Journal ofhttp://jhm.sagepub.

com/
Health Management

The Need for Effective Management in African Health Systems

Anthonia Adindu
Journal of Health Management 2013 15: 1
DOI: 10.1177/0972063413486053

The online version of this article can be found at:

http://jhm.sagepub.com/content/15/1/1

Published by:

http://www.sagepublications.com

Additional services and information for Journal of Health Management can be found at:

Email Alerts: http://jhm.sagepub.com/cgi/alerts

Subscriptions: http://jhm.sagepub.com/subscriptions

Reprints: http://www.sagepub.com/journalsReprints.nav

Permissions: http://www.sagepub.com/journalsPermissions.nav

Citations: http://jhm.sagepub.com/content/15/1/1.refs.html

>> Version of Record - Jun 26, 2013

What is This?

Downloaded from jhm.sagepub.com by guest on September 23, 2014

Article
Impact on Stock Price by the Inclusion to and Exclusion from CNX Nifty Index 1

The Need for Effective Management Journal of Health Management

15(1) 1–13
in African Health Systems © 2013 Indian Institute of
Health Management Research
SAGE Publications
Los Angeles, London,
New Delhi, Singapore,
Washington DC
DOI: 10.1177/0972063413486053
Anthonia Adindu http://jhm.sagepub.com

Abstract
Effective health management is critical at every level of African health systems in order to improve serv-
ices and in turn the current poor health situation in many countries. Specialized professional training
equips health-care workers for clinical services, but is limited in preparing them for the management
of complex health care systems and organizations. Health management involves technical and social
processes for achieving health objectives through effective and efficient use of health resources in view
of social, economic, political and cultural realities. Basic functions expected of African health manag-
ers include health policy analysis and formulation, health planning, organizing, implementing, leading,
coordinating, controlling, monitoring and evaluating services. Health managers at primary, secondary
and tertiary levels require additional specialist training in health management to acquire knowledge and
skills needed for effective and efficient management of complex health-care organizations. This, in turn,
facilitates application of tested theories, systematic approaches and best practices in addressing the
health needs of the people.
Objective
This article advocates effective health-care management in order to achieve the Millennium Development
Goals, health goals of the New Partnership for Africa’s Development, national health goals and to pro-
mote quality in health care, equity and justice. These culminate in improving health of the people and
changing the poor health indices. It also outlines, in brief, the basic functions expected of African health
managers and concludes by advocating health-management training for strategic, departmental and
operational managers at different levels in the health system.
Method
I wrote this article based on literature review, experience working with federal and state ministries of
health in Nigeria and anecdotal reports from senior health officials and public health students.

Keywords
Health managers in Africa, effective health management, functions of health managers

Anthonia Adindu, Associate Professor, Health Services Management, Department of Public Health, College of
Medical Sciences, Nigeria. E-mail: anthonia.adindu@yahoo.com

Downloaded from jhm.sagepub.com by guest on September 23, 2014

2 Anthonia Adindu

Introduction
Many countries in Africa are embarking on health sector reforms to strengthen health care delivery in
order to achieve global and national health goals of improving health of citizens. Effective health man-
agement is critical in the African health care environment grappling with large populations, preventable
infectious diseases, chronic and acute health problems, juxtaposed with emerging diseases such as
acquired immune deficiency syndrome. At the same time, resources are limited and donor support is
dwindling due to competing needs in the world. Integrating mechanisms for strengthening effective
management of limited health resources is a necessary element often missing in health sector transforma-
tion agenda for service delivery at primary, secondary and tertiary levels.
Effect of broad health system reforms is not yet palpable in many African countries. The WHO (2008)
report shows that about 536,000 women died in 2005 due to complications of pregnancy and childbirth,
400 mothers died for every 100,000 live births. The unfortunate ratio is 9 women per 100,000 live births
in developed countries, 450 in developing countries, and 900 in sub-Saharan Africa. Globally, maternal
mortality ratio fell by 5.4 per cent in the 15 years between 1990 and 2005, an average reduction of 0.4
per cent each year.There was hardly any improvement in sub-Saharan Africa, where most deaths occur.
Health sector reform is inadequate without effective management of services. Indeed, the World
Health Organization (WHO) suggests that key component of health systems strengthening is enhancing
the management capacity within health care delivery system (WHO 2007). Application of scientific
management principles and emphasis on effectiveness and efficiency in the management of health serv-
ices permeating systems around the world have not received serious attention in many African countries.
Understandably, highly skilled health professionals doctors, nurses, pharmacists and others are largely
responsible for the management health organizations, programmes, projects and services. Specialized
professional training that equips them for clinical services is limited in preparing them for managing
complex health care systems and organizations. These health professionals put in their best despite
numerous constraints. Hence, the management of health care delivery is generally weak because many
health managers depend wholly on professional training and job experience without the requisite man-
agement training. Rubino (2007) suggests that every setting in the health sector needs effective leaders
and managers to keep the organization moving in a forward direction. However, Kebede et al. (2010)
argue that in Africa less attention is directed at developing health care managers despite their potentially
important role in improving the functioning and quality of health care delivery systems.

Health Management
Management is an old concept without universal definition that fits every perspective and circumstance,
hence the varied definitions in literature. However, Jones and George (2008) define management as plan-
ning, organizing, leading and controlling of human and other resources to achieve organizational goals
efficiently and effectively.
Defining health management is equally open to diverse perspectives; prescribing one best definition is
difficult. Changes in thinking, perspectives, context and time influence the definition, yet basic princi-
ples are consistently about the effective and efficient use of organizational resources to meet health needs
of people. Furthermore, health managers drive the process of transforming health inputs into outputs and

Journal of Health Management, 15, 1 (2013): 1–13

Downloaded from jhm.sagepub.com by guest on September 23, 2014

Need for Effective Management in African Health Systems 3

facilitate smooth running of the health organization to meet health needs of people within a context.
Therefore, in this article, health management involves technical and social interrelated processes and
activities for achieving health objectives through proper use of health resources in the context of social,
economic, political and cultural realities.
A health manager is, hence, any health worker at the top or strategic, middle and operational level
responsible for carrying out management functions that help to meet the needs of people. Indeed, each
health organization, in view of the many units and departments, tends to have numerous managers at
different levels with management responsibilities appropriate to their position. At the core of health
services management are people as managers, as health workers, who provide services, and as clients
who receive these services. Therefore, managers have the moral duty to apply good management princi-
ples, set the right objectives, develop the right plans and use resources properly to provide the right
services, at the right time,within stipulated standards and in view of peculiar nature of the context.

Health System
Health system in this article is a subsystem of the national social and economic development system
which has diverse interrelated subsystems. Events in the health system affect other national subsystems
and the nation as a whole. The health system, in turn, has diverse interrelated subsystems. In terms of
health care delivery, are the primary, secondary and tertiary subsystems with their numerous health
organizations and facilities, as well as individuals, groups and communities that demand and contribute
to health care. At every level of African health systems are interrelated and interdependent subsystems;
synergy of the different parts enhances achievement of goals, while failure in one subsystem affects the
others and also the performance of the health system as a whole and, indeed, the nation.

Need for Effective Management

Complex Health Care Environment

Health care systems and organizations are highly complex and constantly changing, inundated with new
technologies, new drugs and new and changing diseases. The environment of the health care organiza-
tion, objectives, complex health team, limited skills of managers and available resources influence man-
agement effectiveness.Furthermore, health systems are characterized by attributes not applicable to
business or industry. The subjects of health care services are people, the saving or promotion of life
always the focus with little tolerance for ambiguity in service delivery. In Africa, satisfying the many but
diverse needs of internal and external customers; managing limited resource meet increasing complex
health care needs and often operating in rather inclement and unpredictable political environment put
tremendous pressure on managers further underscores the need to strengthen management and leader-
ship.Typically, services are diverse and needs vary; therefore, it is difficult to establish uniform response
to individual client or community. Even where procedures are standardized,variation in output and out-
come is possible. The emotion, empathy and caring at the heart of health care comes from health workers
who must be motivated and managed well.

Journal of Health Management, 15, 1 (2013): 1–13

Downloaded from jhm.sagepub.com by guest on September 23, 2014

4 Anthonia Adindu

Furthermore, the workforce is complex particularly at secondary and tertiary levels where diverse,
highly trained professionals—doctors, nurses, pharmacists, radiographers, laboratory scientists among
many others—converge to provide services even to a single client. In African health organizations, the
desire to exert professional independence remains a source of conflict and challenge. Getting various
groups to imbibe team work requires strong leadership and management skills, tact, diplomacy, flexibil-
ity and holistic thinking.

Achieving the Millennium Development Goals

The Millennium Development Goals (MDGs) and targets that culminated from the September 2000
Millennium Declaration, represent global partnership and commitment to minimize poverty, diseases
and conditions that undermine individual and national development particularly for the most vulnerable
individuals and nations. Building the capacity of health managers to apply basic management principles
for effectiveness and efficiency in programme management must be part of the process of delivering
services to achieve the MDGs. Some agencies take piecemeal measures to improve management of spe-
cific project or programme, which yields limited results.
The MDGs are facing difficulties in many African countries. In Nigeria for instance, despite encour-
aging results often presented sources of data and information for such analysis are still very weak, hence
difficult to confidently claim progress. Effective system for collecting and managing data to assess
progress or failure is a critical element in effective management of interventions to achieve the MDGs.
For instance the 2010 MDGs report suggests that proportion of one year olds fully immunized against
measles fluctuated. One would think that the MDGs reports at this stage in addition to the numbers
immunized would also capture those fully immunized still dying from measles and, indeed, other child-
hood diseases to help establish efficacy of vaccines and effectiveness in the management of immuniza-
tion processes which require stracking the number of children dying from a particular disease after
immunization within a context.
Furthermore, the proportion of one year olds fully immunized against measles went from 46 per cent
in 1990 to 61.8 per cent in 2002, declined in 2003 and 2004, then rose to 60 per cent in 2005 and then
reversed in 2008, the last year with available data. Similarly, reduction in maternal mortality, despite the
efforts of government, was said to be difficult and the major challenges included dearth of reliable data,
poor remuneration of health workers, low absorptive capacity, poor quality of services and dearth of
skilled personnel (Federal Republic of Nigeria 2010). These are obvious symptoms of poor management
in the health system. Achieving the MDGs depends partly on the quality of planning, organization of
services and utilization of scarce resources in the delivery of services at every level. Conceiving laudable
programmes and interventions must, therefore, be matched with mechanisms to train managers to ensure
that interventions are implemented to achieve results.

Achieving Goals of the New Partnership for Africa’s Development (NEPAD)

The world is a supra system, hence, political, economic and social challenges in the twenty-first century
propelled many countries to link with global markets, greater opportunities as driving force for countries
that meet the requirements. Globalization, privatization, political and economic reforms are increasingly

Journal of Health Management, 15, 1 (2013): 1–13

Downloaded from jhm.sagepub.com by guest on September 23, 2014

Need for Effective Management in African Health Systems 5

needed for national survival and development. Perceiving Africa as a subsystem, African leaders, within
the framework of the New Partnership for Africa’s Development (NEPAD), declared that eradication of
poverty and positioning Africa within global economic systems was the responsibility of Africans
through internally driven sustainable development. Leaders attributed the intractable poor health situa-
tion to lack of development and recognized the inextricable relationship between health and develop-
ment, thus positioning health within the broad human development framework. The health objectives
include to:

(1) strengthen programmes for containing communicable diseases,

(2) establish health systems that meet needs and support disease control effectively,
(3) ensure necessary support capacity for sustainable development of effective health care system;
(4) empower the people to act to improve their health,
(5) successfully reduce the burden of disease on the poorest people of Africa and
(6) encourage cooperation between medical doctors and traditional practitioners (NEPAD 2001).

African governments recognized building health systems that effectively address the health needs of
citizens with eventual positive change in the health situation takes time and requires sustained commit-
ment. Achieving these objectives largely depend on their commitment to effective health policy and
planning; bridging the gap between policy and implementation; effective management of services and
resources; quality of health services; dealing with corruption and establishing credible information sys-
tems that facilitate credible performance appraisal. NEPAD objective three, to ensure necessary support
capacity for sustainable development of effective health care system, must go beyond political rhetoric,
particularly in African countries with abysmal health indices. This further means serious action is needed
on the declaration to jointly mobilize resources for capacity building in order to enable all African coun-
tries improve health infrastructures and management.

Achieving National Health Goals

In every African country today, health care organizations of varying sizes and structures exist even in the
most remote rural communities, to provide health services that address needs of the people. Health sys-
tems require policies, plans and resources and people perform different tasks at macro and micro levels
in order to achieve health system goals. Using Nigeria for illustration, the revised National Health Policy
formulated in view of the Health Strategy of the NEPAD, health related MDGs and the Economic
Empowerment and Development Strategy (NEEDS) provide strategic direction.The main goal is to
strengthen the national health system in order to provide effective, efficient, quality, accessible and
affordable health services that improve the health status of Nigerians through the achievement of the
health related MDGs (Federal Ministry of Health 2005).
Health policy targets are consistent with those of the MDGs, NEPAD and NEEDs, achieving a set
implies achieving others.They are interrelated, a nation that achieves the health related MDGs is more
likely to achieve national health goals (see Figure1).On the other hand, achieving national goals depend
on the organization and management of health care interventions at every level, particularly those tar-
geted at the vulnerable groups. Good management practices must become integral part of the way health
managers do things.

Journal of Health Management, 15, 1 (2013): 1–13

Downloaded from jhm.sagepub.com by guest on September 23, 2014

6 Anthonia Adindu

Improved Effective
Health Health
Indices in Management
Africa

Achieving
Achieving
National
Health
Health
MDGs
Goals

Achieving
NEPAD
Goals

Figure 1. Effective Health Management Promotes Achievement of Health Goals

Promoting Equity and Justice

The Alma-Ata Conference brought to light serious inequity in the distribution of health services and
resources among different groups and countries. Social justice is elusive without equitable distribution
and effective management of health resources to meet the needs of the different groups in the society,
particularly the disadvantaged and vulnerable groups. Appropriate health policies, good planning and
management at any level promote equity and justice. Essentially, good management means effective-
ness, efficiency and equity. This further means sensitivity to the health needs of women, men, boys and
girls, rich and poor, when formulating health policies, planning, programming, budgeting, implement-
ing, monitoring and evaluating health interventions.

Promoting Quality in Health Care

Continuous quality improvement initiatives are permeating health systems around the world, approaches and
tools continually being tested for easy application in different contexts. Although no definition of quality in
health care is prescribed for universal application, that of the Institute of Medicine (1990) seems robust and
states that quality in health care is the degree to which health services for individual or population increase
the likelihood of desired health outcomes and is consistent with current professional knowledge. The Institute
of Medicine identified six dimensions of quality: effectiveness, efficiency, equity, safety, patient centeredness
and timeliness. Much earlier, Avedis Donabedian (1966), often considered as the father of quality enterprise
in health care, proposed a broad approach from system perspective, the structure, process and outcome. This
approach is flexible, amenable to the African context and allows health managers to initiate quality pro-
gramme by starting with the structure which is often a major constraint in many health organizations.
Bradley et al (2011), suggest that any effort to strengthen health systems in Africa must incorporate strategy
to improve access and quality of health care services particularly in rural areas. Indeed, Adindu (2010) argues

Journal of Health Management, 15, 1 (2013): 1–13

Downloaded from jhm.sagepub.com by guest on September 23, 2014

Need for Effective Management in African Health Systems 7

that health care and quality are inextricable; to provide health services without concern for quality is unprofes-
sional and potentially deadly. Quality in African health care systems has become a major concern due to seem-
ingly intractable poor health indices. Today, however, few African countries have structured mechanisms for
assessing and assuring quality in health care. Initiating, leading and institutionalizing quality culture at any
level depends on health managers and their commitment to quality. Promoting quality in health care, a sign of
effective management, also promotes equity and justice and means of improving health situation in Africa.

Promoting Effective Management of Health Workers

World Health Organization (2001) defines human resource for health (HRH) to include all persons who
work directly or indirectly to support and create well being. This captures those with the technical skills
and expertise and those who provide support services that facilitate service delivery. Diverse health care
professionals work in synergy bringing different expertise, skills and knowledge to provide health care
services to individuals and groups. Other workers contribute to ensure health clients receive needed
services.The WHO (2006) argues the health sector is labour intensive and depends on precise application
of knowledge and skills of workers to ensure patient security and health and that health workers are the
most important resource for the health system. However, the WHO African Region seems to have the
bulk of problem in developing and managing human resources for health.
For instance, Nigerian Federal Ministry of Health (2009) reports that Nigeria’s stock of human
resources for health is among the largest in Africa with 58,325 medical doctors, 14,353 pharmacists,
137,198 nurses, translating into 92.7 nurses per 100,000 population; a much higher ratio than the sub-
Saharan African’s average of 72 nurses per 100,000 population, with about 93,743 midwives. However,
this stockpile has not translated into quality of service and improvement in health indices. Even the
Gambia with a relatively small workforce of about 4,945 total health workers, including community
health workers, traditional birth attendants and village health workers, suggests that HRH needs in quan-
tity and quality have not been appropriately projected and planned (Africa Health Workforce Observatory,
2009). Furthermore, the Federal Ministry of Health (2006) reported that human resources for health
management and development in the sub-Saharan Africa was in crisis, public health professionals gave
many reasons for migrating or leaving their profession. These factors include: poor condition of service
and demoralizing work environments, lack of basic equipment and no incentive to work hard; delay in
promotion, poor placement after training and unclear opportunities for professional advancement and
lack of standards to guide staffing and utilization of workers.These are symptoms of poor management
and if the most critical resource is poorly managed, service delivery and quality of care are in jeopardy.
Effective human resources management as part of management function is necessary for the delivery of
the right quantity and quality of needed services at the primary, secondary, and tertiary levels in order to
improve health of the people and to begin a change in the current abysmal health indices.

Improving the Poor Health Indices in Africa

Social, cultural, economic and political factors influence health systems, health organization, serv-
ices and their management. The quality of health services determines the level of physical, emotional
and social health within a context and the capacity of individuals and groups pulling energies for

Journal of Health Management, 15, 1 (2013): 1–13

Downloaded from jhm.sagepub.com by guest on September 23, 2014

8 Anthonia Adindu

sustainable community and national development.The health indices in many African countries are
below expectation, maternal and infant morbidity and mortality rates are high, and life expectancy is
low.
The World Health Organization (2010) reports that the African Region had the lowest life expectancy
at birth of 53 years compared with Region of the Americas at 76 years; neonatal mortality 40 per 1000
live births for African Region and 9 for the Americas (see Table 1). Life expectancy for 10 African coun-
tries selected in agglomeration was generally below 60 years with the exception of Ghana that had 62
years (see Table 2). Yet, the total expenditure on health as per cent of gross domestic product (GDP) in
2007 shows the South East Asian Region had the lowest of 3.6 per cent, with life expectancy of 65 years
in 2008 and the African Region with 6.2 per cent of GDP had life expectancy of 53 years in 2008 (see
Table 3).

Table 1. Life Expectancy and Birth and Neonatal Mortality by WHO Region

Neonatal
Mortality per
Life Expectancy at Birth 1000 live births
Male Female Both Sexes
WHO Region 1990 2000 2008 1990 2000 2008 1990 2000 2008 2008
African 49 49 52 53 52 54 51 50 53 40
The Americas 68 71 73 75 77 79 71 74 76 9
South-East Asia 58 61 63 59 63 66 58 62 65 34
European 68 68 71 75 77 79 72 72 75 7
Eastern Mediterranean 59 62 63 62 65 66 61 63 65 35
Western Pacific 68 70 72 71 74 77 69 72 75 11
Source: WHO (2010), World Health Statistics Report, WHO, Geneva.

Table 2. Life Expectancy and Infant Mortality Rates for 10 African Countries

Life Expectancy at Birth Infant Mortality per 1000 Births

Country 1990 2000 2008 1990 2000 2008
Angola 42 44 46 154 141 130
Benin 51 55 57 111 89 76
Cameroon 55 52 53 92 91 82
Ghana 58 58 62 75 71 51
Kenya 60 51 54 68 81 81
Malawi 47 47 53 133 100 65
Nigeria 46 47 49 120 107 96
South Africa 63 58 53 44 52 48
Uganda 47 45 52 114 98 84
Zambia 52 43 48 105 104 92
Source: WHO (2010). World Health Statistics Report, WHO Geneva.

Journal of Health Management, 15, 1 (2013): 1–13

Downloaded from jhm.sagepub.com by guest on September 23, 2014

Need for Effective Management in African Health Systems 9

Table 3. Health Expenditure by WHO Region

Government Private Government External

Total Expenditure Expenditure Expenditure Resources for
Expenditure on Health as on Health as on Health Health as %
on Health as % % of Total on % of Total on as % of Total of Total on
of GDP Health Health Expenditure Health
WHO Region 2000 2007 2000 2007 2000 2007 2000 2007 2000 2007
African 5.9 6.2 43.5 45.3 56.5 54.7 8.7 9.6 5.4 6.9
Americas 12.0 13.6 44.8 47.2 55.2 52.8 15.5 17.1 0.1 0
South East Asian 3.7 3.6 31.2 36.9 68.8 63.1 4.8 5.3 0.9 1.7
European 8.4 8.8 75.3 76.0 24.7 24.0 14.3 15.3 0.1 0
Eastern Mediterranean 4.2 4.1 52.8 55.5 47.2 44.5 7.3 7.5 1.0 1.8
Western Pacific 6.8 6.5 72.7 67.8 27.3 32.2 14.9 15.1 0.1 0.1
Source: WHO (2010), World Health Statistics Report, WHO Geneva.

The poor management of health care organizations, programmes and projects leads to a disconnect
between policy and implementation with negative influence on outcomes of interventions.In Nigeria,
Federal Ministry of Health (2010) reports that primary health care facilities serve only a fraction of
potential patient workload; secondary health facilities is in weak condition; diagnostic and investiga-
tive equipment in tertiary health facilities are obsolete; management of limited health resources is
ineffective and inefficient and corruption and self-interest is common.To change the health indices,
effective management and training of health managers at every level must come to the front burner.
Improving quality of services in order to improve health indices means that strategic, tactical and
operational health managers have the capacity to plan effectively, direct activities and use resources
effectively and efficiently.

Interrelated Functions of Health Managers

Functions of health managers are similar to those of managers in other fields. Good managers in health care
and elsewhere strive to apply good management principles in carrying out their functions. Managers in
African health organizations are responsible for interrelated functions of policy formulation, planning, organ-
izing, controlling, executing, coordinating, leading, monitoring and evaluating performance (see Figure 2).

Health policy analysis and formulation are critical technical management functions. Health policy
analysis is part of strategic decision-making and planning processes and a framework for determining
issues of priority to the health system and resources and how spending alternatives affect the health care
delivery and the people.Health policy culminates from policy analysis. It is a broad statement of intent
that defines health issues; directs decisions and actions and guides the processing of health inputs to
achieve outcomes. Health policy formulation is, therefore, a technical management function. National
health policies provide framework for national health development achieved through the synergy of vari-
ous subsystems, the diverse people, professionals, health and related sectors.

Journal of Health Management, 15, 1 (2013): 1–13

Downloaded from jhm.sagepub.com by guest on September 23, 2014

10 Anthonia Adindu

External Environment

Policy Making
Executing
Planning

Decision-
Making
Organizing Controlling

Monitoring Leading Coordinating

and
Evaluating

External Environment

Figure 2. Interrelated Functions of Health Managers

The rigorous process of national health policy formulation allows different stakeholders in the society
rather than individuals to make decisions on health matters, determine health goals, identify best
approaches for achieving goals and distribute resources to address health needs. Health managers at the
strategic level coordinate the processes. Clear health policies promote consistency in health program-
ming, effectiveness in managing health services and efficiency in allocation of resources. A major chal-
lenge in African health systems today is bridging the gulf between well articulated health policies and
effective implementation of planned interventions.
Decision-making, on the other hand, pervades and forms part of all other management activities. It is a
technical process that helps managers to identify several strategies and decide the best course of action
from many alternatives for the solution of a problem. Decision-making is at the core of health manage-
ment responsibilities and quality information an indispensable ingredient in the process.
Health planning is a process that involves thinking in advance about health objectives, strategies for
action and resources needed to achieve objectives. It is a highly technical process that requires reliable
information because making the right decisions at the planning stage facilitates management and
employee responsibilities and functions and enables the organization to adjust in response to changes in

Journal of Health Management, 15, 1 (2013): 1–13

Downloaded from jhm.sagepub.com by guest on September 23, 2014

Need for Effective Management in African Health Systems 11

internal and external environments.The planning function requires health managers at all levels to think
through their objectives, what needs to be done, resources required and who does what, when and how,
all in advance. The strategic health managers, honourable Minister, Commissioner, Chief Medical
Director, Chief Medical Officer, Primary Health Care Coordinator, among others, in consultation with
other managers develop the strategic plan that provides direction for planning at lower levels.
The organizing function in health care involves effectively dividing tasks, allocating responsibilities,
authority and resources to health professionals and other workers in order to achieve organizational
objectives. It is a technical process of designing the most appropriate structure to help organization
achieve objectives and to meet the needs of the community. Appropriate organizational structure is
essential, depicting lines of communication and information flow, power and accounting structure, lines
of control, coordination and resources distributions.
The implementing function involves putting health policies, decisions and plans into action through
effective and efficient use of health resources. The executing or implementing function is a technical
and social process of directing, supervising and motivating skilled and unskilled health workers to
achieve objectives. Managers must reach out to and collaborate with others in order to implement
plans.
Leading is largely a social function, the act of ethically and morally guiding, influencing and direct-
ing energies and emotions of members of the health team to work collectively to achieve personal
and organizational goals. Effective leaders help health team members reach their potentials, then in
turn help the organization reach its potentials. Health organizations require good managers, who are
also good leaders, with integrity, are able to motivate others, continuously learning and helping oth-
ers learn.
The coordinating function is technical and social process of planned collaboration between individu-
als, units, departments, programmes and services with a common purpose. The health manager pulls and
integrates efforts and inputs of different service providers to meet the needs of health care consumers.
Collaboration is essential to achieve coordination and effective coordination promotes optimum use of
resources.
The controlling function is a technical process of developing standards and mechanisms for ensuring
adherence throughout the organization for effective delivery of quality services through efficient use of
resources to achieve goals. Controlling function requires health managers to measure and compare per-
formance with previous achievements in order to determine whether the organization is on the right
course. Corrective action must be instituted where necessary, enabling health managers to ensure that
actual activities match plans and objectives.
Monitoring and evaluating are responsibilities that form part of the controlling function of every health
manager. Public health depends extensively on reliable information for assessing needs, policy formula-
tion, planning, monitoring and evaluating interventions. Evidence derived from participatory monitoring
and evaluation, using indicators agreed at the planning stage help to determine the relevance, progress,
effectiveness and efficiency of health programmes and projects. Health managers ensure methodical and
clear mechanisms for monitoring and evaluating health interventions to support achievement of objec-
tives and goals at every level.

Journal of Health Management, 15, 1 (2013): 1–13

Downloaded from jhm.sagepub.com by guest on September 23, 2014

12 Anthonia Adindu

Importance of Health Management Training

In the African context as elsewhere, health managers require adequate knowledge and skills to carry out
their management functions effectively. They must apply tested theories, knowledge, systematic
approaches and best practices to achieve objectives of the health organization. This means that health
managers at every level require adequate training to acquire the needed knowledge, skills, and attitude
for the management of complex health systems. Clinical duties require clinical skills and knowledge,
which health professionals tend to have in abundance; management duties also require management
skills that often are not part of the professional training. Management Sciences for Health (2005) sug-
gests that to manage organization well, managers need to continuously pay attention to health services
that the organization provides to ensure they are effective, efficient and of consistently high quality to
meet the clients’ needs.
Hence, the performance of any health care organization in Africa and attainment of objectives depend
largely on capacity, skill and orientation of the health managers in carrying out their functions effec-
tively. Moreover, satisfying the many but diverse needs of internal and external customers and managing
limited resources to meet increasing, complex health care needs put pressure on managers, further under-
scoring the need to strengthen leadership, management and decision—making skills.
Examining the current work patterns, skills and attitude of health managers is critical to identifying
training needs and helping them acquire needed skills to manage more effectively. Fine and Cronshaw
(1999) propose the work-doing systems theory, a framework that suggest a dynamic interaction of three
components of organizational systems. These are: the work organization which includes purpose, goals
and objectives; the worker, who addresses capacities, experiences, education and training and the work
contents, functions, activities, tasks and performance standards. Tasks and responsibilities are assigned
to those with requisite skills and capacity for the organization to achieve its purpose and training oppor-
tunities are available to bridge gaps.
In conclusion, the survival of any contemporary health care organization, sustenance of health sys-
tems and improved health status of populations depend largely on health care systems management.
Effective management is imperative regardless of structure, purpose and attributes. Effective and effi-
cient management of limited health resources must be the component of the transformation agenda for
improving the quality of services; this helps to ensure that health systems set evidence based priorities
that address critical health issues.

References
Adindu, A. (2010). Assessing and assuring quality of health care in Africa. African Journal of Medical Sciences,
3(1), 31–36.
Africa Health Workforce Observatory, (2009). Human Resources for health country profile: The Gambia.
Bradley, E. Thompson, J. Byam, P. Webster, T. Zerihun, A. Alpern, R. Herrin, J. Abebe, Y. and Curry, L. (2011).
Access and quality of rural health care: Ethiopian millennium rural Initiative. International Journal for Quality
in Health Care, 23 (3), 222–230.
Donabedian, A. (1966). Evaluating the quality of medical care. Milbrank Memorial Fund Quarterly, 44(3), 166–206.
Federal Ministry of Health (2005). Revised National Health Policy. Abuja, Nigeria
———. (2006). Human Resources for Health Policy. Abuja, Nigeria.
———. (2009). Health Workforce Country Profile for Nigeria. Abuja, Nigeria.

Journal of Health Management, 15, 1 (2013): 1–13

Downloaded from jhm.sagepub.com by guest on September 23, 2014

Need for Effective Management in African Health Systems 13

Federal Ministry of Health (2010). Human Resources for Health Country Coordination and Facilitation Baseline
Study. Global Health Workforce Alliance, 7 December, 2010.
Federal Republic of Nigeria (2010). Nigeria Millennium Development Goals: Report 2010.
Fine, S.A. and S.F. Cronshaw (1999). Functional job analysis: A foundation for human resource management.
Mahwah, New Jersey: Lawrence Erlbaum.
Jones, G.R. and J.M. George (2008). Contemporary management (p. 5). New York: McGraw Hill, Irwin International
Edition.
Institute of Medicine (1990). Crossing the quality chasm: A new health system for the 21st century. Washington DC:
National Academy Press, 244.
Kebede, S. Abebe, Y. Wolde, M. Bekele, B. Mantopoulos, J. and E. Bradley (2010). Educating leaders in hospital
management: a new model in sub-Saharan Africa. International Journal for Quality in Health Care, 22(1),
39–43.
Management Sciences for Health (2005). Managers who lead: A handbook for improving health services.
Management Sciences for Health, Cambridge Massachusetts, 10.
NEPAD (2001). The new partnership for Africa’s development. Abuja, Nigeria, October 2001, 31–32.
Rubino, L. (2007). Leadership. In S. Buchbinder and N. Shanks Introduction to health care management. Jones and
Bartlett, 1–22.
World Health Organization (2007). Toward better leadership and management in health care. WHO, Geneva.
———. (2008). World Health Statistics 2008, WHO Geneva.
———. (2010). World Health Statistics Report, WHO Geneva.
———. (2001). The People who work for our health: Placing health workers at the heart of health service delivery
in Africa. WHO Regional Office for Africa. Division of Health Systems and Services Development.
———. (2006). Policies and plans for human resources for health: Guidelines for countries in the African region.
WHO Regional Office for Africa, Brazzaville.

Journal of Health Management, 15, 1 (2013): 1–13

Downloaded from jhm.sagepub.com by guest on September 23, 2014

14 M. Selvam, G. Indhumathi and J. Lydia

Downloaded from jhm.sagepub.com by guest on September 23, 2014