Table 1 Examples of interventions that have been attempted to rewire intangible software in India

Approaches intended to enable visioning and leading

 1. No one wants to feel like their job is meaningless: informal gatherings and discussions to understand overarching policy visions and values

When a community monitoring intervention was initiated by the Society for Community Health Awareness Research and Action (SOCHARA) in Tamil Nadu, frontline workers were worried that this “monitoring” process would be used to unfairly accuse them of faults that they believed to be systemic. Hence, the workers were unwilling to cooperate. However, rather than start with an attitude of confrontation, staff from SOCHARA spent a lot of time just informally talking to health workers about notions of accountability and helping them understand why community monitoring processes had value and meaning. The informal discussions helped the health workers to accept the intervention

High-level support from the state authorities and government orders are needed. Not all people were willing to collaborate and be a part of this process, despite the existence of a government order. It was found that in some geographical pockets, people were more willing, and that these pockets could be used to demonstrate to the others who were hesitant the usefulness and value of this community monitoring process

 2. Leadership trainings and nonclinical capacity-building initiatives

The Institute of Public Health has conducted district-level training programmes to build “champions” and “leaders” in Karnataka. There were reports of initial resistance to the training as there was a belief among the health workers that they were being tested during these training sessions. Hence, prior to the training, an extended rapport-building phase was necessary. A detailed evaluation of this training programme has been published [23]

There were anecdotes regarding resistance from the public sector staff to being trained as some of them felt that they were being tested. It took some time for the staff to relax into the programme. The evaluation found that the responses from different geographical divisions varied

 3. It is one champion who can nurture others: Exposure of staff to inspirational examples

An ex-medical officer from a primary health centre shared that in the state she hailed from (anonymized), new recruits were exposed to exemplars or positive deviants in the public health system. This was done as a part of their induction training and aimed to provide new recruits with good role models to look up to, and, in the long term, to potentially add to the tribe of positive deviants in the health system

People learn both good and not-so-good practices from champions; thus, the champions must be carefully chosen. Even champions can’t work without basic infrastructural support

Approaches targeted at engaging with evidence better

 4. Helping routine data to speak differently through eye-opening data workshops

A series of workshops was conducted by the National Health Systems Resource Center on recognizing and engaging with health inequities in the data that health workers routinely encountered. These workshops gave people an opportunity to relook at routine data through a different lens—what the staff had earlier perceived as boring, routine data was used to enable a process of reflection

In some of the district pockets, the officials had attempted to recognize inequities and reach the more vulnerable in their programme in practical ways

 5. Reinforcement of achievements locally using local data

One researcher-cum-implementor used facility-level data in a low-income state in India to engage in discussions with primary care nurses. Nurses looked at synthesized data and tried to reflect on their local achievements. The self-recognition of positive achievements seemed to play an important role in boosting local morale

The lack of supporting infrastructure is a deterrent to even the most motivated of nurses

Approaches targeted at navigating complexities in the context

 6. Buddy systems

This has been tried in some public medical college hospitals in different states in India. Buddy systems attempt to pair young recruits with champions or exemplars, who serve as mentors and support new workers through complex decision-making

The buddy system example here focuses on doctors, but it was suggested that it would be useful to have buddies across cadres. This system would be more effective if exemplars/stalwarts in the health systems came forward themselves to be “buddies” to younger staff

 7. Putting people in a safe space outside of work to reflect: informal reflective spaces

A district-level official from one of the southern states in India conducted a series of residential workshops with the heads of different implementation bodies across sectors in order to break the hesitancy of people as regards collaborating across sectors. These workshops provided space for reflection and bonding away from work. No targets or checklists were used or discussed

Such workshops should be long-term, have repeated sessions over time, and preferably be residential—so that space to reflect and bond together without the interference of routine work is enhanced

Approaches intended to build the cultural competence of health workers and to enhance community relationships

 8. Common understandings: people and the system need to understand each other

The Ekjut trial on PLA took place in Jharkhand and Orissa. In this intervention, regular and iterative meetings were facilitated by accredited social health activists (ASHAs) (link workers associated with the Indian public health system) with women’s groups over 31 months [21]

The intervention needs to be participatory, even at the expense of time issues. Change is a time-consuming process

 9. How to talk to the community trainings: explicit soft skills and communication trainings

In 2018–19, the Center for Enquiry into Health and Allied Themes (CEHAT) led a training intervention on domestic violence for health workers in two tertiary care hospitals in Maharashtra [24]. By codesigning the intervention with stakeholders, incorporating mixed-cadre training sessions and including explicit “soft skill” communication skills as part of the training, this training worked towards tweaking the culture within health facilities to be more sensitive to domestic violence issues

Programme staff realized that conveying some of these concepts, such as “equity” and “gender responsiveness”, during training was not straightforward. It was perceived by staff that attitudinal changes were easier to bring about in younger staff

Approaches that recognize and reward performance

 10. Social awards and incentives

The Kayakalp award scheme is run by the central health ministry in India and recognizes and awards health facilities that demonstrate their commitment to cleanliness, hygiene and infection control practices

Social awards have to be used carefully—for wrongly chosen award schemes (or corrupt awarding practices) can be demotivating

Approaches targeted at enabling collaborative work and breaking power/gender hierarchies

 11. Building confidence: training on soft skills, public speaking and speaking in English

Basic Health Services in Udaipur offered nurses formal leadership positions at primary care clinics [25]. The organization noticed that nurses were culturally hesitant about taking up leadership positions. The nurses were trained using a hybrid technical and soft skills module to build their rigour and confidence. It was reported that public-speaking skills, and particularly learning to speak in English, helped to boost nurses’ confidence

Structural and software interventions were needed to help nurses take up leadership positions. Leadership workshops must be seen only as one important step in trying to break down power hierarchies. Building leadership skills takes time

 12. Sensitization workshops within the health system

The Resource Group for Education and Advocacy for Community Health (REACH) in Tamil Nadu has been supporting the Revised National Tuberculosis Control Programme [now the National TB Elimination Programme (NTEP)], to adopt a gendered lens to TB. As part of these efforts, a gender-responsive training curriculum was developed and piloted with NTEP in October 2020. The training used participatory techniques (including power walks) to sensitize people to power and gender hierarchies

An evidence base was needed to make a stronger case for gender responsiveness before embarking on the workshops, and this was achieved through a TB and gender assessment, followed by the adoption of a gender framework by the national programme. Such trainings must try to balance concepts along with granular action, and help participants understand how they can apply their learning in their specific roles