The adoption and institutionalisation of social innovation in the Malawian health system: the influence of software factors.

BACKGROUND: Universal Health Coverage (UCH) is embedded as a core goal of the Sustainable Development Goals (SDGs). Achieving these goals in Africa requires innovative and creative solutions that are owned at a country level and are responsive to the contextual and cultural realities. The prevailing paradigm through which health programmes and policies are developed is through expert-driven, top-down approaches in which participation of a broader range of actors from across sectors and governance levels, especially engagement of the communities, while encouraged, remains limited. This approach aligns with a mechanistic and economic-reductionist perspective of health systems and fails to account for the system software (human) dimensions, such as ideas, values, relationships and power dynamics. Social innovation has gained attention as an alternative approach to addressing complex systemic challenges – namely, as a ‘complex process of introducing a new program, policy, procedure, process and or design that seeks to address a systemic health challenge and intends to ultimately to shift resource and authority flows, social routines and cultural values of the system that created the problem in the first place. Implementing social innovation can be conceived as an evolving process with the potential to bring about institutional change within systems – provided it is institutionally embedded. Despite the presence of a growing number of social innovations in low and middle-income countries (LMIC), evidence on social innovation in health systems is limited. This thesis examines whether social innovation has a contribution to make to LMIC health systems and how a social innovation initiative can be embedded into the public health system in a low-income country such as Malawi. METHODS: The purpose of this study was to explore the adoption and institutionalisation process of a primary care social innovation in the context of Malawi and to identify the software factors influencing these processes. The research was undertaken as an interdisciplinary qualitative inquiry, situated within the realm of health policy and systems research (HPSR). It was conducted in 2017 - 2020. Two methodologies used were: a semi-systematic narrative scoping review and a case study. The scoping review was comprised of peer-reviewed publications in English over a 10-year time period (2010-2020) and focused on social innovation as applied health or healthcare, from different disciplinary perspectives. The case study was selected, that of ‘Chipatala Cha Pa Foni’s (health centre by phone) adoption and institutionalisation process as part of the public health system of Malawi’. A conceptual social innovation framework, integrating micro-, meso- and macro-level insights from institutional theory, positive organisational scholarship and positive psychology was used to guide the thinking and development of the data collection and analysis. Data were obtained from interviews, observations and document reviews and data collection occurred over 18-months. A total of 54 participants were interviewed from the Ministry of Health, the implementing NGO, community leadership, and other health implementers. Data was triangulated and thematically analysed, drawing on the conceptual framework, through deductive and inductive approaches. RESULTS: Existing social innovation studies held several limitations. First, social innovation studies did not report research methods frequently or in detail, hence making it challenging to assess the quality of evidence. Second, the majority of studies explored social innovation in healthcare from a technocratic paradigm, neglected the institutional paradigm. Social innovation shows alignment with the principles of people-centred health systems, through fostering cross-disciplinary and multistakeholder action. In the case study conducted in Malawi, it was found that a small group of institutional entrepreneurs lead the adoption efforts. This group was extended to include more cross-sectoral and cross-hierarchical actors in support of the institutionalisation process. Five critical software factors emerged as key in supporting adoption and institutionalisation namely: i) cross-boundary relational construction; ii) shared experiences; iii) positive emotions; iv) everyday innovation; and v) contradictory institutional logics influencing national ownership (Malawian collectivist and national identity logics, versus development or Western individualist logics). Multiple positive practices supported each of these software factors in the context of Malawi such as respectful engagement, mutuality, experiential educating, facilitated shared space, shared leadership, hope, advocacy, symbolic work and creative embedding. A collectivist logic, underpinned by history, culture and national identity, had an important influence as to whether national ownership of this initiative was attained. CONCLUSION: Beyond the value of social innovation offers as practical solutions in support of the achievement of Universal Health Coverage, the process of social innovation may hold even greater potential. Social innovation as a process challenges the prevailing instrumental notion of health systems by moving the dial towards more responsive and participatory governance, while simultaneously giving attention to new and dormant resources within the health system. Adopting a logic-attuned implementation approach and utilising positive practices can strengthen national ownership of social innovation and support in achieving its outcomes. Social innovation’s potential to support the institutional strengthening of the technical but also human dimensions of health systems merits further inquiry