Abstract
Research on health system capacity to manage non-communicable diseases (NCDs) has largely focused on 'system hardware' such as infrastructure, workforce, and commodities. However, this overlooks the critical role of 'system software' elements, such as relationships, norms, and power, and the complex adaptive nature of health systems. This study aimed to explore how health system hardware and software elements interact to shape the capacity of the health system to deliver hypertension care in Kilifi County in the coastal region of Kenya. We conducted a cross-sectional qualitative study and collected data using document reviews (n = 13) and in-depth interviews with purposively selected front-line health workers (FLHWs) at five health facilities and health managers at county and national levels (n = 37). We applied a framework approach to data analysis, utilizing complex adaptive systems (CAS) theory as our analytic framework. Complex interactions of system hardware and software elements constrained the provision of hypertension care. Frequent medicines stockouts (hardware) stemmed from budgetary gaps, procurement delays, regulatory restrictions, and weak quantification practices (software). To mitigate medicines shortages, facilities employed adaptive responses such as inter-facility borrowing and sourcing from alternative suppliers (software). Access and continuity of care were enabled by organizational norms like dedicated hypertension clinic days (software) but undermined by inadequate consultation rooms, staff shortages (hardware) and limited training and support supervision (software). FLHWs' ideas to improve medication adherence were undermined by staff shortages (hardware) and inadequate support from facility managers (software), weakening service delivery. The application of CAS theory unpacked the hitherto underexplored aspects of health system capacity. System 'software' plays a central role in shaping health system capacity for hypertension care. Therefore, strengthening health system capacity for NCDs requires coordinated investment in both system hardware and software elements. Importantly, system strengthening interventions should consider the CAS nature of health systems to foster conditions for productive emergence.