforms to improve their performance by adopting new MP known as performance-based financing (PBF) practices. These reforms consist of offering financial incentives to health actors based on performance contracts that are evaluated in the context of health funding. Literature shows that the adoption of PBF practices was facilitated and encouraged by many “diffusion entrepreneurs”, including the World Bank which is the main donor.³ Generally, the transfer process of PBF practices in HSDC, has brought to structural and organizational transformations in the NPM perspective.⁴ However, HSDC reacted differently to those changes caused by the transfer of new MP. On one hand, transfer models (TM) are characterized by “success story” and “failure story” in different settings.^5,6 On the other hand, TM lead to a mix of success and failure within the same setting; hence there is an interest in conducting this review on TMMP.⁷

Different TM have been developed in the literature. We identified three types of these models. In the first type, researchers aimed at suggesting TM which set criteria for analysing the transferability of practices before their “importation” into new settings.^8-12 With the second type, authors have proposed TM which analyse key factors and actors involved during the “implementation” process.^13-16 The last type of TM which has been proposed by researchers, aimed at analysing the extent to which practices can be “exported” to new settings.^17,18 Despite the proliferation of TM, we realise that some action mechanisms as important aspects of those models are ignored. Yet few of them seem to be widely used for many reasons, among them the lack of consensus on which should be used or when.¹⁹

This paper aims at presenting our view of the state of the art in TMMP in HSDC. It helps to identify new research approaches to overcome TM issues. In the methodological approach, our review is both broader and oriented than the major existing literature.^15,19 Burchett et al considered that there are many models with set criteria for assessing transferability while yet few seem to be widely used. So these authors test these tools to assess how easy they were to use and how useful they appeared to be. Sieleunou et al adapting Dolowitz’s model, studied the transfer of specific policies as a result of strategic decisions taken by actors inside and outside the government.¹⁵

Our approach is focussed more broadly in the TMMP as a result of the “continuous story” of new public management. Moreover, it is narrower since we consider TM in a performance perspective related to the ongoing diffusion of PBF in HSDC. We identified ten TM in different articles from databases such as Business Source Premier, Scopus, Springer (journals), and Google scholar. These databases were chosen because they generally cover fields of management and public health. The selection of those ten TM was based on criteria related to the research theme. Concerned articles were published in French and in English between 2006 and 2019. During this period, PBF as one of financial incentives were much transferred to HSDC.

Then, we organized the review around a series of questions which are raised explicitly or implicitly not only by the literature, but also by observation.^15,20 What is the transfer? Why is there MP transfer in HSDC? Which models are used for transferring MP in HSDC? What are the steps of TMMP in HSDC? What problems are there with the current TMMP in HSDC?

While answering those questions, the full implication became clear after using selected TM to answer to those questions. To this end, we used observation techniques and content analysis to answer and bring out findings of this literature review.

TRANSFER MODELS FOR MANAGERIAL PRACTICES IN HEALTH SYSTEMS

What is the transfer?

Literature shows several definitions which have been given to better understand this concept. In fact, transfer is generally defined as a generalization of the skills or behaviours received as well as their maintenance over a period of time.²¹ This definition of transfer assumes that a new practice must be adopted and accepted in the new setting. Faced with diverging opinions on these concepts, some researchers suggest defining them in their contexts, while others prefer to often use them interchangeably by adding complementary aspects.^2,22 Then different attributes were provided in both literatures to facilitate understanding the scope of transfer process.

Thus, there are authors who indicate that transfer is an economic and adaptive process that allows the cognitive system to circumvent some of its limits in a problem-solving approach.²² In this way, transfer as epiphenomenon involves many organizational transformations that include professional quality improvement. In addition, it has been shown that the understanding of transfer extends to the key elements to be transferred for the process success.²³ This includes for example hard elements (regulations, policy instruments, work tools) and soft elements (skills, principles, ideas, or organizational culture).

For other authors, the understanding of the transfer process can go through its different degrees (integral, emulation, combination, or inspiration) and its different types (voluntary, coercive, or mixed).¹⁵

Then, we define transfer as an inter-organizational or institutional process which involves several actors and multiple factors in a specific route to introduce, implement and spread policies and practices from one setting to another. This process should concern policies and practices from a given perspective, in a given field and at different levels. The concept of transfer finally refers to an exchange of practices between two or more settings; some being in need while others having solutions to share. It is in this exchange that TM are designed to facilitate this relationship.

Why is there MP transfer in HSDC?

Generally, organisational problems must first be felt to exist in order for innovation or change to occur. Globalisation is prompting the introduction of MP to improve quality services in public organisations because they have been characterized by poor performance for many decades. Then, one of the key elements to be considered by public managers is the innovation diffusion process.² The idea was to introduce MP in those organisations in the perspective of performance improvement. The most transferred MP in this context are contracting practices related to financial incentives, good governance, and participatory management practices.¹

Literature has shown overall that there is a generalizable relationship between financial incentives and desired goals.²⁴ This is the main reason why financial incentives, as part of contracting practices, are being transferred in HSDC for a couple of decades. All these MP are widely spread according to NMP orientations to strengthen HSDC.⁴

However, this generalization gives rise to criticism in certain case studies. Some studies in countries like France show that there are not enough empirical results to support or reject the use of financial incentives to improve the quality of primary care.^24,25 While in some developing countries, human resource redeployment programs to rural areas have been successful through the establishment of financial incentives.²⁶ This is a dilemma context in which financial incentives as part of MP are transferred in some developing countries.

There has been a strong interest of researchers on the transferability and diffusion of health interventions, particularly the different types of financial incentives as well as their effects on the quality of health services. These types include practices such as pay-for-performance, performance-based incentive, result-based bonus, performance-based financing, results-based financing, quality-based purchasing, results-based aid, and the value-based purchasing. Despite the diversity of these types of MP, their basic principle remains the same. It refers to “the transfer of money or material goods conditional on taking a measurable action or achieving a predetermined performance target”.²⁷ From this characterization, it raises the question related to the process and the extent to which these MP are transferred from one setting to another in order to reach the desired performance. This question arises from the fact that new MP are introducing structural changes without being able to consider that these positive or negative changes are caused solely by the factor relating to financial incentives. Literature, for example, shows that even if the transfer of financial incentives is done in performance perspective, its process includes many actors with various targets, and results are different from one setting to another.^3,28 The intervention of those actors would be the origin of the continuing contradictory debate between supporting researchers, and critic researchers stressing the weakening PBF practices within HSDC.^29,30

The transfer of financial incentives as part of MP is important for improving the performance of HSDC. However, the transfer process should be rethought with a view of adapting it to contexts and actors changes.

Which models are used for transferring MP in HSDC?

The existence of TM depends on several reasons, including dissatisfaction or the status quo which often characterize current organisational practices. This is the case of many public services characterized by poor performance and which are introducing new MP according to new public management in the globalization context. Other origin factors of TM design concern the search for new approaches to deal with problems whose characteristics have changed.³¹ This includes the imposition of practices by intermediary actors as well as the potential role of external factors such as socioeconomic, technological, political factors, organizational changes, and pressures from different stakeholders. TM consist of import-export processes of policies and practices in a dynamic relationship of sharing. Then we have categorised the ten TM identified in three main types which are developed by researchers.

First, researchers developed TM which set criteria for assessing the transferability of practices. These types of TM aim at analyzing the applicability of some practices before they spread out in new settings. These TM suggest taking into account origin and target factors during their transfer process. Among these factors, authors identify internal and external organization environments, similarities, and differences between origin and target settings.^8,12 In these conditions, some authors emphasize on the importance of supporting the implementation process of transferred practices.⁹ Some other researchers have developed TM on the identification of basic elements in a transferability analysis. These are functions of the practices to be transferred, the needed resources for the implementation of practices within a new setting, and other contextual factors.^10,11 While analyzing this first type of TM, we found that they were developed to be used upstream of the transfer process.

Then, there is another type of TM which assesses practices transfer during the implementation process. The authors focussed on analyzing the process and influencing factors. These TM are characterized by the analysis of multiple factors that facilitate or constrain the transfer process. Most of these models answer the questions of "who, what, where, how, and when?" of the transfer process.¹⁵ Thus, some authors identify, for example, decision-making power as one of the aspects of the transfer and the lack of a legal act clarifying the conditions as one of the factors constraining the transfer process.¹⁵ While other authors insist, for example, on the need to set up principles such as users' perceptions to facilitate the transfer process, especially when it comes to be decision-making tools.¹⁶ Some of these TM such as the Normalization Process also help to explain the processes by which complex interventions are systematically integrated into existing practices, for example by institutional arrangements.^13,14 The analysis we made on this second type of TM shows that there are multiple factors that facilitate or hinder the transfer process. We note that these TM were developed for use when implementing transfer processes.

Finally, there are TM developed to study the diffusion of practices in other different settings. Authors who developed these TM intended to analyze the extent to which practices can spread out among target settings. Mostly, these TM identify diffusion factors such as the innovative nature of practices to be spread as well as the diffusion causes related in particular to the “learn from others”.^17,18 According to our analysis from this last type of TM, we noticed that several factors encourage the inspiration or the “learn from others” techniques. It seems to us that these TM were developed to be used downstream of the transfer process.

While identifying these models used to transfer MP in health, we want to clarify that some aspects deserve to be integrated into new models. This could be the factor related to interaction between all actors involved in the transfer process.

What are the steps of TMMP in HSDC?

There are increasing concerns regarding TM since the implementation of new MP must be contextualized.²⁸ In many HSDC, different strategies have been adopted according to NPM orientations. In recent years, MP that became widespread in those countries, are PBF practices of developed countries origin. We found that TM of these MP were promoted by the World Bank who mainly funded implementations and also developed a toolbox for this process. Thus, TM used to “import” and “export” PBF practices seem to have more similarities than differences. They converge with four main steps. These are the implementation of pilot projects, the evaluation of pilot projects results and the generalization or abandonment of the implementation. These first three steps are each reinforced by an important transversal step. This step includes assessment practices for regular adaptation.

Considering pilot projects, literature shows that countries involved in PBF reforms passed through the first phase which entails the development of pilot projects.⁷ In developing countries, this preliminary phase consists in introducing this type of payment mechanism to improved performance in several areas of health care. In most cases, pilot projects result in increased use of services, health coverage and improved quality of services.^5,29 However, in some other cases, these phases can fail.^6,32 Nevertheless, opportunities are often supported by donors to rethink and adapt pilot projects activities based on the challenges encountered.⁷ During adapting activities, it is important to take into account contextual factors because it could facilitate appropriation by local actors as suggested in some TM.^8,12

After pilot project implementation, there comes the step of its assessment. Like any project, there is a need for monitoring and evaluation of different aspects of PBF pilot projects. The monitoring consists of regularly collecting and analyzing information intended to provide project managers and stakeholders with necessary elements for management and decision-making. Evaluation is a periodic process of critical analysis of the relevance, efficiency, and impact of the project in relation to its initial objectives, strategy, and available resources.

Pilot project assessment is important because managers could decide, according to progress to go beyond pilot implementation.⁷ It is also important because several aspects of program implementation, such as timely disbursement of incentives and monitoring transparency and health facility performance could be further strengthened to maximize PBF impact.³³ Pilot project assessment could also help to adjust the PBF scheme more closely to context and to the original planning.³⁴ The assessment practice however could help to discover institutional arrangements in the transfer process of MP.¹⁴

The implementation of the pilot project and the result of its assessment are followed by the generalization or the abandonment of new practices. Generally, pilot projects are assessed positively in order to be generalized at all levels of HSDC. However, this generalization created contradictory debate among the scientific community on the real benefits of PBF; especially in developing countries.³⁵ This debate is overall more important because some countries are experiencing many difficulties in PBF implementation, while others prefer to abandon this project.^6,28,32 That is why ideas are arising to suggest undergo regular evaluation by targeting areas of poor performance to better understand implementation and adaptation factors that modify it effectiveness.³³

Overall, there has been an important number of PBF programs implemented differently in developing countries. Literature showed that this idea was from developed countries and the diffusion was facilitated by many actors among them, the World Bank. This spread model seems to converge with the process of policy transfer and diffusion in three dimensions: the global, international, and transnational levels, the macro-level, and the inter-organizational level.²

Our view is that the transfer of MP in HSDC is a complex systemic process including introduction, implementation, and diffusion steps. Accordingly, the steps seem to be interconnected even if the used TM seems to ignore the relation between actors involved and contextual factors in the transfer process. We further found that the transfer process of PBF practices is an ongoing process related to contextual factors and actors changes.

What problems are there with the current TMMP in HSDC?

Despite the proliferation of TM, some of them have remained theoretical for many reasons, including unrealistic criteria, a little focus on potential effectiveness in the new setting, and a lack of an explicit focus on their mechanisms of action.¹⁹ We have shown that many HSDC have chosen to consider origin and target factors as TM. During the implementation process, steps or practices are often distorted when it comes to adapt them to local settings. This transformation increases uncontrolled consequences on the desired performance because the literature shows that “the search for best practice can often lead to a tendency to discount or ignore some of the inherent problems and limitations of new approaches or the conditions necessary for their effective application”.³⁶

Then, existing efficient TM have limitations on the fact that they ignore the existence of interconnected steps as well as contextual factors and actors changes in the transfer process. On our view, TM should go beyond by integrating mechanisms of action focussing on stakeholders’ interactions during the transfer process to overcome existing performance paradox. This idea meets with the fact that during the transfer of HR practices, social relationships between organizations influence the outcome of the process.³⁷ Even international actors play a certain role especially in the transfer process, we cannot ignore that actors are able to shape a subset of different factors “by taking certain decisions regarding transferability, adoptability and process design, albeit within the boundaries of the environment”.^23,38 It is hoped that this approach will avoid the functional complexity caused by the transfer process within HSDC and limit consequences that could arise from contexts asymmetry.

CONCLUSION

This paper aimed at presenting our view of the state of the art in TMMP in HSDC. Literature shows that “transfer” is both complex and systemic process, especially in the health sector, as some authors have demonstrated. Aside from the fact that few TM seem to be widely used, we found that existing TM ignore taking into account interactions that exist in transfer processes as well as the evolution of key actors and changes in contextual factors.

This article has shown the need to create new models for the efficient transfer of managerial practices in public health organisations. We propose to develop new TMMP which consider changes in the import-implement-export process and where the role of interactions between involved actors and contextual factors is highlighted in the perspective of performance improvement. The transfer process of PBF practices could likely serve as case study to set up new TMMP in HSDC.

In order to avoid creating more and more new tools, without reflecting on their utility, new approaches need to be tested and discussed to overcoming transfer process issues towards desired performance in many HSDC.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

1. 1. Jetté C, Goyette M. Social practices and managerial practices: possible convergences? New Soc Pract. 2010;22(2):25-34.
2. 2. Marsh D, Sharman JC. Policy diffusion and policy transfer. Policy Stud. 2009;30(3):269‑88.
3. 3. Gautier L, Tosun J, De Allegri M, Ridde V. How do diffusion entrepreneurs spread policies? Insights from performance-based financing in Sub-Saharan Africa. World Dev. 2018;110:160‑75.
4. 4. Turcotte-Tremblay A-M, Gautier L, Bodson O, Sambieni NE, Ridde V. The role of global health actors in expanding performance-based funding in low-income countries. J Med Manag Econ. 2018;36(5):261-79.
5. 5. Roland EEA. Performance based Financing as a Health System Reform: Success Story on how the Application Performance based Measures Improve Performance both in Quantity and Quality of Health in South West Region. Texila Int J Manag. 2019;5(1):66‑72.
6. 6. Kiendrébéogo JA, Shroff ZC, Berthé A, Yonli L, Béchir M, Meessen B. Why performance-based financing in chad failed to emerge on the national policy agenda. Heal Syst Reform. 2017;3(2):80‑90.
7. 7. Shroff ZC, Bigdeli M, Meessen B. From scheme to system (part 2): findings from ten countries on the policy evolution of results-based financing in health systems. Health Syst Reform. 2017;3(2):137‑47.
8. 8. Wang S, Moss JR, Hiller JE. Applicability and transferability of interventions in evidence-based public health. Health Promot Int. 2006;21(1):76‑83.
9. 9. Cambon L, Minary L, Ridde V, Alla F. A tool to support the transferability of health promotion interventions: ASTAIRE. Public Health. 2014;26:783-86.
10. 10. Villeval M, Bidault E, Shoveller J, Alias F, Basson JC, Frasse C, et al. Enabling the transferability of complex interventions: exploring the combination of an intervention’s key functions and implementation. Int J Public Health. 2016;61(9):1031-8.
11. 11. Fianu A, Villeval M, Naty N, Favier F, Lang T. Analyzing the transferability of an intervention: application of the key functions / implementation / context model to a diabetes prevention program. Public Health. 2017;29(4):525-34.
12. 12. Schloemer T, Schröder-Bäck P. Criteria for evaluating transferability of health interventions: a systematic review and thematic synthesis. Implement Sci. 2018;13(1):88.
13. 13. May C, Finch T, Mair F, Ballini L, Dowrick C, Eccles M, et al. Understanding the implementation of complex interventions in health care: the normalization process model. BMC Health Serv Res. 2007;7(1):148.
14. 14. Bertone M-P, Meessen B. Studying the link between institutions and health system performance: a framework and an illustration with the analysis of two performance-based financing schemes in Burundi. Health Policy Plan. 2013;28(8):847‑57.
15. 15. Sieleunou I, Turcotte-Tremblay A-MM, Yumo HA. Transferring the purchasing role from international to national organizations during the scale-up phase of performance-based financing in Cameroon. Health Syst Reform. 2017;3(2):91‑104.
16. 16. Street RB, Pringle P, Lourenço TC, Nicolletti M. Transferability of decision-support tools. Climate Change. 2019;153(4):523‑38.
17. 17. Gandara D, Rippner JA, Ness EC. Exploring the ‘How’ in policy diffusion: national intermediary organizations’ roles in facilitating the spread of performance-based funding policies in the states. J Higher Educ. 2017;88(5):701‑25.
18. 18. Abomo P. The diffusion of pay for performance in health system reforms in sub-Saharan Africa and the depoliticization of health intervention. Soc e Cult. 2018;21(2).
19. 19. Burchett H, Blanchard L, Kneale D, Thomas J. Assessing the applicability of public health intervention evaluations from one setting to another: a methodological study of the usability and usefulness of assessment tools and frameworks. Health Res Policy Syst. 2018;16(1):88.
20. 20. Chiang FFTT, Lemański MK, Birtch TA. The transfer and diffusion of HRM practices within MNCs: lessons learned and future research directions. Int J Hum Res Manag. 2017;28(1):234‑58.
21. 21. Baldwin T, Ford K. Transfer of training: a review and directions for future research. Pers Psychol. 1988;41(1):63‑105.
22. 22. Bracke D. Towards a theoretical model of transfer: the constraints to be respected. J Educ Sci. 1998;24(2):235-66.
23. 23. Stone D. Understanding the transfer of policy failure: bricolage, experimentalism and translation. Policy Polit. 2017;45(1):55‑70.
24. 24. Dormont B. Payment for performance: unethical or in the service of public health? Les Trib la santé. 2013;40(3):53.
25. 25. Scott A, Sivey P, Ouakrim DA, Willenberg L, Naccarella L, Furler J, Young D. The effect of financial incentives on the quality of health care provided by primary care physicians. Cochrane Database Syst Rev. 2011(9).
26. 26. Bertone MP. The challenge of retaining health workers in rural areas: analysis of the strategies implemented in seven French-speaking African countries. Public Health. 2018;S1(HS):33-43.
27. 27. Oxman AD, Fretheim A. Can paying for results help to achieve the Millennium Development Goals? Overview of the effectiveness of results-based financing. J Evid Based Med. 2009;2(2):70‑83.
28. 28. Renmans D, Holvoet N, Criel B, Meessen B. Performance-based financing: the same is different. Health Policy Plan. 2017;32(6):860‑8.
29. 29. Zeng W, Sun D, Nair D, Nam JE, Gheorghe A. Strengthening performance-based financing as a health system approach for quality improvement. J Glob Health. 2018;8(2).
30. 30. Paul E, Albert L, Bisala BN, Bodson O, Bonnet E, Bossyns P, et al. Performance-based financing in low-income and middle-income countries: isn’t it time for a rethink?. BMJ Glob Health. 2018;3(1):e000664.
31. 31. Turner E, Green S. Understanding policy convergence in Britain and Germany. Ger Polit. 2007;16(1):1‑21.
32. 32. Ssengooba F, McPake B, Palmer N. Why performance-based contracting failed in Uganda- An “open-box” evaluation of a complex health system intervention. Soc Sci Med. 2012;75(2):377‑83.
33. 33. Zeng W, Shepard DS, Rusatira J de D, Blaakman AP, Nsitou BM. Evaluation of results-based financing in the Republic of the Congo: a comparison group pre–post study. Health Policy Plan. 2018;33(3):392‑400.
34. 34. Bodson O, Barro A, Turcotte-Tremblay A-M, Zanté N, Somé P-A, Ridde V. A study on the implementation fidelity of the performance-based financing policy in Burkina Faso after 12 months. Arch Public Health. 2018;76(1):4.
35. 35. Soucat A, Dale E, Mathauer I, Kutzin J. Pay-for-performance debate: not seeing the forest for the trees. Heal Syst Reform. 2017;3(2):74‑9.
36. 36. Bresnen M, Marshall N. Understanding the diffusion and application of new management ideas in construction. Eng Constr Archit Manag. 2001;8(5/6):335‑45.
37. 37. Björkman I, Lervik JE. Transferring HR practices within multinational corporations. Hum Resour Manag J. 2007;17(4):320‑35.
38. 38. Minkman E, van Buuren MW, Bekkers VJ. Policy transfer routes: an evidence-based conceptual model to explain policy adoption. Policy Stud. 2018;39(2):222‑50.