This latter example highlights a key challenge in health service delivery. That is, to balance
the need for broad policy oversight with sufficient flexibility so that managers and
providers can innovate and adapt policies to local needs and contexts in a dynamic way.
Population-based and clinical health services that can be refashioned through negotiation
and adapted during implementation at the discretion of agencies and their staff are more
responsive to the health needs and non-health expectations of the population than those
that are implemented through rigid centralized bureaucracies (46–49). This is consistent
with the relations between responsiveness and service characteristics described in Chapter
2. But this approach may lead to outcomes quite different from those intended at the outset.
The more focused managers and staff are in pursuing a clear mandate, the more likely
it is that broader policy objectives will be achieved without having to resort to rigid hierarchical
structures for control (50).