Diffusion of complex health innovations—implementation of primary health care reforms in Bosnia and Herzegovina

• Published in: Health policy and planning 2007-01, Vol.22 (1), p.28-39
• Main Authors: Atun, Rifat A, Kyratsis, Ioannis, Jelic, Gordan, Rados-Malicbegovic, Drazenka, Gurol-Urganci, Ipek
• Format: Article
• Language: English
• Subjects: Ambulatory care; Bosnia and Herzegovina; Bosnia Herzegovina; Bosnia-Herzegovina - Health conditions; Bosnia-Herzegovina - Social policy; Civil war; Diffusion of Innovation; family medicine; GDP; Gross Domestic Product; Health administration; Health care; Health care policy; Health Care Reform; Health policy; health systems; Hospitalization; Hospitals; Humans; Infrastructure; Initiatives; Innovation; Innovations; International; Interviews as Topic; Medicine; Mortality; Original articles; Patient satisfaction; Per capita; Physicians; Population; Primary care; Primary health care; Primary Health Care - organization & administration; Public health; Qualitative research; Reconstruction, Postwar; Reform; Reforms; Studies; Surveys and Questionnaires; War
• ISSN: 0268-1080; 1460-2237
• DOI: 10.1093/heapol/czl031

Most transition countries in Central and Eastern Europe and Central Asia are engaged in health reform initiatives aimed at introducing primary health care (PHC) centred on family medicine to enhance performance of their health systems. But, in these countries the introduction of PHC reforms has been particularly challenging; while some have managed to introduce pilots, many have failed to these scale up. Using an innovation lens, we examine the introduction and diffusion of family-medicine-centred PHC reforms in Bosnia and Herzegovina (BiH), which experienced bitter ethnic conflicts that destroyed much of the health systems infrastructure. The study was conducted in 2004–05 over a 18-month period and involved both qualitative and quantitative methods of inquiry. In this study we report the findings of the qualitative research, which involved in-depth interviews in three stages with key informants that were purposively sampled. In our research, we applied a proprietary analytical framework which enables simultaneous and holistic analysis of the context, the innovation, the adopters and the interactions between them over time. While many transition countries have struggled with the introduction of family-medicine-centred PHC reforms, in spite of considerable resource constraints and a challenging post-war context, within a few years, BiH has managed to scale up multifaceted reforms to cover over 25% of the country. Our analysis reveals a complex setting and bidirectional interaction between the innovation, adopters and the context, which have collectively influenced the diffusion process. Family-medicine-centred PHC reform is a complex innovation—involving organizational, financial, clinical and relational changes—within a complex adaptive system. An important factor influencing the adoption of this complex innovation in BiH was the perceived benefits of the innovation: benefits which accrue to the users, family physicians, nurses and policy makers. In the case of BiH, policies or the innovation are not simply disseminated, but rather assimilated into the health system. The assimilation and implementation of the new PHC model relied on the consensus of a diverse group of adopters; the changes brought by the reforms were aligned with the expectations of the adopters: this created a ‘receptive context’ for adoption and diffusion of the innovation. The new family-medicine-centred PHC service model had a major impact on professional identity, inter-professional