Improving health service delivery organisational performance in health systems: a taxonomy of strategy areas and conceptual framework for strategy selection

Health systems strengthening (HSS) is a priority for global health funders, policy-makers and practitioners. Although many HSS efforts have focused on policy levers such as financing approaches, payment schemes or regulatory reforms, less attention has been directed to targeting the organisations that deliver health services such as hospitals, health centres and clinics. Evidence suggests that the impact of organisation-level interventions varies by context; however, we lack a general framework for integrating organisational context into performance improvement strategies for health service delivery organisations. Drawing on open systems theories from organisational behaviour and management as well as a review of 181 empirical studies of health service delivery organisations in low- and middle-income countries, we propose a taxonomy of seven strategy areas for improving organisational performance as well as a multistage conceptual framework for selecting among them. We propose that the choice of strategy for improving health service delivery organisational performance should be informed by: (i) the root cause of the organisation's performance gap; (ii) the environmental conditions facing the organisation; and (iii) the implementation capability of the organisation. We also highlight conditions under which different strategy areas may be expected to be optimally effective. The approaches presented in this paper offer a way for health system decision-makers and researchers to systematically assess and incorporate organisational context in the process of developing strategies to improve the performance of health service delivery organisations and, ultimately, of health systems.