Where is the ‘theory’ in theory of change? Analysing four local theories of change in a systemwide integrated care initiative

Background and context: Theory of change is a structured participatory process that articulates how and why an intervention is assumed to work.   Theories of change are often ‘atheoretical’, in that they reflect a bottom-up approach to understanding how a program works, and seldom systematically integrate knowledge of theoretical frameworks and empirical evidence. This means that a key component of the theory of change approach, that of knowledge generation, is incomplete. And it means that it is challenging for evaluators and stakeholders to discern which aspects of the theory of change (how and why the program works in practice) are universal and which are specific – limiting application of the lessons learned to other settings. This study was conducted as part of the evaluation of a New South Wales Health (Australia) initiative, Collaborative Commissioning, whereby regional alliances of hospital and primary care develop and implement local integrated care solutions.

Methods and findings: Drawing on four local theories of change developed by our team as part of the evaluation of Collaborative Commissioning, we identify and apply relevant theory and evidence to critically examine and explicate the critical assumptions and mechanisms of change underpinning each local theory of change.  The bottom-up approach found stark differences in underlying mechanisms of change in this state-wide initiative, warranting a further exploration of theory in this case. Program designers, managers, implementers and other stakeholders in each of the four regional collaborative commissioning groups (Northern Sydney, Western New South Wales, Western Sydney and Murrumbidgee) were engaged in developing and refining their local theories of change through interview, and face-to-face workshops. In this paper, we identify the underlying theoretical assumptions across the resulting four local theories of change and demonstrate the value of a systematic process to bridge the nexus between wider theory-informed approaches and participatory bottom-up approaches to enrich understanding of how and why integrated care initiatives work in different local settings.  The implications for overcoming collaboration and implementation challenges to integrated care that exist in a federal and state-managed health system are considered.

 

 

 

References

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2. Koff E, Pearce S, Peiris DP. Collaborative Commissioning: regional funding models to support value‐based care in New South Wales. The Medical Journal of Australia. 2021 Oct;215(7):297.