Governance, Leadership & Management For Health System Strengthening

Pg G O V E R N A N C E , L E A D E R S H I P & M A N AG E M E N T F O R H E A LT H S YS T E M S T R E N G T H E N I N G
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AMREF Headquarters
P.O Box 27691-00506, Nairobi, Kenya
Email: ahlmn@amref.org
G O V E R N A N C E , L E A D E R S H I P & M A N AG E M E N T F O R H E A LT H S YS T E M S T R E N G T H E N I N G Pg
Table Of Contents
Module 1: Overview and context of a health system 13

Unit 1: Defining a health system 14 - 24
Unit 2: Components of a health system 25 - 28
Unit 3: Systems thinking for health systems strengthening 29 - 32
Unit 4: Characteristics of a functioning health system 33 - 34
Unit 5: Challenges and emerging health systems issues 35 - 36
Module 2: Governance in health 37

Unit 1: Overview of governance concept 38 - 44
Unit 2: Principles and characteristics of good governance 44 - 48
Unit 3: Governance structures and functions in health 48 - 53
Unit 4: Health laws and regulations on governance 53 - 59
Unit 5: Practices in accountability and transparency 59 - 63
Module 3: Leadership in health 64

Unit 1: Concepts and styles of leadership 65 - 92
Unit 2: Characteristics of effective leadership and strategic direction 92 - 103
Unit 3: Leadership in health systems building blocks and change management 103 - 116
Unit 4: Approaches for practicing effective leadership in health 116 - 124
Module 4: Management for health 125

Unit 1: Overview of management for health 126 - 132
Unit 2: Functions and roles of a manager 133 - 144
Unit 3: Strategic management approaches 144 - 178
Unit 4: Characteristics of effective teams 178 - 199
Module 5: Human resources for health management (HRHM) 200

Unit 1: Overview and context of human resources for health 200 - 207
Unit 2: Human resources policies and plans 208 - 212
Unit 3: Human resources for health planning 213 - 222
Unit 4: Performance management for human resources for health 223 - 244
Unit 5: Human resources development, retention and exit management 244 - 262
Module 6: Health management information systems 263

Unit 1: Introduction to HMIS 264 - 271
Unit 2: Roles and functions of HMIS 272 - 277
Unit 3: Policies, legal frameworks and ethical issues in health systems strengthening 277 - 280
Unit 4: Information and knowledge management 281 - 286
Unit 5: Design implementation 286 - 289
Unit 6: Role of ICT in HMIS strengthening 289 - 295
Module 7: Health financing 296

Unit 1: Overview of health financing 297 - 301
Unit 2: Mechanisms of health financing 301 - 311
Unit 3: Financial management 311 - 320
Unit 4: Expenditure tracking and reporting 320 - 324
Module 8: Service delivery 325

Unit 1: Concepts and models of service delivery 326 - 328
Unit 2: Characteristics of effective service delivery 328 - 359
Unit 3: Effective referral systems 360 - 363
Unit 4: Concepts and approaches in accreditation 363 - 367
Module 9: Supply chain management 368

Unit 1: Overview of supply chain management 369 - 384
Unit 2: Policies, laws and regulations in supply chain management 384 - 392
Unit 3: Procurement management 393 - 407
Unit 4: Distribution and stock control 407 - 410
Unit 5: Quality assurance and control 411 - 415
Module 10: Monitoring and evaluation 416

Unit 1: Overview of monitoring and evaluation 417 - 423
Unit 2: Monitoring and evaluation systems and frameworks 423 - 426
Unit 3: Tools and methods for monitoring and evaluation 427 - 431
Unit 4: Evaluative research in health systems strengthening 432 - 445
Module 10: References 446 - 448
Module 10: List of Contributors 449

Preface
Health systems in Africa are broken down and hardly responsive to the needs and demands of clients,
population and sub-groups at community, national and regional levels. While there are many possible
explanations for this state of affairs, key amongst these are inappropriate leadership, weak management
and governance structures and practices. This is clearly demonstrated by the piecemeal rather than
holistic approaches to health systems strengthening. The African Union Health Strategy (2007), and the
Africa Health Leadership and Management Network (AHLMN), through its constitution, acknowledge
this; they posit that most African countries are unlikely to achieve their national health targets and those
espoused in Millennium Development Goals, without strengthening leadership, management and
governance at all levels of the health system.
There are many capacity building Health Systems Strengthening (HSS) initiatives supported by various
partners including JICA in various countries across Africa. However, there has not been a unified and
standardized training curricula or manuals in this area, hence the development of this regional training
initiative carried out under the auspices of AHLMN. Through this, member countries and institutions
within Francophone, Anglophone and Lusophone Africa will have, at their disposal, ready-made training
materials in Leadership, Management and Governance.
This curriculum has been developed as a regional course for practicing senior managers, newly re-
designated and aspiring managers in the health sector. The intention is to effectively build competencies
of the participants in health leadership, management and governance to enable those trained to apply
the gained skill, knowledge and attitudes to improve the functioning and outcomes of their respective
health systems. The curriculum is organized in the following ten modules benchmarked by the six
building blocks of a health system:
• Module 1: Overview and Context of the Health System
• Module 2: Governance in Health
• Module 3: Leadership in Health
• Module 4: Management for Health
• Module 5: Human Resources for Health Management
• Module 6: Health Management Information Systems
• Module 7: Health Financing
• Module 8: Service Delivery
• Module 9: Supply Chain Management
• Module 10: Monitoring and Evaluation

The course neither competes with nor negates other courses in health leadership, management and
governance but seeks to complement these by adding value from the regional perspective in five
ways. Firstly, it was developed using participatory approaches that brought together experts in health
leadership and management from eleven member countries and institutions under the AHLMN.
Secondly, although the course targets senior level health workers, the curriculum is relevant and useful
to health workers at all levels. Thirdly, the modular course, which is intended to take two weeks of
residential training, can be customized to a one-week intense course, offered as individual stand-alone
modules or even expanded to diploma level. Each country and institution is therefore free to determine
the appropriate level of certification based on the needs of the country health system at national or
devolved sub-national levels such as districts and counties. Fourthly, the course is among few in the
region that have been translated and offered in English, French and Portuguese. Lastly, the curriculum
provides for post-course continual learning through the action plans or projects, where knowledge,
skills and competencies gained from the training are applied at the work place within the first six
months.
Finally, the various modules can easily be incorporated into pre service training curricula of doctors,
nurses and other midlevel and low level health care providers. It is our belief that if every health worker,
regardless of their level of training, was equipped with a repertoire of competencies in Leadership,
Management and Governance, health systems in Africa would become more responsive and the
delivery of care would be effective and efficient.
Dr. S.K. Sharif, MBS Dr. Peter Ngatia, EBS

Director of Public Health and Sanitation Director of Capacity Building
Ministry of Public Health and African Medical & Research Foundation (AMREF)
Sanitation, Rebublic of Kenya Nairobi, Kenya
Mr. Masaaki KATO

Chief Representative
Japan International Cooperation Agency
JICA, Kenya Office
ACKNOWLEDGEMENT
We are indebted to numerous individuals who have shared with us their experiences in governance,
leadership and management in Health Systems Strengthening (HSS). These include senior academicians
and health practitioners who either participated in the initial phase of developing this training manual
and/or later as participants of the first Training of Trainers (TOT) course where the materials were further
pre-tested and refined.
We wish to acknowledge all those individuals and organisations/institutions whose contributions have
influenced the development and final production of this manual. Special appreciation goes to the
following Africa Health Leadership and Management Network members: CESAG, ESAMI, ECSA-HC, ENSP
(Burkina Faso), INSP (Ivory Coast), CEFA/CAFS (Togo), IDM, MSH, GIMPA, Kenya Methodist University
(KEMU), African Medical & Research Foundation (AMREF) and World Health Organization (WHO) as
well as Kenya Ministry of Public Health & Sanitation (MOHPS), for releasing their staff to support the
development of this manual.
We appreciate the contribution of the following persons;Ms. Faith Tombale, Mr.Paul Tebatso, Dr.
Koffi Amani, Prof. Sano Daman, Dr Katche Jacques, Prof Stephen Hendricks, Dr. Afua Kufuor, Dr Maty
Diagne Camara, Ms.Jenniffer Kaahwa, Dr.Spéro-guy Comlan, Dr Ranga Taruvinga, Prof. Kiyombo Mbela,
Ms.Audrey Kgosidintsi, Mr.Chaltone Munene, Dr.Josephine Mbiyu, Dr. Mollent Okech, Dr G. Koryoe Anim-
Wright, Mrs. Jennifer Nyoni, Dr. Habib Somanje, Prof. Jotham Micheni, Dr. Abel Nyakiongora, Mr. Mikihiro
Toda, Dr. Anastasia Kimeu, Mr. David Njoroge, Prof. George Odhiambo-Otieno, Dr. Mabel Nangami, Mrs.
Margaret Karangatha, Prof Simon Kang’ethe, Mr. Eiichi Shimizu, Dr Tomohiko Sugishita, Dr Naftali Agata,
Dr. Peter Ngatia, Mr. Nzomo Mwita, Ms. Wairimu Njoroge, Dr. Linet Nyapada Oyucho Mr.Nicholas Kiambi,
Ms. Betty Omore and Mr Francis Namisi.
We finally wish to acknowledge the Kenya Ministry of Public Health and Sanitation for support in the
implementation of this programme and the Japan International Cooperation Agency (JICA) for their
financial and technical support.
Acronyms and abbreviations
AHLMN Africa Health Leadership and Management Network
AMREF African Medical and Research Foundation
ANC African National Congress
AOP Annual Operation Plan
ART Antiretroviral Therapy
CBHF Community Based Health Financing
C/VHC Community or Village Health Committee
CEDAW Convention on the Elimination of All Forms of Discrimination against Women
CESAG Centre Africain d’Etudes Supérieures en Gestion
CORPS Community Resource Persons
CPD Continuing Professional Development
CRC Convention on the Rights of the Child
CRM Customer Relationship Management
DHS Demographic Health Survey
DSS Demographic Surveillance Sites
EHP Environmental Health Perspective
FCTC Framework Conventional on Tobacco Control
FEFO First to Expire, First Out
FGD Focus Group Discussion
FIFO First In First Out
FIS Financial Information Systems
GAVI Global Alliance for Vaccines and Immunization
GEH Government Expenditure on Health
GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria
GIMPA Ghana Institute of Management and Public Administration
GRNs Goods Received Notes
HAF Health Action Framework
HALE Health Adjusted Life Expectancy
HFC Health Facility committee
HIV/AIDS Human Immunodeficiency Virus/ Acquired Immunodeficiency Syndrome

HMIS Health Management Information System
HMOs Health Maintenance Organisations
HMT Health Management Team
HRH Human Resources for Health
HRHD Human Resources for Health Development
HRHM Human Resource for Health Management
HRIS Human Resource Information System
HRM Human Resources Management
HSS Health Systems Strengthening
ICT Information Communication Technology
ILO International Labour Organisation
INCB International Narcotics Control Board
LMIS Logistics Management Information System
LPOs Local Purchase Orders
LSOs Local Service Orders
MDGs Millennium Development Goals
MDI Management Development Institute
MOH Ministry of Health
MTEF Mid-term Expenditure Framework
NGO Non-Government Organisation
NHA National Health Account
NHSSP National Health Sector Strategic Plan
NMRAs National Medicines Regulatory Authorities
NQCL National Quality Control Laboratories
OECD Organisation of European Community Development
PAHO Pan American Health Organization
PAICPD Programme of Action of the International Conference on Population and Development
PBF Performance Based Financing
PMTCT Prevention of Mother to Child Transmission
PPOA Public Procurement Oversight Authority
RBF Results Based Financing
RECs Regional Economic Communities

10
SCM Supply Chain Management
SOPs Standard Operating Procedures
SQA Service Quality Assurance
STDs Sexually Transmitted diseases
TBAs Traditional Birth Attendants
T/PNA Training /Performance Needs Assessment
TEHIP Tanzania Essential Health Interventions Project
THE Total Health Expenditure
TOR Terms of Reference
TRIPS Trade Related aspects of Intellectual Property
UNDP United Nations Development Programme
USIU United States International University
USAID United States Agency for International Development
VCT Voluntary Counseling and Testing
VHW Village Health Worker
VIE Vacuum Insulated Evaporator
WAHO West African Health Organisation
WHO World Health Organisation
WISN Workload Indicators of Staffing Needs

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Introduction
Health system weaknesses are a major impediment to achievement of the Millennium Development
Goals and other health targets. Globally, health systems strengthening have been recognised as
critical for improvement of health services. Challenges in health system governance, leadership and
management; health financing; critical shortages and inadequate performance of human resources for
health; inadequacies and inappropriate usage of health information for decision making; limited access
to medicines and technology as well as poor service delivery need to be adequately addressed as a
matter of priority. Most countries in around the world and in Africa have weaknesses in their health
systems.
So far, there is a wide variety of training programmes in general leadership and management being
implemented across Africa. However, it is becoming increasingly clear that in order to have greater
impact in health system strengthening, these training programmes need to be better integrated,
harmonised and linked to address all the key components of the health system.
This training manual seeks to provide both the trainers and trainees with a comprehensive approach to
health system strengthening. Upon implementation, this manual is expected to produce a critical mass
of policy makers and practitioners who understand the tenets and principles of health systems and will
contribute to overall health systems strengthening to improvement of health outcomes across Africa.
Purpose of the course

The purpose of this course/training programme is to build the capacity (knowledge, skills, and
attitudes) of health managers to enable them implement programmes to strengthen health systems in
Africa.
Target group
The course is designed for senior policy makers and planners (central, regional and district /county,
sub-district), health facility and programme managers, newly recruited health managers, public health
association managers, academicians and researchers in health systems in both private, public and non-
governmental institutions.
Course duration
The course is designed in a modular format which allows for very flexible implementation. It can be
implemented in a period of 10-20 days to cover all the modules.
Certification
Participants shall be awarded a certificate accredited by a recognised training institution affiliated to
the Africa Health Leadership and Management Network (AHLMN) upon successful completion of the
course.
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Trainers and facilitators

Trainers and facilitators for the course will be drawn from among various experts in the different areas
of health system. Trainers and facilitators will undergo a training programme on facilitation before
curriculum implementation. The experts will be drawn mainly from AHLMN membership
Performance assessment
The learners will be assessed through pre-tests and post-tests. Continuous assessments will also be
used through questions and answer sessions, and attendance for all the modules will be mandatory.
Assignments and group activities will also be assessed and feedback given.
Implementation
This is a ten (10) module manual which can be delivered individually or in various combinations of
two or more modules. The duration of the course will be dependent on the level of the target group,
module(s) selected and teaching/learning approaches. The curriculum will be adapted for online
learning.
Review and change

End of module evaluation will be conducted by participants and facilitators. Review will be conducted
in line with the country accreditation boards/councils regulations. AHLMN and other relevant
stakeholders will be involved.
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TRAINING MANUAL IN GOVERNANCE, LEADERSHIP

AND MANAGEMENT FOR HEALTH SYSTEMS
STRENGTHENING IN AFRICA
MODULE ONE
OVERVIEW AND CONTEXT OF
THE HEALTH SYSTEM
Objectives
By the end of this module the participant should be

able to:
• Define concepts of a health system
• Describe the components of a health system
• Explain the importance of systems thinking for
health systems strengthening
• Discuss the characteristics of a functioning
health system
• Describe the challenges and emerging health
systems issues in Africa
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UNIT 1
DEFINING A HEALTH SYSTEM
Activity 1.1: Brain storming in plenary

(8 minutes)
WHAT IS A SYSTEM?
WHAT IS A HEALTH SYSTEM?

15
Definition of a health system
“A system is a group of interacting, interrelated,

or interdependent elements forming a complex
whole”
(Heritage Dictionary, 4th ed., 2000 by Houghton Mifflin Company)
“A health system consists of all organizations,

institutions, people and actions whose primary
intent is to promote, restore or maintain health”
(WHO, 2007)
Illustration of a health system
Source: IDRC, 2003

16
Definition of a healthcare system
A healthcare system is a means of organised

social response to the health conditions of the
population
It is narrower than a health system and is often

described in terms of the levels of healthcare
and organisational structure of the Ministry
responsible for health in most countries
Definition of systems thinking
• Systems thinking is a paradigm shift that

emphasises a deeper understanding of
dynamism, linkages, relationships, interactions
and behaviours among the elements that
characterise the entire system
• It focuses on holistic approach to designing,

implementing and evaluating health interventions
• It is an approach to problem solving that views

‘problems’ as part of a wider dynamic system
17
Definitions: health systems strengthening
Health Systems Strengthening (HSS) is

defined as... building capacity in critical
components of health systems to achieve
more equitable and sustained improvements
across health services and health outcomes
(WHO, 2007)
Principles of a health system
• People-centred - Equity and fairness

• Results-oriented - Quality management system for
continual quality improvement
• Evidence-based - Technocrats, academicians,
politicians, community/local context and change
• Community-driven- Leadership, governance
accountability, transparency and sustainability
• Context-specific - In most SSA, context is
synonymous with resource-constrained environment
• Ethically sound – Human rights and dignity, safety
for the client, community and environment
• Systems thinking- Holistic view of the health system
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Context of the health system in Africa
• Organisational arrangements
• Economic context
• Socio-cultural and political context
• Legislative context
• Main actors in the health system
Health systems: organisational arrangements
• Centralised health systems
• Decentralised health systems
• Organisational levels of health systems

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Health systems: centralised
• Top-down approach
§ Authority concentrated at the top
§ Bureaucratic
§ Minimal community involvement
• Vertical programming
(Participants share examples of centralised

systems)
Health systems: decentralised

• Bottom–up approach
§ Active participation of community actors
§ Ownership
§ Sustainability
• Horizontal, primary health care programming
• Various types of decentralisation include:

§ Deconcentration
§ Delegation
§ Devolution and
§ Privatisation – outsourcing and contractual
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Devolved health system and

its linkages to other structures
Source: WHO, 2004 Health sector Reform and District Health System Regional Office for Africa (Fig 4 page 29)
Health systems: organisational levels

The service delivery levels vary across countries.
The following are generic levels:
• Tertiary
§ Central or national
• Secondary
§ Regional, provincial or county
• Primary
§ District, sub-district or sub-county
• Community
§ Dispensaries, clinics, villages or groups
• Household
§ Individuals or families
Each level has standards and norms that define the

service delivery and health facilities
21
Decentralised organisational system:

client focus
Involvement in
activities and
focus on client
Community/Individual client satisfaction
Adoption of standards
Primary health care
Shared vision
and leadership Monitoring standards
District
for continuous
quality services
Regional
Setting standards
Central
Health systems: economic context
• High poverty levels

• Low investments in health at all levels
• Unsustainable and fluctuating donor support
• Uneven progress in health, growing gaps
§ Focus on few programme areas, with others ignored / missed
§ Gaps in health services increasing, as focus driven by priorities
of donors
§ Burden of healthcare financing through user fees
• Persisting inequalities in access, use and financing of
services
§ Poor, illiterate, and other disadvantaged groups still not
accessing services
• Inappropriate application of technology
22
Health systems: socio-cultural

and political context
• Strong cultural norms and values that influence

behaviour
• Resilient yet ineffective traditional health system
• Poorly operationalised social dimensions of
health
• Political and civil strife from protracted wars
and/or conflicts
• Weak political will to implement policies and
commitments
Health systems: socio-cultural

and political context ...
• Poor stewardship
• New challenges to health and health systems
§ New / re-emerging conditions, and health threats
§ Changing behaviour, leading to new risks for various
diseases
• Rising expectations and growing dissatisfaction
§ Globalisation, better information flows mean persons
aware of rights
§ Mismatch between expectations and performance
23
Health systems: legislative context
Laws, declarations and commitments on

Health
• Global
• Regional
• National
Health systems: legislative context
Declarations and commitments on health

• Global
§ MDGs with emphasis on health related goals
§ Paris – Aid effectiveness
§ Regional health declarations and commitments

§ Ouagadougou Declaration on primary health care
(mentioning Bamako and Alma Atta) and health system
strengthening
§ Abuja - health sector financing
§ Maputo – strengthening of laboratory systems Libreville -
social determinants of health
§ Algiers - research for health
§ Regional economic commitments relevant to health

24
Activity 1.2: Brainstorm commitments on

health activity on Declarations (15 minutes)
• List five regional and international declarations

and/or commitments in health
• Briefly describe the purpose and content of one

declaration and/or commitment
Health systems: main actors in the arena
Core partners have the following primary roles: funders,

providers, purchasers, implementers, watchdogs
• Government
• Private /NGOs
§ Not for profit (e.g. faith-based)
§ Private for profit
• Civil society organisations
• Development partners
§ International
§ Bilateral
§ Foundations
• Media
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UNIT 2
COMPONENTS OF A HEALTH SYSTEM
Health System Building Blocks/Components

BUILDING BLOCKS
GOALS / OUTCOMES
SERVICE DELIVERY
Access
Improved health
(level and equity)
HEALTH WORKFORCE Coverage
Responsiveness to
INFORMATION legitimate needs
MEDICAL PRODUCTS,
VACCINES & TECHNOLOGIES
Social, and financial risk
protection
Quality
FINANCING
Improved
Safety
LEADERSHIP / GOVERNANCE Efficiency
Source: World Health Organization. Everybody’s Business: Strengthening health systems to improve health outcomes—WHO’s Framework
for Action. Geneva: WHO, 2007, page 3.
26
Components of a health system
1. Service delivery includes delivery of

effective, safe, quality personal and non-
personal health interventions to those that
need them, when and where needed, with
minimum waste of resources. Demand for
care, service delivery models and
integrated packages; leadership and
management; and infrastructure and
logistics
Components of a health system ...
2. Health workforce refers to a human resource

that is responsive, fair and efficient in order to
achieve the best health outcomes possible,
given available resources and circumstances.
Need norms/standards that govern production of
sufficient staff and ensure fair distribution(HRH
must be competent, responsive and productive);
HRH observatories are essential for facilitating
HRH management
27
3. Health information system ensures the

production, analysis, dissemination and use of
reliable and timely information on health
determinants, health system performance and
health status by decision makers at all levels of
the health system; standardised and integrated
systems & tools; linkages– local, national,
regional, global
4. Medical products and technologies ensure equitable

access to essential medical products and technologies that
provide scientifically sound, quality, safe, efficacious
efficient and cost-effective. The medical products include
medicine, reagents, etc.
Technologies include health infrastructure (e.g. X-ray, lab,

vaccines, etc.)
There is need for norms/standards and policy options on

products and technologies
Procurement processes, monitoring, innovation and

patenting of new products are essential
28
5. Health financing system includes:

• raising adequate funds for health
• ensure that people can use needed services
• protection from financial catastrophe or
impoverishment associated with having to pay for
health services
• providing incentives for providers and users to be
efficient
• policies that support sustainable options/social
protection
• use of information, sound financial management/
dialogue
6. Leadership and governance is

stewardship that involves ensuring that
strategic policy frameworks exist and are
combined with effective oversight, coalition-
building, regulation, attention to system-
design, transparency and accountability
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UNIT 3
SYSTEM THINKING FOR HEALTH

SYSTEMS STRENGTHENING
Activity 1.3: Discussion on Video Clip “Health

systems create healthy futures: Meet Maya” (10
minutes)
• In plenary session, facilitator should ensure all

participants watch the video clip on Baby Maya
• Allow the participants to discuss in pairs (use the

sitting arrangement to avoid movements and
save on time) and come up with the most
important message from the video
• Share in plenary (each pair presents one key

message)
30
Rationale for systems thinking

• Systems thinking works to reveal the underlying
characteristics and relationships of systems
• Every intervention, from the simplest to the most complex,

has an effect on the overall system. The overall system also
has an effect on every intervention
• It is a tool for diagnosing organisational issues and

understanding change dynamics
• Work in fields as diverse as engineering, economics and

ecology shows systems to be constantly changing, with
components that are tightly connected and highly sensitive to
change elsewhere in the system
Elements of systems thinking

System Managing and leading a system; the types of rules that govern the
Organising system and set direction through vision and leadership; set prohibitions
through regulations and boundary setting; and provide permissions
through setting incentives or providing resources
Systems Understanding and managing system stakeholders; the web of all

Networks stakeholders and actors, individual and institutional, in the system,
through understanding, including, and managing the networks
Systems Conceptually modelling and understanding dynamic change; attempting
Dynamics to conceptualize, model and understand dynamic change through
analysing organizational structure and how that influences behaviour of
the system
Systems Managing content and infrastructure for explicit and tacit knowledge; the
knowledge critical role of information flows in driving the system towards change,
and using the feedback chains of data, information and evidence for
guiding decisions
Source: WHO, 2009 Systems Thinking for Health System Strengthening (p 45 Box
2.5)
31
Principles of systems thinking
Senge outlined the following five principles,

which he considered as core to an
organisation’s learning and innovation
§ Personal mastery
§ Mental models
§ Building shared vision
§ Team learning
§ Systems thinking
(The Fifth Discipline, Doubleday, 1990, p. 7)
The dynamic architecture and interconnectedness of

the health system building blocks
Source: WHO, 2009, Systems thinking for health system strengthening, P.32 Fig 1.2
32
Activity 1.4: Systems-level interventions

(15 minutes)
• Divide the participants into country-level

groups
• Each group should identify and describe one

example of a systems level interventions from
their home country
• Share examples in plenary to demonstrate

cases of systems thinking in health
Skills of systems thinking
Usual approach Systems thinking approach

Static thinking Dynamic thinking
Focusing on particular events Framing a problem in terms of a pattern of
behaviour over time
Systems-as-effect thinking System-as-cause thinking
Viewing behaviour generated by a system Placing responsibility for a behaviour on internal
as driven by external forces actors who manage the policies and "plumbing"
of the system
Tree-by-tree thinking Forest thinking
Believing that really knowing something Believing that to know something requires
means focusing on the details understanding the context of relationships
Factors thinking Operational thinking
Listing factors that influence or correlate Concentrating on causality and understanding
with some result how a behaviour is generated
Straight-line thinking Loop thinking
Viewing causality as running in one Viewing causality as an on-going process, not a
direction, ignoring (either deliberately or one-time event, with effect feeding back to
not) the interdependence and interaction influence the causes and the causes affecting
between and among the causes each other
Source: WHO, 2009 Systems Thinking for health system strengthening, page 43-Table 2.1
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UNIT 4
CHARACTERISTICS OF A FUNCTIONING
HEALTH SYSTEM
Activity 1.5: What is a functioning

health system? (10 minutes)
Participants to list the characteristics of a

functioning health system in plenary
34
Nine characteristics of a functional

health system
1. Access to services
2. Quality of care and service delivery
3. Safety
4. Coverage
5. Equity
6. Efficiency
7. Effectiveness of health care delivery
8. Ethics, and rights-based approach in delivery
of services
9. Sustainability of services
Characteristics of a responsive health system
Speed and
timeliness of
delivery/
Punctuality
User-friendly
Courtesy and
systems/less
helpfulness
bureaucracy
Positive attitude
Service reliability
from staff
Accuracy of Consistency in
paperwork service delivery
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UNIT 5
CHALLENGES AND EMERGING

HEALTH SYSTEM ISSUES
Activity 1.6: Challenges and emerging issues

(35 minutes)
Participants should work in groups
• List key health system challenges facing your country’s

health systems
• List five key emerging issues in your country’s health

systems
• Prioritise what you consider the most significant challenges

and emerging issues in your view/country
• Suggest context-specific solutions to address and mitigate

the effects of these challenges and emerging issues in health
systems in Africa
• Share/present group work in a plenary

36
Challenges and emerging issues
Discuss challenges and issues related to:

• Leadership and governance (stewardship)
• Service delivery
• Health workforce
• Health information
• Medical products, vaccines and
technologies
• Health financing
Review questions
• Distinguish between a health system and a

healthcare system
• List the components of a health system
• Why is systems thinking important for HSS?
• Identify the characteristics of a functional
health system
• Give specific examples of challenges and
emerging health system issues in Africa
37

MODULE TWO
GOVERNANCE IN HEALTH
Objectives
By the end of this module, the participant should be

able to:
• Define the concepts of good governance in
health
• Outline the principles and characteristics of good
governance
• Describe the governance structures in health and
their functions at various levels
• Discuss various health laws and health-related
regulations impacting on good governance
• Discuss factors that promote or hinder good
practices on accountability and transparency
38
UNIT 1
OVERVIEW OF GOVERNANCE CONCEPT
Activity 2.1: (5 minutes)
Brainstorming in pairs
• What is governance?
• Sample a few participants to share in plenary

39
Conceptual framework of governance

and leadership
WHO Framework For Action.

Everybody’s business, strengthening health systems and improving health outcomes 2007
Definition of governance
There are as many definitions of governance as there are

contexts. It is neither homogenous nor a one-dimensional
concept. Examples include:
• “Is the exercise of political, economic and administrative

authority in the management of a country’s affairs at all
levels”
(UNDP, 2007)
• “The manner in which public officials and public institutions

acquire and exercise the authority to provide public goods
and services, including the delivery of basic services,
infrastructure, and a sound investment climate”
World Bank, (GAC strategy) 2007
40
Definition: governance in health
• “It is about the role of the government in health and

its relation to other actors whose activities impact on
health. This involves overseeing and guiding the
whole health system, private as well as public in
order to protect the public interest”
(WHO, 2008)
• The government exercises its stewardship function

by developing, implementing, and enforcing policies
that affect the other health system functions
Ask participants provide examples of strong

government stewardship in Africa
Definition: governance concepts

• Oversight
§ Ensuring generation, analysis and use of intelligence on trends and
differentials in inputs, service access, coverage, safety, on responsiveness,
financial protection and health outcomes, especially for vulnerable groups, on
the effects of policies and reforms, on political environment and opportunities
for action and on policy options
• Stewardship
§ Managing properties, finances or other affairs for others. It requires careful
and responsible management for the well being of the population
• Transparency
§ Openness to public scrutiny, clarity and visibility in decision making process
• Accountability
§ Responsibility for the use of resources and the decisions made, as well as the
obligation to demonstrate that work has been done in compliance with
agreed-upon rules and standards and to report fairly and accurately on
performance results vis-à-vis mandated roles and/or plans
41
Definition: governance concepts ...

• Corruption
§ Abuse of public office for private gain or personal interest
• Integrity
§ Adherence to moral and ethical principles; soundness of moral
character and honesty
• Participation
§ Citizens’ engagement and empowerment in decision making
processes
• Ethics
§ System of or code of moral values that provide rules and standards of
conduct. It has three principles; respect for persons, beneficence, and
justice
Definition: governance concepts ...

• Equity
§ The absence of systematic disparities in health. It implies social justice
and fairness to attain full health potential. Equity is different from equality
(universal coverage, access to health)
• Regulation
§ Designing regulations and incentives and ensuring they are fairly
enforced
• Collaboration and coalition building

§ Across sectors in government and with actors outside government,
including civil society to influence action on key determinants of health
and access to health services; to generate support of public policies, and
to keep the different parts connected
• System design
§ Ensuring a fit between strategy and structure and reducing duplication
and fragmentation
42
Definition of organisational /
corporate governance
• Organisational governance is the processes and structures
used to guide and direct an organisation’s operations and
activities in order to serve the interests of the customers
• Corporate governance refers to structures and processes of

aligning interest of individuals, of corporations and of society so
as to sustainably attract investment
(Sir Adrian Cadbury,, Global Corporate Governance Forum, 2003)
• Corporate Governance is essentially about leadership:

§ leadership for efficiency
§ leadership for probity
§ leadership with responsibility
§ leadership which is transparent and which is accountable
Importance of organisational governance
• Promotes accountability, transparency and efficient

management of resources
• Ensures strategic direction of organisation towards

goal achievement
• Enhances efficient and impartial practice of rule of

law
• Augments equitable distribution and use of

resources
• Encourages effective networking and partnerships

among internal and external actors
43
Importance of organisational governance...
• Enhances mainstreaming of human rights approach

in policy making and resource framework
• Increases access to and use of new knowledge

management
• Ensures that proper and supportive supervision is

given
• Strengthens capacity in health policy analysis and

links to evidence-driven policy making
• Fosters rapid growth in health investments
Role of health manager in organisational governance
• Defines the division of power

• Establishes mechanisms to achieve accountability
in the organisation
• Ensures policy/decision-making
• Offers oversight of the organisation’s operations
• Strengthens positioning and planning the
organisation towards achieving its mission
• Fosters acceptability, credibility, viability and good
reputation of the organisation
• Ensures social and environmental protection
44
Linking governance and management to results
UNIT 2
PRINCIPLES AND CHARACTERISTICS OF

GOOD GOVERNANCE
45
:
Overall framework on governance principles
Source: Institute of Policy Development at the Civil Service College, Singapore 2006
General principles of governance
These three principles guide the practice of

governance in all sectors
• Transparency
• Accountability
• Participation
46
Characteristics of good governance
Source: UN-Economic and Social Commission for Asia and Pacific, 2006
Principles of governance in health
• Strategic vision
• Participation and consensus orientation
• Rule of law
• Transparency
• Responsiveness
• Equity and inclusiveness
• Effectiveness and efficiency
• Accountability
• Intelligence and information
• Ethics
47
Assessment of the principles of governance

• Work in teams to select and discuss an
example of principles of governance in health
A) specify the level

B) describe the governance structures
C) describe the application of at least one
principle at the selected level in your own
country
Weak governance - government effectiveness

correlates with health outcomes
M. Lewis 2006. Governance and Corruption Public Health Care Systems.

Center for Global Development. WP 78
48
“The Road to good governance in the

health sector is long and ragged...”
Discuss and cite examples:
• WHO - stewardship
• PAHO – functions of public health
• World Bank - six basic
• UNDP – principles
UNIT 3
GOVERNANCE STRUCTURES AND

FUNCTIONS IN HEALTH
49
Governance structures
Participants to work in pairs and based on
country experiences carry out this task
§ Outline the governance structures for

health at various levels in your country
Governance structures at various levels
Refers to structures for execution of authority at various levels:

• International level, includes summit of Health Ministers and
Heads of State
• Central/National level, the governance structure for the
health system include autonomous boards and committees at
national/parliamentary level, Ministries of Health and Office of
the President
• Regional/Provincial/County levels, the health boards set up
under the regional, provincial, county administrators
• District and other sub-regional levels, health boards or
committees responsible for and district and other sub-regional
level administrators including health facility boards
• Community level, village and community health boards or
committees that provide oversight for health matters
50
Governance structures for health facilities
• Hospital level, the Hospital Boards appointed by the

Minister responsible for health, provide the oversight
role to the delivery of medical services to citizens
• Primary health Care level, Health Facility

Committees (HFC) with membership drawn from
community members, provide the oversight functions
• Community level, governance structures are

represented by Community or Village Health
Committee (C/VHC) and have a big role to play in
governance of health outposts/centres, dispensaries
and clinics
Roles of other governance structures

The following agencies perform some governance
functions. For each, list the main functions:
• Unionism
• National health observatories
• Regional organisations such as the African
Union
• Civil society organisations
Participants to add to this list

51
Functions of governance
• Defines the division of power

• Establishes mechanisms to achieve
accountability in the organisation
• Ensures policy/decision-making
• Offers oversight of the organisation’s operations
• Strengthens positioning and planning the
organisation towards achieving its mission
• Fosters acceptability, credibility, viability and
good reputation of the organisation
• Provides social and environmental protection
An Example of poor governance – a leaking

health system!
Source: unknown
52
Functions of governance at various levels
• International level, summits of Ministers of Health

and/or Heads of State have mandate to harmonise
policies through declarations and commitments
• Central/national level, mandate to formulate policies,

provide strategic oversight, financial, regulatory
functions, presidential accent to bills, performance
monitoring, accountable to stakeholders
• Regional and district level, health boards provide

oversight for policy implementation, planning, and
resource allocation and use for the health system at
these levels, adherence to national laws
Functions of governance at various levels ...
• Hospital Boards provide the oversight role for

effective functioning of the facility in order to delivery
quality services to citizens
• Primary level, Health Facility committees draw

representation from the community members and
provide the oversight functions for primary care
facilities
• Community level, Village Health Committee ensure

effective community participation in management of
health services
53
Governance functions: other health agencies
• International bodies for standards and technical backstopping

§ World Health Organisation (WHO)
§ Organisation for Economic Co-operation and Development (OECD)
• Professional regulatory bodies for standards and accreditation

§ Regional and national medical and paramedical practitioners boards
for medical products, food, and environmental protection such as
– Pharmacy and Poisons boards
– Laboratory products
– Radiation protection boards
• Regional bodies such as the

§ West African Health Organisation (WAHO)
§ Eastern, Central and Southern African Health Community (ECSA-HC)
§ Southern African Development Corporation (SADC)
UNIT 4
HEALTH LAWS AND REGULATIONS

ON GOVERNANCE
54
Role of health laws in governance

Forms the legal basis for technical corporation in promoting
good governance and regulation of registration of medical
products
Examples include:
Public health law
• Concerns legal powers and duties of the state to assure
the conditions for people to be healthy – links to oversight
role in governance
• Defines limitations on the power of the state to constrain

the autonomy, privacy, liberty, proprietary, or other legally
protected interests of individuals for the protection or
promotion of community health – links to transparency
and stewardship
Health laws and related regulations
Health laws
International and national healthcare laws; mental health,
public health, specific laws governing the health industry:
physicians, nurses, health insurers,
law of negligence and trespass to a person;
law of confidentiality and access to health care
information; abortion; whistle-blowing strategies; HIV/
AIDS, STDs; consent to treatment, competency,
incompetent adults and children; medical indemnity
among health professionals
Health Acts
Country specific Acts of parliament and legal statutes
dealing with health issues
55
Health laws and regulations: human rights
• International conventions on human rights including:

§ International Labour Organisation (ILO)
§ the Convention on the Rights of the Child (CRC)
§ the Convention on the Elimination of All Forms of Discrimination
against Women (CEDAW)
§ the Program of Action of the International Conference on
Population and Development
• Rights of access to health care and health service charters
• Sexual and reproductive health and gender issues
• Alcohol control
• Mental Health Law in the community
• Rights of a patient; patient and provider safety in health facilities
consent to treatment, competency, incompetent adults and children
among others such as vulnerable population sub-groups

Participants work in groups to discuss selected health laws in
their countries
§ Smoking (tobacco laws)
§ Substance abuse (alcohol and drugs laws)
§ Child labor/slavery (human rights laws)
§ Road traffic accidents (transport laws)
§ Maternal health (under age marriage, inheritance and
female genital mutilation/cutting and other gender
issues)
For each selected set of laws

§ What is the nature of the health problem (causes and
consequences)
§ Describe the scope of the law (what it covers)
§ What are the limitations (what is not covered)
56
International public health laws/declarations

• International Health regulation
• World Trade Organisation’s (WTO) Agreement on
Trade-Related Aspects of Intellectual Property Rights
(TRIPS)
• 2000 - Leaders of G8 countries committed to the
need to mobilise resources for aids, malaria, TB and
other infectious diseases in 2000 meeting in Okinawa,
Japan; 2000 – UN - MDGs
• The 2001 African leaders summit in Abuja, Nigeria
Declaration (commitment to allocation of 15% of the
national budget to health care); 2001 – the Global
Fund was created to provide a new channel for
resource mobilisation
• 2005 -Paris Declaration on aid effectiveness
International PH laws and Trade Related aspects of

Intellectual Properties (TRIPS)TRIPS
• Balances between providing incentives for

future inventions/creation and allowing
people to use existing inventions and
creations
• The agreement covers a wide range of

subjects:
§ copyright and trademarks
§ to integrated circuit designs and trade
secrets
§ patents for pharmaceuticals and other
products are only part of the agreement
57
International PH Laws and Trade Related aspects of

Intellectual Properties (TRIPS)
• Paragraph 6 of the Declaration on the TRIPs

Agreement and Public Health allows
countries to export patented medicines to
third countries with no manufacturing capacity
in the pharmaceutical sector, by making use
of compulsory licences
• Ensures provisions of cheap medicines to

poor people, transfer of technology and
regional cooperation through compulsory
Examples of international PH laws
The WHO Framework Convention on Tobacco

Control (WHO FCTC):
• 1st treaty negotiated under the auspices of the

WHO
• Reaffirms the right of all people to the highest
standard of health
• Asserts the importance of demand reduction
strategies as well as supply issues
• The WHO FCTC was developed in response to
the globalisation of the tobacco epidemic
58
Declarations & Commitments: MDGs
• MDGs were endorsed by UN member

countries to set out targets to be reached by
2015
• The following 3 of the 8 goals relate to health

Goal 4: Reduce child mortality
Goal 5: Improve maternal health
Goal 6: Combat HIV/AIDS, malaria and
other diseases
Abuja Declaration: 2001
The ICPHCHSA meeting in Ouagadougou, April 2008,

reaffirmed the principles of the Declaration of Alma-Ata of
September 1978, particularly in regard to:
• Health as a fundamental human right and the

responsibility that governments have for the health of their
people
• Need for accelerated action by African governments,
partners and communities to improve health
• The importance of the involvement, participation and
empowerment of communities in health development
• Recognising the importance of a concerted partnership
with civil society, private sector and development partners
59
Aid effectiveness - Paris Declaration, 2005
The Key Elements

• Ownership - Developing countries set their own strategies for
poverty reduction, improve the institutions and tackle
corruption
• Alignment - Donor countries commit to respect partner
country leadership and help strengthen their capacity to
exercise it
• Harmonization - Donors’ actions are more harmonised,
transparent and collectively effective through implementing
common arrangements and simplified procedures to share
information and avoid duplication
• Results - Developing and donor countries shift focus to
managing resources and improving decision-making for results
• Mutual accountability - Donors and partners are accountable
for development results
UNIT 5
PRACTICES IN ACCOUNTABILITY
AND TRANSPARENCY
60
• In plenary ask participants to write down one

positive or negative experience of
accountability or transparency at their
workplaces
• Discuss in plenary the following issues
1. What are the key messages from the example?
2. What types of accountability and transparency are

evident from the examples given by participants?
Types of accountability
Political
• Government delivering its promises to improve healthcare
through services responsive to clients and meeting
emerging societal needs
Financial
• Tracking and reporting on allocations, disbursements and
use of financial resources
Social
• Being answerable for/ and relies on civic engagements in
which ordinary citizens participate in exacting
accountability
Performance
• Achieving agreed performance targets for service delivery
and results
61
Transparency
The following are ways of enhancing transparency:

Information disclosure
• Through various media
Grievance redress mechanisms

• Clear code of regulations
• Clarity of tasks and communication on
expectations
• Impartiality in addressing issues
Participation
• At various levels and through various forums
Participants to work in groups and present in plenary
• What is corruption?
• What are the common sources of corruption in your
health systems? (brainstorm and then prioritise your
list to top 2)
• What are the consequences of the top corruption
source on the health system performance?
• What are your suggestions for preventing the
identified type of corruption?
62
Corruption in the health sector: risk areas

and consequences (Weerasuriya, 2004)
Source: Corruption in the health sector, Issue 2008 page 6 – Figure 1-1; U4 anti-corruption centre
Participants to brainstorm in plenary on

challenges to good governance
63
Examples of challenges to good governance
• Good governance has been associated with an attempt

by the west to propagate and promote western style
democracy
• Historically, good governance has been constructed as
a condition for external aid to Africa
• Linking the concept to human rights is perceived as
‘witch hunt’ for the ‘bad boys’ rather than fulfilling
international norms on human rights
• The concept of ‘good governance’ has primarily been
donor driven vs. domestic imperatives
• Lack of capacity to effectively implement the
governance principles in diverse institutional contexts
Review questions
• Explain the meaning of governance in health

and characteristics of good governance in
health
• Outline the governance structures in health at
various levels
• Describe key functions of governance
• Identify the various health and health-related
acts and regulations
• Outline experiences on accountability and
transparency in health governance
64

MODULE THREE
LEADERSHIP IN HEALTH
Objectives
By the end of this module, the participant should

be able to:
• Define the concepts and styles of leadership
• Describe characteristics of effective leadership
• Discuss the place of leadership in the health

systems building blocks
• Analyse approaches for effective leadership in

health
65
UNIT 1
THE CONCEPTS AND STYLES

OF LEADERSHIP
• What troubles your heart in the health sector?
• What are you doing about it?

66
Concepts and styles of leadership
When leadership and management is facilitated,

communities will achieve good health
• Brainstorm on the concepts of a Leader and

Leadership
• Give examples of leaders whose leadership

is outstanding / you admire
67
Definition of a Leader
An individual who is able to influence and

inspire a group or organisational members
to help the group or organisation achieve
its goals
Definition of Leadership
Definition 1:
Leadership is a process whereby an individual

influences a group of individuals to achieve a
common goal
(Northouse, 2007)
68
Definition of Leadership …
Definition 2:
Leadership is a function of knowing yourself,

having a vision that is well communicated,
building trust among colleagues and taking
effective action to realise your own leadership
potential
(Warren Bennis)
Definition of Leadership …
Definition 3:
Leadership is a function of a leader, the

followers, and the situation in striving to
achieve a common purpose or goal
69
Leadership vs. Management
• Ensures that processes and procedures, staff,

and other resources are used in an effective
(correct) and efficient (correctly) manner
• It organises the internal parts of the

organisation to implement systems and
coordinate resources to produce reliable
performance
(Concept of management will be discussed in module 4)
What does this picture say about a

Leader and Leadership?
Brainstorm
70
Some leadership theories
1. Great man theory 7. Transactional
2. Trait theory 8. Transformational
3. Behavioral 9. Servant leadership
4. Participative 10. Level 5 leadership theory
5. Situational 11. Followership
6. Contingency theory
A brainstorming exercise on leadership styles
• Working in groups, use a flip chart and make

three columns. Identify leaders with different
styles of leadership, name their leadership
style and list the characteristics of their style
• Report back to the plenary

71
Some leadership styles
Styles of Characteristics
leadership
1 Laissez - faire
2 Autocratic
3 Servant
4 Transactional
5 Democratic
6 Bureaucratic
7 Transformational
Qualities of a good leader
• Visionary and forward-looking
• Must be adaptable and change with changing

circumstances
• Must be honest and sincere of purpose
• Able to see things in perspective
• Able to admit mistakes and learn from others

72
Qualities of a good leader …
• Must be self-confident
• Must have a sense of humour
• Must listen to his subordinates
• Understands problems of those under
him/her
• Diplomatic and humble
Ask participants to cite other qualities
Transactional and transformational

leadership
• Transactional leadership occurs when

leaders and followers are in an exchange
relationship in order to get needs met
• Transformational leadership serves to

change the status quo by appealing to
followers’ values and their sense of higher
purpose
73
Transactional leadership
• Transactional theories:
§ Focus on the management of the
organisation
§ Focus on procedures and efficiency
§ Focus on working to rules and contracts
§ Managing current issues and problems
Transactional leadership ...
More commonly a male trait

• Men tend to view job performance as a
series of transactions with subordinates in
terms of exchanging rewards for services
rendered or punishment for inadequate
performance
• More likely to use power that comes from

organisational position and formal authority
74
Transactional leadership
• Management by exception (watches for

deviations)
• Keeps the system operating smoothly

§ Uses reward and coercive power bases
§ Recognises what workers want and tries
to deliver it
§ Rewards according to worker effort
§ Responsive to worker self-interests
§ Is transformational leadership built “on
top of” transactional leadership, or is it
just a special case of charismatic
leadership?
Transactional leadership …
• Gives rewards in exchange for performance /

services
• Manages by looking for deviations from rules
• Intervenes only if standards are not met
• Abdicates responsibilities
75
Transformational leadership
• More commonly a female trait
• Women tend to get subordinates to transform

their own self-interest into the interest of the
group through concern for a broader goal
• Usually ascribe power to personal

characteristics like charisma, interpersonal
skills, hard work, or personal contacts rather
than to organisational stature
Transformational leadership …
Transformational leadership is a process that

changes and transforms individuals
•It is concerned with:

§ Emotions
§ Values
§ Ethics
§ Standards
§ Long-term goals
•It includes assessing followers’ motives, satisfying

their needs, and treating them as full human beings
76
• Transformational leadership involves an

exceptional form of influence that moves
followers to accomplish more than what is
usually expected of them
• It is a process that often incorporates

charismatic and visionary leadership
Transactional vs. Transformational
• Transactional leadership
§ Refers to the bulk of leadership models, which
focus on the exchanges that occur between leaders
and their followers
§ Managers who offer promotions to employees who

surpass their goals are exhibiting transactional
leadership
§ The exchange dimension of transactional

leadership is very common and can be observed at
many levels throughout all types of organisations
77
• Transformational leadership
§ Refers to the process whereby an individual engages

others and creates a connection that raises the level of
motivation and morality in both the leader and the
follower
§ This type of leader is attentive to the needs and

motives of followers and tries to help followers reach
their fullest potential
§ Mohandas Gandhi is a classic example of

transformational leadership. Gandhi raised the hopes
and demands of millions of his people and in the
process was changed himself
The implication of transitional and transformational leadership for individuals, team, and organisation
development by B.M Bass and B.J Avolio 1990a,research in organisational change and
development, 4 , 231-272
78
The implication of transitional and transformational leadership for individuals, team, and organisation
development by B.M Bass and B.J Avolio 1990a,research in organisational change and
“The implication of transitional and transformational leadership for individuals, team, and organisation
development “by B.M Bass and B.J Avolio 1990a,research in organisational change and
79
How does the transformational approach work?
• The transformational approach to leadership is a

broad-based perspective that encompasses
many facets and dimensions of the leadership
process
• In general, it describes how leaders can:

§ initiate
§ develop
§ carry out significant changes in organisations
80
• Transformational leaders set out to empower

followers and nurture them in change
§ They attempt to raise the consciousness of
individuals and get them to transcend their own
self-interests for the sake of others
• To create change, transformational leaders

become strong role models for their followers
• It is common for transformational leaders to

create a vision
§ The vision emerges from the collective
interests of various individuals and units
within an organisation
• Transformational leaders also act as change

agents who initiate and implement new
directions within organisations
81
• The transformational approach also requires

that leaders become social architects
§ This means they make clear the emerging

values and norms of the organisation
§ They involve themselves in the culture of

the organisation and help shape its
meaning
Transformational leader
• Charismatic/Inspirational
• Focuses on vision
• Is not as concerned with day-to-day issues

82
Kouzes-Posner leadership model

(transformational leadership)
• Challenging the process
• Inspiring a shared vision
• Enabling others to act
• Modeling the way
• Encouraging the heart
Guidelines for becoming a transformational leader

Suggestion Explanation
Develop a vision that is both clear and A clear vision will guide followers
highly appealing to followers toward achieving organisational goals
and make them feel good about doing
so
Articulate a strategy for bringing that don’t present an elaborate plan; rather,
vision to life state the best path towards achieving
the mission
State your vision clearly and promote Visions must not only be clear, but made
It to others compelling, such as by using
anecdotes
Show confidence and optimism about If a leader lacks confidence about
your vision success, followers will not try very hard
to achieve hat vision
Express confidence in followers’ capacity Followers must believe that they are
to carry out the strategy capable of implementing a leader’s
vision. Leaders
should build followers’ self-confidence
83
Guidelines for becoming a transformational leader …
Suggestion Explanation
Build confidence by recognising small if a group experiences early success, it
accomplishments toward the goal will be motivated to continue working hard
Celebrate successes and Formal or informal ceremonies are useful

accomplishments for celebrating success, thereby building
optimism and commitment
Take dramatic action to symbolize key Visions are reinforced by things leaders
organisational values do to symbolise them e.g. one leader
demonstrated concern for quality by
destroying work that was not up to
standards
Set an example; actions speak louder than Leaders serve as role models, if they want
words followers to make sacrifices, for example,
they should do so themselves
Leadership truth
We praise leaders too much when

organisations succeed, and blame them too
much when organisations fail
84
Level 5 leadership
• The key to an organisation becoming

great is having a Level 5 leader
• Level 5 leader is an individual who blends

extreme personal humility with intense
professional will
Hence, the equation
HUMILITY + WILL = LEVEL 5
Level 5 leadership …
• Level 5 leaders are the one who takes

companies from good results to great results
• Level 5 leader should possess capabilities of

all lower levels along with Level 5
characteristics
• An individual can show Level 5 Leadership

and it is not necessary to move from one level
to another
85
Source: Kirk B. Kenneth
The highest level in a hierarchy

of leadership capabilities
• Leaders at the other four levels in the

hierarchy can produce high levels of success
but not enough to elevate organisations from
mediocrity to sustained excellence
• Good-to-great transformations don’t happen

without Level 5 leadership
86
The level 5 hierarchy
• Sits on top of a hierarchy of capabilities

• Four other layers lie beneath it
• Each one is appropriate in its own right, but
none with the power of Level 5
• We do not need to move sequentially through
each level of the hierarchy to reach the top
• But to be a fully-fledged Level 5, we need the
capabilities of all the lower levels, plus the
special characteristics of level 5
The level 5 hierarchy …

• Level 1 – Highly Capable Individual – Makes productive
contributions through talent, knowledge, skills, and good
work habits
• Level 2 – Contributing Team Member – Contributes to the
achievement of group objectives; works effectively with
others in a group setting
• Level 3 – Competent Manager - Organises people and
resources toward the effective and efficient pursuit of
predetermined objectives
• Level 4 – Effective Leader - Catalyses commitment to and
vigorous pursuit of a clear and compelling vision; stimulates
the group to high performance standards
• Level 5 – Executive - Builds enduring greatness through a
paradoxical combination of personal humility plus
professional will
87
• People generally assume that transforming

from good to great organisations requires
charismatic, larger than-life leaders
• Not the case in study of many successful

companies
• Level 5 leadership is an essential factor for

taking an organisation from good to great, but
it’s not the only one
• There are other “drivers”, combined with

Level 5 - the combined package which takes
the organisation beyond unremarkable
• The drivers are – First Who, Stockdale

Paradox, the Flywheel, Flywheel, The
Hedgehog Concept and A Culture of
Discipline
88
Level 5 leadership is a study in duality

• Modest and willful
• Shy and fearless, do not talk about

themselves
• They would talk about the organisation, about

the contribution of others and instinctively
deflect discussion about their own role
Personal Humility Professional Will
Demonstrates compelling modesty, Creates superb results, a clear catalyst in the

shunning public adulation; never boastful transition from good to great
Acts with quiet, calm determination; relies Demonstrates an unwavering resolve to do

principally on inspired standards, not whatever must be done to produce the best
inspiring charisma, to motivate long-term results, no matter how difficult
Channels ambition into the organisation, Sets the standard of building an enduring
not the self; sets up successors for even great organisation; will settle for nothing else
more greatness in the next generation
Looks in the mirror, not out the window, to Looks out the window, not in the mirror, to
apportion responsibility for poor results, apportion credit for the success of the
never blaming other people, external organisation – other people, external factors,
factors, or bad luck and good luck
89
An unwavering resolve
• Besides extreme humility, Level 5 leaders

also display tremendous professional will
• They possess inspired standards, cannot

stand mediocrity in any form, and utterly
intolerant of anyone who accept the idea that
good is good enough
Succession planning
• Level 5 leaders have ambition not for themselves but for
their organisations
• They routinely select superb successors
• They want to see their organisations become even more

successful in the next generation
• Comfortable with the idea that most people won’t even

know that the roots of that success trace back to them
• Level 4 leaders often fail to set up the organisation for

enduring success – what better way to demonstrate your
personal greatness than that the place falls apart after you
leave
90
Born or bred? Can Level 5 be developed?
• There are two categories of people
§ Those who don’t have the Level 5 seed

within them
§ And those who do
First category
• Will never bring themselves to subjugate their own

needs to the greater ambition of something larger
and more lasting than themselves
• Work will always be first and foremost of what they

get – fame, fortune, power, adulation, etc.
• Work will never be about what they build, create and

contribute
• The great irony is that the personal ambition that

often drives people to become a Level 4 leader
stands at odds with the humility required to rise to
Level 5
91
Second category
• Could evolve to level 5
• Capability resides in them, perhaps buried or

ignored
• Under the right circumstances – with self-

reflection, a mentor, a significant life
experience, loving parents, or other factors
§ the seed can begin to develop
“I believe you are in this category”
Case study
Participants are expected to have read

the case study of Dr. V.
Discussion to follow at the end of this

module
92
Watch videos (15 minutes)
• Watch the following video as examples of great

leaders and leadership skills
• Martin Luther King – Dream (1 Min)
• Martin Luther King – Last Speech (2 Mins)
Reflection
• How do you assess your leadership style?
• Include some action points in your JAMII Project
UNIT 2
CHARACTERISTICS OF EFFECTIVE
LEADERSHIP AND STRATEGIC DIRECTION
93
Characteristics of effective leadership
• Know yourself and seek self-improvement
• Helping employees understand the company's

overall business strategy
• In order to know yourself, you have to

understand your "be," "know," and "do"
attributes
• This is possible by continually strengthening

your attributes by reading and self-study
• Be technically proficient
Characteristics of effective leadership …
• As a leader, you must know your job and have a

solid familiarity with your employees' jobs
• Seek responsibility and take responsibility for your

actions. Search for ways to guide your
organisation to new heights. And when things go
wrong, do not blame others
• Make sound and timely decisions. Use good

problem solving, decision-making, and planning
tools
• Set the example. Be a good role model for you

employees. They will believe what they see - not
what they hear
94
• Know your people and look out for their well-

being
• Know human nature and the importance of

sincerely caring for your workers
• Keep your people informed. Know how to

communicate with your people, seniors, and
other key people within the organisation
• Ensure tasks are understood, supervised, and

accomplished. Communication is the key to
this responsibility
• Develop a sense of accountability, ownership

and responsibility in your people
• Train your people as a team
• By developing team spirit, you will be able to

employ your organisation, department
These traits will help them carry out their

responsibilities with professionalism
95
Challenges of leadership in health in Africa
Discuss the key leadership challenges in health in

your country? To what extent…
•is care comprehensive, integrated, continuous and
effective?
•is access guaranteed and are people aware of what
they are entitled to?
•are people protected against the economic
consequences of ill-health?
•are authorities effective in ensuring protection
against exclusion from care?
•are they effective in ensuring protection against
exploitation by commercial providers?
Visionary leadership: mission and vision
• What is the vision of your institution?
• What is your mission?
• Critique the mission and vision of your

organisation
• What challenges do you experience in

actualising this vision?
• How can a leader obtain buy in into their

vision and mission?
96
What is a vision statement and why have one?
A vision statement
• Reflects desired impact of • Is achievable, even if far
the organisation in the out in the future
future • Provides a clear picture of
• Describes future the future
aspirations • Helps keep mission on
• Defines the dream, long track
term, unconditional • Helps organisational focus
direction organisation is • Has a possible team
heading in building effect
• Is inspirational,
motivational, hopeful
What is a mission statement?
• Expresses organisation’s identity and

over-riding purpose
• Outlines contribution organisation will

make and outcomes it seeks to deliver
• Captures interest of key stakeholders and

motivates them in a common direction
97
What are values?
• Principles or commitments that organisational

members stand for
• Qualities and behaviors most highly regarded by

organisation as a whole
• Define the ethical guidelines and standards that direct

action in the organisation
• Typically limited to 3-5
• Deeply embedded
• Withstand test of time
Value based leadership
• Integrity
• Commitment
• Humility
• Respect
• Trust
• Courage to take risks
• Continuous learning
MSH Managers Who Lead, Page 4-5

98
Development cycle
ATTITUDE (Humility, curiosity…)

Incompetencies
EXPERIENCE (Action, risk…) Awareness,
INFORMATION (Feedback…)
LEARNING
Knowledge
Good behavior
Incompetence
Competence
Development
Incompetence cycle
Incompetence
Awareness
Humility
Incompetence Competence
Unawareness
MSH: Managers who Lead

99
The challenge model

MEASURABLE RESULTS
OBSTACLES AND PRIORITY ACTIONS :
-------------
ROOT CAUSES :
-------------
------------- -------------

CURRENT SITUATION
Challenge: How shall we achieve the desired results in light of the obstacles that
we need to overcome?)
Strategic direction
The strategic direction of a Health Institution is

informed by Global Health direction such the
MDGs and the National Health Systems
Strategic Plan (NHSSP)
100
Sound NHSSP: Framework

• Includes policy, National Health Policy
strategy, budget, Health Vision, and policy directions
and operational National Health Strategic Plan
Medium Term Strategic Objectives, System Investments, Programs description
plans
• Links priorities,
ECD Strategy
HIV Strategy
Child Health
EPI Strategy
RH Strategy
(Roadmap)
with budgets
Strategy
Strategy
Malaria
Others
• All plans inter-
linked Budget / Expenditure Framework
Budget / Expenditure Framework

• Country led in all
processes Budget / Expenditure Framework
• Developed
1st Annual 2nd Annual 3rd Annual 4th Annual 5th Annual
inclusively Operational Operational Operational Operational Operational
Plan/review Plan/review Plan/review Plan/review Plan/review
Millennium Development Goals (MDGs)
The United Nations Millennium

Development Goals are eight goals
that all 191 UN member states have
agreed to try to achieve by the year
2015. The United Nations Millennium
Declaration, signed in September
2000 commits world leaders to
combat poverty, hunger, disease,
illiteracy, environmental degradation,
and discrimination against women.
The MDGs are derived from this
Declaration, and all have specific
targets and indicators.
http://www.who.int/topics/millennium_development_goals/en/
28th May 2011
101
Millennium Development Goals (MDGs)…
MDG1: Eradicate extreme poverty and hunger

MDG2: Achieve universal primary education
MDG3: Promote gender equality and empower
women
MDG4: Reduce child mortality
MDG5: Improve maternal health
MDG6: Combat HIV/AIDS, malaria and other
diseases
MDG7: Ensure environmental sustainability
MDG8: Develop a global partnership for
development
National health priorities
As leaders in Health care, you need to be

aware of your country’s national health
priorities and to align your goals and actions
accordingly
102
Example of Malawi
• It is important to know the mission and vision statements

of your Ministry of Health (MOH)
• MOH Mission Statement for Malawi

“ to stabilize and improve the health status of Malawians
by improving access, quantity, cost-effectiveness and
quality of the EHP and related services so as to alleviate
the suffering caused by illness, and promoting good
health, thereby contributing to poverty reduction.”
• Share your the vision and mission statement of your

organisation
Using the Challenge Model
• See handout on how to use the Challenge

Model
• The participant will use this to work on their

JAMII Project which is also covered in the
participants handout
• This project will be developed throughout this

course and is what the participant will
implement when they get back at the end of
the course
103
Using the Challenge Model to

develop JAMII project
STEP 1 Review your organisational mission

and strategic priorities
STEP 2 Create a shared vision
STEP 3 Agree on one measurable result
NB: The other steps will be developed

under the management module
UNIT 3
LEADERSHIP IN HEALTH SYSTEMS

BUILDING BLOCKS AND CHANGE
MANAGEMENT
104
Health systems building blocks
WHO Framework For Action..Everybody’s Business, Strengthening Health Systems and

improving Health 0utcomes 2007
Using the health systems building blocks:

• Discuss the framework of your country
• Critique the framework of your organisation
• Report back in the plenary

105
Change management
• Change is inevitable in today's complex

environment. It has been said that change is
the only constant
• A leader would learn change practices that

produce results
Definition of Change Management
• Change management is a structured approach

to shifting/transitioning individuals or teams
from a current state to a desired future state
• An organisational process aimed at helping

employees to accept and embrace change in
their current work environment
All leaders and managers must be prepared for

changes by being flexible, positive and
proactive in their approach
106
Step 1: Individual reflection

• Think of a change that you have experienced
• What did others do to support you during the change?
• Write down your reflection about this
Step 2: Team discussion

• In your groups, share your responses about what
happened
• Write the most helpful answers on a flip chart
Step 3: Large group discussion

• Read all the answers from group work
• Add anything from your own experience that is missing
from the list
“Leading Change” Framework

© 2003 Dorothy M. Wylie Nursing Leadership Institute
Work plan, Vision, Values

Communication Purpose and
and Monitoring Goals
Managing
the Change
Being Strategic
Change
Initiative
Engaging People
Stakeholders
and Team
Members
107
A small body of
determined spirits fired
by an unquenchable
faith in their mission can
alter the course of
history
Factors required for effective change

management in organisations
Culture
Structure Leadership Activities
People
Source: www.jiscinfonet.ac.uk
108
Changing people
Can be most
readily changed
Knowledge Skill
Can be changed over
intermediate term
Demeanor Network
Not easily
changed
Values Aptitudes Cognitive
Style
Means of changing people
Training & Development

Knowledge Skill
Incentives, Coaching
Demeanor Network
Additions & Replacements

Values Aptitudes Cognitive
Style
109
Basic facts about change
• Change is constant and is inevitable
• Change can be managed if the environment is

understood
• Change is a fact of life and does not care who it

hurts
• Change can be traumatic through anxiety, fear

and stress
• Change is a pre-requisite for organisational

growth and development. It seeks to add value
Basic facts about change …
• Change in one sub-system will affect other

sub-systems and ultimately the entire
organisation system
• To change a sub-system or the entire

system, relevant aspects of the
environment must also be considered
110
Group Discussion: Questions for Change

Management (15 minutes)
• What changes are occurring in the
environment? What will be their implications
for our organisation?
• What changes should we make in order to

achieve our development objectives,
improve our performance? (Incorporate your
answers in your JAMII Project)
• What undesirable changes will occur in our

organisation if we do not take timely steps
for prevention?
Vicious cycle of human behavior and change
A.The Source
- Disempowering
Belief system
- Non-aligned value
system
- Disempowering
D. The Result environment B. Disempowering
- Full potential not realised Attitudes
- Declining public/staff - Negative Perceptions
confidence - Negative conditioning
- High staff turnover - Learned helplessness
C. Behaviour/Action
- Resistance to change
- Them vs. Us attitudes
- Sabotage
- Lack of ownership
- Lack of teamwork
111
Resistance to change
• “Change” is actually a frightening word for

many people
• People resist and try to avoid changes that

will leave them worse off than they are now
• But, resistance may be met even if the

proposed change is neutral, or beneficial to
the persons concerned
Why people resist change
• They believe it’s not in their interest to change

• They think the change is the wrong thing to do
§ “If you knew what I knew”
• They are skeptical about the possibility of success
• They don’t understand why change is happening
§ It isn’t relevant to them
• They don’t understand exactly what change is
required
• They don’t have the time or resources to change
• They don’t think that they will be able to change (Fear
of failure)
• They feel they were not involved in the decision to
change
112
Why people resist change …

• Lack of conviction that change is needed
• Dislike of imposed change
• Dislike of surprises
• Fear of the unknown
• Reluctance to deal with unpopular issues fear of

inadequacy and failure
• Disturbed practices, habits and relations
• Lack of respect and trust in the person promoting
change
Strategies for dealing with change resistance
Resistor position… Helpful responses…
“Step into their shoes”

• They believe it’s not in their interest to
change
• They feel they were not involved in the Communicate with
honesty and integrity
decision to change
• They are skeptical about the likely Build credibility
success of the project
• They think the change is the wrong thing Build awareness,
to do clarify relevance
• They don’t have the time or resources to

change Resource, prioritise
• They don’t think that they will be able to

change (fear and anxiety) Encourage, coach
113
Steps to successful change management
• Increase urgency - inspire people to move, make objectives

real and relevant
• Build the guiding team - get the right people in place with
the right emotional commitment, and the right mix of skills
and levels
• Get the vision right - get the team to establish a simple

vision and strategy, focus on emotional and creative aspects
necessary to drive service and efficiency
• Communicate for buy-in - Involve as many people as

possible, communicate the essentials, simply, and to appeal
and respond to people's needs. De-clutter communications -
make technology work for you rather than against
Steps to successful change management …
• Empower action - Remove obstacles, enable constructive

feedback and lots of support from leaders - reward and
recognise progress and achievements
• Create short-term wins - Set aims that are easy to achieve -

in bite-size chunks. Manageable numbers of initiatives. Finish
current stages before starting new ones
• Don't let up - Foster and encourage determination and

persistence - ongoing change - encourage ongoing progress
reporting - highlight achieved and future milestones
• Make change stick - Reinforce the value of successful

change via recruitment, promotion, new change leaders.
Weave change into culture
114
Change management ... (Kotter’s Model)
• Create a feeling that change is needed. Involve as many

people as possible in the process of change, starting from the
present situation as it really is. Use other people’s ideas freely
but give them the credit
• Create a sense of the urgency of change. Ensure people
understand the reasons for change and the importance of it, and
get them committed to it. Take opportunities as they present
themselves and seize the critical moment
• Create a vision which is easy to communicate. Be positive
and optimistic in your language, presenting an inspiration rather
than starting from negative problems
• Communicate the vision rigorously. Try to ensure the
message does not become garbled and misunderstood on its
way through the organisation
Change management ... (Kotter’s Model)

• Remove obstacles. Involve those who might oppose the change and
enlist their support. Those who are unwilling to change will find their
power diminished as empowered staff increasingly take the lead
• Build a critical mass. Involve all cadres of staff in discussing and
developing change, so that sufficient numbers become committed to it
and the change becomes inevitable
• Systematically plan for easy wins early on. The change process
may take a long time – work in small incremental steps and celebrate
small successes early, with awards or good publicity, so that staff are
encouraged
• Don’t declare victory too soon. The hardest part is often maintaining
momentum for change after the first excitement has subsided and
ensuring that changed methods and processes are “locked in” to the
system. Keep reinforcing the value of commitment and of the new
(changed) arrangements
(Kotter, J.P. (1995) Leading Change: Why Transformation Efforts Fail. Harvard Business
Review, March/April 1995)
115
Change management …(Kurt Lewin’s Model)
Unfreeze> make change> refreeze

• Unfreeze
§ Trigger for change exists as a means of establishing the
need for change
• Make change. Best approach will depend on
§ how much resistance you meet
§ how much power you have
§ how much you need others' commitment
§ what level of risk you are willing to accept
• Refreeze
§ Ensures change takes on, resistance is overcome,
procedures are put in place and norms are established
Using the checklist for successful change

initiative which is based on the Challenge
Model, discuss the following in your groups and
write your answers in the “comments” column
of the handout
•How will you communicate the urgency of your
proposed change effort? Examine if the
challenge is framed clearly to facilitate this
•In the large group, review as many of the other

questions as time permits
116
UNIT 4
APPROACHES FOR PRACTICING

EFFECTIVE LEADERSHIP IN HEALTH
Practical enabling skills of a leader
• Visioning
• Communication skills
• Setting an enabling environment/organisation culture
• Advocacy
• Delegation
• Negotiation skills (Use a game)
• Stakeholder analysis (to be covered more in
Management module)
• Change management skills
• Team building
• Motivation
• Conflict management
117
Practical enabling skills of a leader …
To improve your abilities to lead, as well as

manage for results, you need to:
• Empower yourself and others to face
challenges
• Link leading and managing to positive
outcomes
• Strengthen your leading and managing
practices
• Become skilled in using the leading and
managing practices and integrating them
into your daily work
Case study: Dr. V. of Aravind Eye Hospital

(60 minutes)
• What leadership skills did Dr. V. use to

successfully implement the eyes program in
the hospital?
• What were the outcomes of his leadership?
• Using the Challenge Model, include in your

JAMII project some actions that you plan to
take to improve your leadership skills for better
results
118
Step 1 Discuss characteristics of advocacy

and inquiry
Step 2 Discuss different types of inquiry
Step 3 Discuss different types of advocacy
• Identify types of advocacy (promotion) we use to persuade, and

reflect on how these affect people (for example, a sales
promotion for a new service or behaviour change
• Communication in a workplace AIDS prevention programme
• How does the type of advocacy affect people’s stance toward

you or what you are promoting?
• List types of advocacy in the appropriate column to distinguish

types that encourage learning from types that block learning
Source: Managers who Lead (MSH)

119
Activity 3.9: Prisoners dilemma (2 hours)
The purpose of this exercise is to demonstrate

that negotiation requires trust and how difficult it
is to regain trust when it is lost
Objectives of the activity
• To identify the basic principles of and

strategies for successful negotiation
• To experience and understand the need to

seek ‘win/win’ outcomes in negotiations for
both the individual and the group
• To explore issues of trust and

communication
120
Expected objectives of the activity …
• The basic principles and strategies for

successful negotiation identified
• The need to seek ‘win/win’ outcomes in

negotiations for both the individual and the
group experienced and understood
• Issues of trust and communication explored
Activity 3.9 …
• There will be three games played simultaneously with two
groups competing
• Each group will be given 2 cards (one marked red and the
other marked blue)
• Each game will play ten rounds with poses after every
three rounds (each card played by one team attracts
points depending on the card played by the other team) –
table below
• The first three rounds will be played without any

communication between the groups, then after every three
rounds the teams can negotiate for three minutes
121
Activity 3.9… scoring scheme
Team A Team B Team A Team B

plays plays scores scores
Red Red +5 +5
Red Blue -10 +10
Blue Red +10 -10
Blue Blue -5 -5
Activity 3.9 …
Plenary discussions on strategies and

principles for negotiation
122
Principles and strategies for negotiation
• Planning including defining the negotiation

objectives
• Avoid a clash of wills by applying criteria or

standards that are verifiable and independent
• Negotiations and their results have long term

effects – be careful what you argue for
because you cannot easily change your
position in the future
Principles and strategies for negotiation …
• May produce some compromises – begin

negotiating once one has identified a range of
acceptable results (not just one desired option)
• Be wise enough to know when not to negotiate
• Agreements where one side “wins” often fail

123
While negotiating
• Show respect for the other side’s point of view.

Always seek common ground and shared interest
• Negotiate in good faith. Find ways to show the other
side you are sincere about reaching an agreement
• Communicate your position clearly. Make sure you fully
understand the position and issues of the other side
• Never argue or disagree within your negotiation team
in front of the other side
• Steer the negotiation towards the issues you want to
talk about. Call for a recess if discussions go off track,
and use humor if things become tense
The usefulness of this activity

• It has the ability to expose participants to most
of the important principles of negotiation
• Negotiations do fail due to focus on winning at
all costs (greed) and this exercise shows how
one side easily looses if greed is the motivating
factor
• By enabling the players to decide when to
discontinue negotiating, the seemingly winning
side ends up loosing also
• Perhaps the most important feature of the
exercise is the fact that there is only one
strategy to win – “win-win strategy”
124
Conclusion
• Leadership is the moral and intellectual ability to

visualise and work for what is best for the
organisation and for the employee
• Moral capital (social and ethical capital) is needed
to ensure that we make a difference in Africa in all
sectors, including health
• Leaders can be developed at every level in the
organisation
• Leadership skills can be learned
This requires commitment on your part and on the

part of the organisation
125

MODULE FOUR
MANAGEMENT FOR HEALTH
Objectives
By the end of this module, the participant

should be able to:
• Define the concepts and principles of

management for health
• Describe the functions and roles of a
manager in health systems strengthening
• Discuss strategic management approaches
• Describe the characteristics of effective
teams
126
UNIT 1
OVERVIEW OF MANAGEMENT
Management for health
• Today’s managers face complex situations that

call for critical thinking
• Examination of management processes,
structures and behavior, focusing on the
changing nature of management in response to
turbulent internal and external environments
are necessary
• In particular, various theories are integrated
into applied dimensions of successful business
practices in the health sector, and emphasis on
global management perspectives that need to
be considered
127
Attempt the following question in your groups

and report back to plenary
•Using relevant examples, discuss the

following statement “A manager-leader gets
better results than a leader-manager”
Definition of management
• The effective and efficient use of resources to

meet an organisation’s goals
• Management is a process of working with and

through others to achieve organisational
objectives in a changing environment
• Management is a process of planning and

controlling the performance or execution of
any type of activity
128
Characteristics of management
• Management has the following characteristics

§ It is a process or a series of continuing and related activities
§ It involves and concentrates on reaching organisational goals
§ It reaches these goals by working with and through people
and other organisational resources
• There are five components of this definition

§ Working with and through others
§ Achieving organisational objectives
§ Balancing effectiveness and efficiency
§ Making the most of limited resources
§ Coping with changing environment
Leading and managing for results
• How do management and leadership contribute to

improved service delivery?
When applied consistently, good leading and

managing practices strengthen organisational
capacity and result in high quality services
and sustained improvements in health
129
Management and leadership
Managers Leaders
• Managers cope with • Leaders cope with

complexity change
• Managers plan and • Leaders set direction
budget and shared values
• Managers organise and • Leaders align people with
staff a business the organisation and
therefore empower them
• Managers control and • Leaders motivate people,
problem-solve including through networks
of informal relationships
Managing versus Leading
Managers Leaders
• Administer • Innovate
• Maintain • Develop
• Control • Inspire
• Short-term view • Long-term view
• Ask how & when • Ask what & why
• Initiate • Originate
• Accept the • Challenge the
status quo status quo
• Do things right • Do the right things
130
Managerial skills
Skill category Skills Description

Technical: Applying the 1. Technical Skills acquired and
education, training, and expertise experience; to understand
experience to effectively and communicate key
organise the work technical details
2. Clarification of The is the ability to organise
goals and and schedule the work so
objectives that it is achieved and meet
the set standards
3. Problem solving Ability to solve problems

confronted in daily work.
Team collaboration in solving
problems
4. Imagination and Ability to originate ideas to

creativity correct and develop ways to
improve productivity
Managerial skills …
Team building: Listening 5. Listening for Keeping aware of activities

carefully and communicating insights. for your team.
clearly to develop and coordinate
an effective group or team
6. Directing and Meeting your goals and

Coaching standards. The team’s
skills are kept up to to the
target
7. Solving problems Helping your team

as teams contribute ideas to
improve their performance
8. Coordinating and Demonstrating a

cooperating willingness to work with
others
131
Managerial skills …
Drive: Setting goals, maintaining 9. Standards of This is an effort to keep the
standards, and evaluating performance organisation moving, and
performance to achieve effective willingness to be busy to aim
outcomes involving costs, output, higher
product quality, and customer
service
10. Control of Overseeing the performance
details of work at a close level to
meet performance goals and
standards
11. Energy Demonstrating to the
colleagues a readiness and
willingness to work and that
you expect their cooperation
12. Exerting Urging others to perform by
pressure shaping your activity to be
perceived as teamwork, not
domination
Principles of management
• Division of labour:
§ The essence of division of labour is specialisation and
productivity
• Authority and responsibility:
§ You can not give responsibility without authority
• Unity of direction:
§ Similar activities are grouped together to achieve common
objectives
• Equity:
§ Treating staff with respect
• Order:
§ A systematic way of arranging activities and ideas
• Discipline:
§ Consistent observance of rules and regulations
132
Principles of management …
• Initiative:
§ Eagerness to take action without being asked to do so
• Fair remuneration and other rewards:
§ Commensurate compensation for work done
• Stability of tenure:
§ Job security
• Span of control:
§ There is a limit to how many people a manager can work
with effectively
• Span of influence:
§ The number of people that a leader can influence
Ask participants to discuss the following

questions in plenary:
• Which of the principles of management are

NOT applicable in your institution?
• How can you use learnt skills to lobby for

change in these?
133
UNIT 2
FUNCTIONS AND ROLES OF A MANAGER
Integrated leading & managing process
Source: MSH
134
Leading and managing for results model
Leadership Management Results

Improved
Scan Plan Improved capacity to
work respond to
Focus Organise
climate change
Align/ Implement
Mobilise
Improved Improved Improved
Inspire Mobilise & services health
management outcomes
evaluate systems
Source : MSH
Functions of a manager
The traditional functions of management are:

1. Planning
2. Organising
3. Staffing
4. Directing/Leading
5. Coordination
6. Controlling
(Henri Fayol)
135
Functions of a manager…
Contemporary functions of management include:

1. Planning
2. Decision making
3. Organising
4. Staffing
5. Directing
6. Communicating
7. Motivating
8. Leading
9. Controlling
Participants’ reflections:
• Have you ever planned to undertake an

activity in the health sector?
• If the answer is yes, then, explain how you

went about from planning to the execution of
the plan
136
Planning
Definition of planning:
• It is deciding in advance what is to be done,
how and when to do it
• It includes identifying strategies & resources
for the tasks
• Developing mission and vision
• Determining enterprise’s mission and goals
Planning…
Planning involves:
• Deciding in advance what, where, how, who and
when to do it
• What - involves setting objectives and goals
• How - setting strategies, allocate adequate
resources (money, people and materials)
• Where - is at what level whether at departmental
level or business level
• Who - involves the people (personnel)
• When - involves the timing of the particular strategy
137
Brainstorm on definition of organising and

organisation
• Explain the meaning of the term organising
• How is work organised in your organisation?
Organising
• The essence of organising is effectiveness and

efficiency (to maximize output with minimal
input)
• Developing framework or organisational chart/
structure e.g. health management teams
• Identification and grouping of activities to be
carried out
• Creation of departments/divisions
• Creation of authority & responsibility
relationships
• Organisation of resources in the best way to
yield best results
138
Essence of organising
These are:
• Specialisation
• Well defined jobs
• Clarifies authority
• Coordination
• Effective administration
• Growth and diversification
• Sense of security
• Scope for new changes
Staffing
Allow participants to discuss and put their findings on
flip chart and report back
• What do we understand by staffing?

• Is the term staffing appropriate?
• State the major staffing issues in health?
(These will be discussed in detail in the HRH

management module)
139
Staffing
Process of staffing:
• Task analysis
• Job descriptions
• Plan for recruiting
• Recruitment process
• Hire and deploy
• Motivation
• Retention
• Exit
NB: These issues are covered in detail in the HRH

Management module
Directing/Leading
• This is the influencing process of leaders and

followers to achieve organisational objectives
through change
• Key elements of leading

1. Leaders-followers
2. Influence
3. Organizational objective
4. Change
5. People
140
Coordination
• This involves ensuring that all the functions of

management are working together to produce
results
• All departments and units see the inter-
connectedness of their work
• Ensure that there is shared vision in all the
departments or units
• Communication is important aspect of
coordination - share information regularly and
in a timely manner
Controlling
• Is the process of monitoring performance and

taking action to ensure desired results
• It involves comparing actual performance with
the plans or standards set
• Checking the enterprise activities to ensure that
everything is on track for the achievement of
goals
§ Any deviation is remedied to ensure
attainment of the goals
§ Quality assurance in health services provision
is upheld through monitoring and evaluation or
controlling
141
Importance of controlling in management
• It helps to ensure that right things happen in the right way

and at the right time
• Done well, it ensures that the overall directions of individuals

and groups are consistent with short and long range plans
• It helps to ensure that objectives and accomplishments are

consistent with one another throughout an organisation
• It helps to maintain compliance with essential organisational

rules and policies
§ Establish objectives and standards.
§ Measure actual performance.
§ Compare results with objectives and standards.
Due to the changing environment in the health

sector, the role of today's manager is also
changing
• Discuss the impact of decentralisation of

health service to the role of the manager
Make reference to:

• service agreements/contracts
• outsourcing of services
142
Basic management roles
Mintzburg identified three types of manager roles:
• Interpersonal roles: Roles that involve

coordination and interaction with employees
• Informational roles: Roles that involve

handling, sharing and analysing information
• Decisional roles: Roles that require decision

making
Managerial roles …
Interpersonal roles
• Figurehead -performs ceremonial and

symbolic duties, e.g. bestowing honours and
making speeches
• Leader -inspires, motivates, guides, provides

example to the followers
• Liaison-maintains relationships with other

organizations
143
Management roles …
Informational roles
• Monitor - Observes collects, refuse data on

meeting of standards and take note on compliance
• Disseminator -Transmits information and

judgments about internal and external
environments
• Spokesman/person - He speaks for the

organisation, lobbies and defends it and its policies
and carries out public relations activities
Management roles …
Decisional roles
• Entrepreneur -Initiates changes authorises actions, set
goals and formulates plans for the organisation
• Disturbance handler -Deals with conflicts and complaints,

negative actions of competitors and disturbing issues
within the organisation, e.g. absenteeism
• Resource allocator - Approves budgets, schedules and

promotion, and set organisational priorities
• Negotiator -Works out and signs agreements with external

organisations and groups e.g. customers, financiers,
suppliers, etc
144
The unorganised manager (Video - 1 hour)
Watch the movie and discuss the following question

• What management skills did the manager use to
organise for results?
Personal reflection:
• Which management skills do you plan to
strengthen?
• Journal your thoughts in the action section of
your JAMII Project
UNIT 3
STRATEGIC MANAGEMENT APPROACHES

145
Group discussion
• What do you understand by strategic thinking

and strategic management?
• How many of you have strategic plans and

what is the value of the strategic plan to your
organisation/unit?
Strategic thinking
• This is a mental process whereby we strive to develop a

systematic and logical approach(es) in creating or
innovating ways of dealing with a situation
• A process of building a strategy to solve a problem/

handle a situation
• The processes are:

§ The process of organisation
§ The process of scanning
§ Process of viewing
§ Process of driving forces
§ Process of ideal positioning
146
Strategic thinking process
1. Organisation
2. Scanning
4. Driving forces
3. Viewing
Organisation in strategic thinking
Involves the means and ways of combining

human resources, financial resources, social
resources and physical resources together to
achieve your ideal outcome
It basically addresses the questions of HOW?

i.e. how to address the problem
147
Scanning in strategic thinking
• This is Scanning of a situation so as to

become more aware of how to solve problems
more effectively, and how to distinguish
between alternatives
• It enables you to understand the situation

better
Viewing in strategic thinking
Different ways of thinking about a situation to help

you think about outcomes, identify critical elements
and adjust your actions to achieve your ideal
position.
When you are looking down at the world from an

airplane, you can see much more than when you are on
the ground. Strategic thinking is much the same in that
it allows you to see things from “higher up”
148
Driving forces in strategic thinking
• The process of setting your vision and mission in

relation to the situation being thought about .
• Driving forces usually lay the foundation for what

health management teams want people to focus
on in their facilities/communities
• Setting permanent solutions to problems
The case of Manyatta village

There has been prolonged heavy rains in Manyatta
village. All communication infrastructure to and out of their
health facility is completely cut off. Suddenly there is an
outbreak of diarrhoea in the village
• Identify the problem points

• Identify the problems at each point and prioritise their
problems
• Prioritise the problem points for action
• Suggest solutions (immediate & future) to the problems
• Identify the resources required
• Identify sources of the required resources
149
Strategic thinking competencies

• Being able to clearly understand the situation
(critical interpretation)
• Being able to understand implications of strategic
actions (a systems perspective)
• Being more determined and less distractible
(intent focused)
• Being able to hold past, present and future in mind at
the same time to create better decision making and
speed implementation
‘Strategy is not driven by future intent alone it is the gap
between today's reality and intent for the future that is
critical’
Strategic thinking competencies …
• Being hypothesis driven, ensuring that both

creative and critical thinking are incorporated
in strategy making
• Being responsive to good opportunities

(intelligent opportunism)
150
Relevance of strategic thinking to

leaders/managers
§ Can you recall what you ever established as

a new idea in your working environment over
years?
§ What was the cause of your new idea?

(Plenary discussion )
Understanding planning & strategy:

Definitions
Ask the following questions:
• Why plan?
• Benefits of planning
• What is a strategy?
• What is strategic planning?
• What is operational planning?
151
Definition of a strategic plan
A strategic plan is visionary, conceptual and

directional, tactical, focused, implementable
and measurable guide
Steps in strategic planning
• Strategy formulation
• Strategy implementation
• Strategy monitoring and evaluation

152
Concept of the
Organisation
GENERIC STRATEGIC PLANNING PROCESS MODEL
Vision
Organisation's
• Mission Objectives
• Goals
• Philosophies / Policies
Organisation's
Desired Position
External
Environment
Marketplace Trends
• • Strategic Plan
Market
• Competitors
• Implementation
• Industry
Plan
Opportunities & Strategic • Action Steps
Strategic
Issues
Threats Gaps
Macro Trends • Schedules
• Responsibilities
• Economy
• Socio-political • Resources
• Technological, Etc. • Etc.
Current
Internal Environment
Position
Appraisal of the
Organisation's
organisation and its
Strengths & Weaknesses
performance
Key Success Factors
Core Competencies.
Strategic Management Model

Evaluation &
Strategy Formulation Strategy Implementation
Control
Mission
Objectives
Strategies
External
Environmental Scanning
Society &
Task Policies
Environment
Internal
Programs
Structure
Culture
Resources
Budgets
Procedures
Performance
Feedback
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153
Eight step planning process

1. Stating the vision, mission and values
2. Analysing the external environment
3. Analysing the internal environment
4. Establishing goals
5. Defining SMART objectives
6. Formulating strategy & selecting strategic options
7. Implementing strategy & developing action plans
8. Evaluating strategic performance
What is a vision statement and why have one?
A vision statement
• Reflects desired impact of the • Is achievable, even if far out
organisation in the future in the future
• Describes future aspirations • Provides a clear picture of
• Defines the dream, long term, the future
unconditional direction • Helps keep mission on track
organisation is heading in • Helps organisational focus
• Is inspirational, motivational, • Has a possible team building
hopeful effect
154
How “big” should your vision be?
• The answer is how deeply do you care?
• How much are you willing to change?

§ Every vision has a price
§ If stakeholders really want something, they
must be willing to pay the price
Shared vision
When there is no
shared vision,
people go in
different directions
Source: Government of Kenya (GOK) 2007 Kenya Vision 2030

155
Shared vision …
When there is a
shared vision,
people go in the
same direction
Source: Government of Kenya (GOK) 2007 Kenya Vision 2030
What is a mission statement?
• Expresses organisation’s identity and over-

riding purpose
• Outlines contribution organisation will make

and outcomes it seeks to deliver
• Captures interest of key stakeholders and

motivates them in a common direction
156
What are values?
• Principles or commitments that organisational members

stand for
• Qualities and behaviours highly regarded by organisation as

a whole
• Define the ethical guidelines and standards that direct action

in the organisation
• Typically limited to 3-5
• Deeply embedded
• Withstand test of time
Participants share the mission and vision

statements of their organisations/institutions
• What would you change if you could?
• Re-write your statements

157
SWOT analysis in strategic planning
There are different approaches to strategic

planning and environmental scanning is one of
them. SWOT analysis has been used for this.
SWOT analysis
Opportunities
• An opportunity is a major favourable situation in
a firm's environment
Threats
• A threat is a major unfavourable situation in a
firm's environment
• Threats are key impediments to the firm's

current or desired position
158
SWOT analysis
Strengths
Strength is a resource, skill, or other advantage relative
to competitors and the needs of the markets a firm
serves or expects to serve. A distinctive competence
gives the firm a comparative advantage in the
marketplace. Strengths may exist concerning
financial resources, image, market leadership,
technology, and other factors
Weaknesses
A weakness is a limitation or deficiency in resources,
skills, and capabilities that seriously impedes a firm's
effective performance
External environmental analysis
External environment Goals of external analysis
Analyze opportunities & • Identify and analyze current

Challenges in: issues
• Trend analysis • Detect signals of emerging
• Macro environment analysis issues
• Task environment • Speculate on likely future issues
• Market analysis • Provide organised information
• Client analysis • Foster strategic thinking
159
Analysis of the external environment …
Analysis of the external environment should

take into account key Health statements and
declarations such as:
• Priority areas as outlined in Ougadougou

Declaration
• MDGs
Name any other health statements and

declarations
Priority areas as outlined in Ougadougou

Declaration
• Leadership & governance for health

• Health services delivery
• Human resources for health
• Health financing
• Health information
• Health technologies
• Community ownership & participation
• Partnerships for health development
• Research for health
160
MDG 4 and 5 (maternal & child health)
• Skilled attendants for every delivery are required

to accelerate attainment of MDG 4 and 5
• Evidence shows that where maternal mortality has

reduced, availability of skilled attendants at
delivery has been a contributing factor
• Health workers with appropriate skills to prevent

and manage common childhood illnesses and
other prevalent conditions contribute to reduction
of under five mortality
Group work:
What are the opportunities and threats in each

of the following external factors in health
industry?
• Political
• Economic
• Social
• Technological
• Legal & lifestyle
• Competition
161
Internal environmental analysis
Internal environment Goals of internal analysis
• Organisation strengths & • Leverage strengths and core

weaknesses in three broad competencies
categories: • Evaluate ways to create
§ Culture value for clients and
stakeholders, current &
§ Structure
prospective
§ Resources
• Answer the question: What
• Organisational profile can the organisation do?
• Key success factors
Internal assessment
• What is in our favour? (we must continue)
• What do we need to watch out for?

(positive/negative)
• What must we eliminate/control or not

be caught up by in terms of organisation,
location, governance, staffing,
recruitment, marketing, financial,
materials, methods, products /services –
position in market
162
Internal assessment …
• Our culture
§ Communication
§ Planning
§ Coordination
§ Use of time
§ Treatment of the customer
§ Quality of service
• Our structure
§ Governing structures
§ Leadership and management structures
§ Organogram
Internal assessment …
• Our Resources (Use 7 Ms)

§ Manpower
§ Machinery
§ Money
§ Markets
§ Methods
§ Minutes (moments)
§ Materials
163
Critical success factors
The following questions are to be considered in

determining critical success factors:
• How will we get there?
• What are the critical things that need to happen

to achieve strategic priorities?
• What are the essential outcomes/conditions to

achieve success?
• What are the things we have to do to meet our

customers needs?
Use the handouts provided to assess different

aspects of your internal environment
•What are the organisation’s top strengths?
•What are the organisation’s greatest

weaknesses?
•What are the key success factors in your

organisation?
164
SWOT sample
Strengths Weaknesses
1. Reliable budgetary provision 1. Lack of clear organogram

2. Availability of qualified and 2. Lack of teamwork among
professional staff Departments
3. Wide research and expertise 3. Poor staff attitude to service
in HIV/AIDS issues provision
Opportunities Threats
1. Good support of HIV work by 1. Possibility of political

donor agencies and other interference.
partners 2. High mortality rates due to
2. A growing economy. AIDS scourge.
3. Big need for quality Health 3. Quacks
care
Using the SWOT matrix to develop

strategies
• S-O: Pursue opportunities fitting in our strengths. We will

go on doing what we are good at
• W-O: Overcome our weaknesses to pursue

opportunities. We will equip ourselves better for taking
opportunities
• S-T: Use our strengths to fight the threats. We will be

pro-active in facing threats
• W-T: Prevent our weaknesses with a defensive plan. We

will train and equip ourselves to face those threats
165
Strategic goals
• Goals are key results, stated broadly and

qualitatively, that an organisation has decided
to target, given its stated mission and vision.
Strategic goals …
Establishing long-term goals include:

• Generating alternative strategies
• Selecting strategies to pursue
• Best alternative - achieve mission and
objectives
166
Examples of goals
(AMREF HIV/AIDS project)
• Mission
§ To reduce transmission of HIV from mothers to
children and to improve the care of people living
with HIV/AIDS
• Goals
§ Increase awareness of the public (women and
youth) about AIDS
§ Improve access to VCT, PMTCT plus and ART
services for HIV positive women and newborns
§ Increase MOH capacity to provide ANC, VCT/
PMTCT, PMTCT plus and ART services
Defining objectives
Objectives flow from the goals an organisation

has developed and offer a logical sequence for
achieving a goal. They enable goals to become
operational
167
Objectives
• An Objective - A specific condition that we want to

achieve to help us realize a vision
• It is recommended that they should be a maximum of 5
• Remember objectives must be SMART!

§ Specific
§ Measurable
§ Attainable
§ Realistic
§ Time bound
Examples of Goals &

SMART Objectives
• Goal: Increase capacity of AMREF and
Ministries of Health (MOH) and communities
to provide quality HIV/AIDS Care packages
• Objective #1: Community has been

sensitized, leading to 40% increase in VCT
uptake
• Objective #2: 12 health facility staff have

been trained as counselors and clinicians
168
Example of a measurable result
For a program whose mission is to prevent the

spread of HIV & AIDS
• The number of voluntary counseling and testing

sites in the district will increase by 50% in the next
6 months
• It is good to state the exact number: “9 testing sites

fully functioning in 6 months”
• The current reality is that there are now 6 sites
• In small groups, practice writing goals and

smart objectives
• Select one of them to share in plenary

169
Strategy formulation
Strategy formulation:
• involves making decisions using data gathered
• is a logical, sequential process
• is a decision-making process
§ How to commit and how to leverage resources

§ How to respond to the external and internal
environments
§ How to leverage the organisations core competencies
§ What actions to consider based on key success factors
Strategy formulation …
• Strategy formulation is based on creating

value for the clients
• There is value if the societal outcomes

exceed the societal resources
170
Key to obtaining a good strategy
Good strategies have three main characteristics:
• They identify a company’s core business

§ Involves identifying the existing customer groups,
those whose needs are being addressed
§ Involves identifying customers’ needs and noting

those needs that are being met vs. those that are
not being met
§ Determining how the needs are being satisfied,

addressing the technologies and functions being
performed by organisations
Good strategies …
• They communicate the vision and mission

inside and outside the company
§ Within the company, communicating the vision

involves motivating employees to embrace the
new purpose
§ Outside the company communicating the vision

involves ‘selling’ the new purpose to the
stakeholders
§ The vision and mission should be clear and

concise
171
Good strategies …
• Include information on whether the strategic

course and mission will be altered and/or
maintained and take into account the external
and internal environment
What makes a good strategy?
A good strategy:
• is planned well in advance

§ It anticipates what is likely to happen. It also
considers what isn’t likely to happen but
might happen anyway
• is flexible
§ It leaves room for alternative plans
• builds on the experiences of people

172
What makes a good strategy? …
• Involves people
§ It takes into account that how we get there is as
important as the ultimate destination. People learn as
much from the process as the content of a campaign
• Realistic
§ It develops out of an analysis of what the membership
can and cannot do
• Includes activities that build spirit, that keep people

interested and involved along the way
• Has depth
§ It includes not only good ideas but steps to carry out
those ideas
Goals, smart objectives and strategic options
S/N Goal Smart objectives Strategic options
1. Prevent the spread of HIV/ 1.1 Increase the 1.1.1 Partner with
AIDS number of testing Government to
sites by 50% i.e. open testing sites
from 6 to 9 ) in six the their clinics
months (.e. by
XXX) 1.1.2 Open new
sites, one per
month.
1.2. provide 1.2.1. Engage
counseling on professional project
behavior change to writers to write
50% of clients who projects t source
visit the testing for funding
sites by December 1.2.2. Engage
2012 trained counsellors
173
Strategy implementation
Activity 4.13: Group discussion

A research carried out shows that “globally for 25 out of
45 countries (55%)” have evidence of implementation
of the plans
Group 1:
• What are the hindrances to implementation of
strategic plans?
Group 2:
• What action can be taken to increase the
implementation rate?
Strategy implementation …
• Implementation is:
§ not the biggest issue facing companies today but it is

something nobody has explained satisfactorily
§ not just something that gets done or not done
§ a specific set of behaviours and techniques that a

company needs to master to have a competitive
advantage
§ a process on its own. It is critical for success in a

company regardless of size
174
Strategy implementation …
§ helps a leader choose a more robust strategy
§ Sets the pace for everything.
The main requirement for leadership in

implementation is that a leader has to be deeply
and passionately involved in the organization
Implementation arrangements: key tasks
Build
Lead Budget
175
• Strategy implementation involves:

§ Action planning
§ Develop programme
§ Develop projects
§ Budget for activities within the programmes/
projects
What is an action plan?
• A blueprint that shows how the organisation

will achieve goals and SMART objectives
• A detailed map defining how a strategy will be

implemented
176
Components of an action plan
1. Goal
2. Objectives
3. Activities
4. Responsibility
5. Timeline (duration & completion)
6. Costs
Sample action plan
GOAL: Reduce the spread of HIV AIDS

OBJECTIVE: 1.1 Increase the number of testing sites by
50% i.e. from 6 to 9 ) in six months (.e. by XXX)
S/N Activity By Who By When Cost
1. Prepare a HMT 30th April 50,000

project
proposal
•
•
•
2. Meet the PS
177
Action planning issues
• Gaining buy-in
• Identifying complementors/collaborators
• Establishing checkpoints
• Motivating employees
• Identifying roadblocks and contingency
planning
• Communicating effectively
• Measuring success
“Weak Leadership can wreck even the

soundest strategies, forceful execution of
even a poor plan can often bring victory”
(Sun Xi)
178
Strategy evaluation
• Strategy evaluation is core to the success of

implementation of strategic plans
• M&E: continuous monitoring of

implementation, midterm evaluation, final
evaluation
NB: This will be covered in detail in module 10
UNIT 4
CHARACTERISTICS OF
EFFECTIVE TEAMS
179
Team building
TEAM BUILDING
Overview
Concept of teams, team building and organizational culture
Relevance of team building in health systems strengthening
Process of team building
Characteristics of effective teams
Managing team diversity
Experiential learning- team building

180
Facilitator to give a team building exercise
Definition of a team and team building
SYNERGY: 1+1>2
A team is a collection of
individuals, who highly Combined efforts of team members
can achieve more than what single
communicate, directing their individuals can
energies towards a known
defined goal, which is Together
achieved through their joint,
complementary efforts, for Each
the benefit of all
Achieves
More
181
Definition of a team and team building …
• Two or more individuals with a high degree of

interdependence geared toward the achievement
of a goal or the completion of a task
• Teams make decisions, solve problems, provide

support, accomplish missions, and plan their
work
• Nobody is perfect but a team can be
Examples of teams
• Healthcare Team – several healthcare professionals working

closely together for the benefit of a patient or group of patients
• Athletic Team – people working together to win a game
• Natural Work Group – people working together every day in

same office with similar processes and equipment
• Business Team – cross-functional team overseeing a specific

product line or customer segment
• Improvement Team – ad hoc team with responsibility for

improving an existing process
182
Organisational culture
• Corporate or organisational culture can be

defined as a blend of ideas, customs, traditional
practices, values, beliefs philosophies and
shared meanings that help define normal
behaviour for everyone who works in the
organisation.
• Organisations like people have a mentality and

culture. When institutionalized within the
organisation, this mentality becomes what is
called corporate culture.
Organisational culture …
• As it relates to organisations, culture is the

general pattern of behaviour, shared beliefs
and values that members have in common.
Culture can be inferred from what people say,
do and think. It reflects the underlying
assumptions about the way work is performed
and what behavior and actions are encouraged
or discouraged
183
Elements of culture
• Communication and • Relationships

language
• Value and norms
• Sense of self and space
• Beliefs and attitudes
• Dress and appearance
• Mental process and
• Food and feeding habits learning
• Time and time • Work habits and

consciousness practices
Elements of culture …
• Rewards and • Perception

recognition
• Music and dance • Predisposition
• Art and literature • Stereotypes
• Religion • Gestures and body

language
• Laws
• Aesthetics
• Customs
184
Elements of culture …
Review the • Establish habits, practices,

values, beliefs and
• Vision subcultures which are not
consistent with all the
• Mission above
• Strategy • A SWOT analysis will

assist a lot towards this
• Core values and the negative cultural
habits will come under
• Service charter Strengths and
weaknesses.
Ask participants to:

• outline three main challenges in the area of
team building facing your team
• suggest three strategies for addressing

each of the challenges highlighted in bullet
above
185
Rationale of team building
Team building is necessary because:

• Managers spend 50% of their working day in
one team or another
• Organisations are broken down into functional

teams known as divisions, departments and
sections
• Organisational tasks require the cooperation

of individuals in units and sub-units
Importance of teamwork in healthcare
• Promoting teamwork and good communication

among health professionals can dramatically
improve efficiency and effectiveness of healthcare
delivery, resulting in better outcomes for the
consumers
§ Healthcare delivery systems has potential to be

outstanding
§ Health system is currently not as safe, effective, or

efficient as it should be.
186
Team development process
Forming (The Polite Stage)
storming
CONFLICT IS EVIDENT (The Fighting Stage)
FROM “Disorder & instability “, TO

(ORDER) & STABILITY) (The Settling Stage)
Performing ACHIEVE GOALS & RESULTS

(The Performing Stage)
Adjourning EXIT IN STYLE, REWARD & SANCTION

The “Ending” Stage
Stage 1 – forming
• Provide structure, broad goals/norms/TOR and clarify

task direction
• Focus on basic information, keep social distance
• Allow for “get-acquainted time”, break the ice, create

atmosphere of confidence and optimism
• Members tend to feel suspicious and confused
• Be visionary, inspiring, facilitate communication/

interaction/active involvement
• Members tend to accept the power & authority figure

187
Stage 2 - storming
• Conflict evident but encourage participation, and
appreciate individual differences
• Leader is a facilitator, trainer, coach and role model
• Acknowledge personalities & conflicts that emerge and

resolve issues
• Lack of unity & cohesiveness prevails hence guide

others toward consensus
• Get members to assume more task than people

oriented responsibilities
• Train on conflict resolution methods
Stage 3 - norming
• Teams emerge at the norming stage in group development
• Coach and sponsor new norms “modus operandi”
• Norms can be written or unwritten
• Give feedback and support, clarify roles, norms and values
• Plan celebrations for short term wins
• Allow for less structure and promote discussion & contributions

from all team members
• Encouraging others to make decisions and assess relevance of

norms to team productivity
188
Stage 4 - performing
 Observe, inquire , facilitate and fulfill team needs and

achieve results
 Provides little direction and allow members to

participate more in final decisions
 Low amounts of two-way communication needed
 Give positive reinforcement and support
 Leader sets goals: team accomplishes, solves

problems, share new information
Stage 5 - adjourning
 Help team with options for renewal or termination
 Effective active listening and provision of information in

many different formats
 Offer direction to move group back through initial stages

and guide the process
 Create opportunities for feedback, rewards & sanctions
 Reflect and engage in continuous learning and

improvement for the next task
189
Characteristics of a team
• Teams embody a collective action arising out of

task interdependency
• Members of the team agree on the goal
• Members agree that they must work together to

achieve the goal
• Each member is viewed as having one or more

important roles to play to successfully achieve the
goal
• There is less hierarchy within the unit than in most

work groups
Characteristics of effective teams
• Team goals are developed through team interaction and

agreement
• Participation by all team members and roles are shared
• Feedback is asked for by members and freely given as a way

of evaluating the team's performance and clarifying both
feelings and interests of the members
• Leadership is distributed and shared among team members

and individuals willingly contribute their resources as needed
(Francis and Young,1979)
190
Team effectiveness …
• Problem solving, discussing team issues, and
critiquing team effectiveness are encouraged by all
team members.
• Conflict is not suppressed members are allowed to

express negative feelings and confrontation within
the team which is managed and dealt with by team
members.
• Team member resources, talents, skills, knowledge,

and experiences are fully identified, recognized, and
used whenever appropriate.
• Risk taking and creativity are encouraged. When

mistakes are made, they are treated as a source of
learning rather than reasons for punishment.
• High level of interdependence among members
• Team leader has good people skills & is

committed to team approach
• Each member is willing to contribute , relaxed

climate for communication
• Members develop mutual trust
• Team and individuals are prepared to take risks

191
• Clarity about goals and establishes targets
• Roles are defined, team members know how to examine

team and individual errors without personal attacks
• Team has capacity to create new ideas
• Each team member knows he can influence the team

agenda
• Team decision making involves a process that

encourages active participation by all members
Team leader
An effective team leader makes sure that:
• Team members understand and share the

leader’s vision
• Team members respect and ideally like one

another
• Individuals derive satisfaction from being

members of the team
192
Team leader …
• The team learns to work together in a relaxed

fashion
• Team recognition and credit for a good job is

freely given
• Team members understand and share goals,

objectives, vision and mission
Causes of team failure
• Unclear goals and objectives
• Non-measurable goals
• Poorly defined boundaries and responsibilities
• Inappropriate leadership style and behaviour
• Ineffective meetings
193
Causes of team failure …
• Unwillingness of team members to accept

responsibility
• Individually oriented rewards and/or

recognition
• Functional resistance and politics
• Stifling of individual creativity and other

resourcefulness
Symptoms of a failing team
• No shows at scheduled meetings/events
• Late arrival and early departure
• Substitutes, time and time again
• Chronic complaining and non-constructive criticism
• Domination and bull-dozing
• Drop outs (from the team)
• Missed/unmet deadlines
194
Managing team diversity
Conflict
• Conflict is a natural phenomenon, neither good

nor bad, but may have positive or negative
outcomes
• Conflict management is a process of working

through opposing views in order to reach a
common goal or mutual purpose
Key components of conflict resolution
• Control emotional responses
• Seek understanding
• Identify needs and common interests of self

and others in the team
• Seek mutual benefit or purpose

195
A model of styles to handle conflict
Competing Collaborating
Compromising
Avoiding Accomodating
Thomas, K(1976)
Reactions to team conflict
Competitive/Domination Avoidance (Turtle)

(Shark): • Refusing to become involved
• Winning conflict at expense of in conflict
others • Protecting vs Withdrawing
• Forcing Vs Contending
Accommodating
Compromise (Fox)
(Teddy Bear)
• Focus on give & Take
• Firm Vs Flexible • Yielding ones opinion to
appease others
Collaborative/Integration • Yielding vs Conceding
(Owl)
• Try to ensure everyone wins
• The best but most difficult
196
Accommodation
Uses Danger of Inappropriate Use
• To build the relationship • Your needs are not met
• When the issue is relatively unimportant • You may begin to feel taken
to you, but important to the other person advantage of and resentful
• When you have less experience or

expertise than the other person
• When preserving harmony and avoiding

disruption are especially important
Avoidance
• When the issue or relationship is unimportant • Conflict may fester until it

escalates
• To prevent an immediate conflict (e.g.
inappropriate time, place, or feelings are • The relationship remains
escalated) superficial
• When someone else can resolve the conflict

more effectively
• When you have little chance of satisfying

your concerns (e.g. national policy,
someone’s basic personality, etc.)
197
Collaboration
• To find a solution that integrates both sets of • May waste time and energy
concerns, as they are both important on issues that are not
important
• To merge insights from people with different
perspectives on a problem • As the process can take
longer it may frustrate some
• When commitment and “buy-in” is needed to people
implement a solution
• When hard feelings have been interfering

with an interpersonal, working relationship
Competition/Directive
Uses Danger of Inappropriate

Use
• When quick, decisive action is • May weaken relationships if
important, such as emergencies it is perceived that you
won and the other person
lost
• When your core values need to be • You receive less input and
defended ideas from others
• When it is important to you to have it • Others may not “buy-in”

your own way and sabotage the decision
198
Compromise
• When an agreement needs to be reached – • Nobody really gets what they

time is important want or need
• When mutually exclusive goals prevent • The focus becomes what you
collaboration did not manage to get re
needs/wants
• To achieve temporary settlements to complex
issues • Problems reoccur as they
were not fully explored and
• As a backup mode when collaboration or resolutions found that truly
competition is unsuccessful work for those involved
Conflict resolution skills & roadblocks
AVOID
• Get the facts • Name calling
• Engage in Active/Reflective • Personalizing issues

Listening
• Sarcasm/Ridicule/Insulting
• Defuse/manage anger
• Threats/Blaming/Inflexibility
/negotiate outcomes
• Defensive body posturing
• Empathize and appeal to
cognitive restructuring • Offensive language
• Deal with clashing Egos

- Styles Of Conflicts
199
Remember!!
“Aspire to inspire before you expire”
“Resist the urge to be a star, strive

to develop stars and you will be a star”
Experiential learning
Advertise Your Team On TV!!
• In your Groups discuss and rehearse
• Presentation in plenary
• Plenary discussion
Oh, How Lucky you are!

Your National TV Station is now giving you a

right of 3 minutes advertisement for FREE

Let’s advertise your team on TV!!

200

MODULE FIVE
HUMAN RESOURCES FOR HEALTH
MANAGEMENT (HRHM)
UNIT 1
OVERVIEW AND CONTEXT OF HUMAN

RESOURCES FOR HEALTH
201
Objectives
By the end of this module, the participant should be

able to:
• Define the concept of human resources for health in

the context of health systems strengthening
• Discuss the relevant human resource policies and
plans in human resource management
• Describe the process of human resource planning
• Discuss performance management in the context of
human resources for health
• Describe various approaches that can be used in
human resource development
Ask participants to brainstorm on different

definitions and concepts in relation to
human resources for health management
and report in plenary
202
Definitions of concepts
Human resource management (HRM) is the

systematic acquisition, maintenance,
utilisation and outplacement of work force to
achieve organisational objectives. It has
several functional areas like planning, training
and development, performance management
amongst others.
Source: Dessler (2006) Human Resource Management
Definitions of concepts…
Human resources for health are those

individuals with health and non-health
vocational education and training working
in the health services industry
Monitoring & Evaluation of HRH (WHO 2009)

203
Definitions of concepts …
Human resources for health are all

categories of health care workers from
specialists physicians/surgeons through
to community health workers
Source: World Health Report (WHO 2010)
Definitions of concepts …
Human resources for health is the stock of all

individuals engaged in the promotion, protection or
improvement of population health
Health workers are all people primarily engaged in

actions with the primary intent of enhancing
health. This includes health service providers who
constitute two thirds and health management and
support workers one third
Source: WHO Report 2006, Human Resources for Health: Developing Policy for
Change (WHO 2000)
204
Definitions of concepts…
Human resources for health

management is the integrated use of
policies, systems and management and
leadership practices to plan for necessary
staff and to recruit, motivate, develop,
and maintain employees so that a health
institution or organisation can meet its
goal
Source: USAID MSH e-handbook for Leaders and Managers (2010)
Evolution of HRM
• American labour history from colonial period

to 1900s
• Early labour unrests in the 20th century
• Civil rights movements of the 1960s
• Today’s contemporary issues
• Government regulations and professionalism
205
The Health Action Framework
WHO (www.who.int/workforcealliance 2005)
Human resources for Health Action

Framework (HAF)
The framework identifies the six components
of planning and managing the workforce and
describes the goals of each
The components include:
• HRM systems, policy, leadership,
partnerships, education and finance
•The HAF provides a roadmap for developing
a comprehensive
Source: USAID MSH e-handbook for leaders and managers (2010)
206
The Human resources for Health Action

Framework (HAF)…
The HAF is useful for:

• Conducting assessment on the national
situation of human resources
• Developing strategies and implementation
plans
Global HRH crisis

Three major challenges leading to the global HRH crisis:
• Coverage:
§ Inadequate numbers
§ Inadequate skill mixes of health workers
• Work environment
§ Poor remuneration
§ Lack of opportunities for career development
§ Lack of supportive health systems
• Competencies
§ Lack of appropriate attitudes and skills
§ Lack of opportunities for continuous learning
§ Failure to create conditions for leadership and
enterpreurship
(Source: Joint Learning Initiative, 2004)
207
Current trends, emerging issues and

practices in HRH
• Task shifting and task sharing
• Increasing the pipeline and rationalisation of training
• Inter-governmental contracts compensation for
migration
• Performance management
• Work place improvement
• HIV/AIDS work place policies
• HRM practices
• HRH strategic plans
• WHO code of practice
• Formal and incentivised community health workers
• Strengthening HRD units
• Creation of HRH observatories
Linkage of HRH & HSS
HRH is the most important aspect of health care

system because:
• Human involvement is implicit in services
delivery
• Personnel represents one of the largest
element cost
• The effectiveness of human resource rests on
its ability to mobilise and manage other
resources in health care system
208
UNIT 2
HUMAN RESOURCES POLICIES AND PLANS
Functions of HR policies
• Provide a mechanism to manage risks by keeping

up to date with current trends in employment
standards and legislations
• Allow health systems to be clear on expectations,

procedures, what is acceptable and consequences
of unacceptable behaviour
• Can also be very effective at supporting and

building the desired culture for HRH e.g.
recruitment and retention policies and labour laws
outline the way a flexible workforce is valued
209
Introduction labour laws

Labour or employment laws are designed to protect both
workers and employers
Definition:
Labour laws are the body of laws, administrative rulings, and
precedents which address the legal rights of workers and their
organisations
• The laws address issues of equal pay for equal work,
discrimination, benefits e.g. insurances, pension, and
others (job security)
• Good labour laws are as good as their enforcement.

Legislation is useless without law enforcement to back it up
Types of labour laws
There are International and national labour laws. For

example in Kenya, the following are some of the labour
laws
•The Employment Act, Cap 226
•The Regulation of Wages and Conditions of Employment
Act, Cap 229
•The Trade Unions Act, Cap 233
•The Trade Disputes Act, Cap 234
•The Factories and Other Places of Work Act, Cap 514
•The Workmen’s Compensation Act, Cap 236
210
Ask participants to discuss on various Labour

Laws from their country and share in plenary
Components of a HRH policy document
• Key components
§ A statement of the issue which the policy addresses
§ Summary of the principles underlying the policy
§ Outline of the objective of the policy
§ A background to the current situation in which the policy is set
§ Statement(s) of what is to be done under the policy
• Other components
§ History of previous (relevant) policies
§ Data about the target population or client group
§ Description of existing services covered by the policy
§ Presentation of “macro-policy” statements with a list of
proposed actions or activities to make each policy statement
effective
211
Definition of health care policy

• Traditional approach
§ Understands policy as a cyclic process, the different stages of
which can be separately analysed. In order to resolve a problem,
a policy is devised, a number of objectives are set and strategies
are defined to achieve them. The operational implementation of
the policy is expected to lead to resolution of the problem
• Alternative approach
§ Puts the emphasis on the interpersonal and contextual relations
of the policy process. Policy is conceived not as a sequential
process but as an integrated process in which values and
differences are made explicit, consensus agreements sought,
compromises made, alliances formed and action justified
“Health care policy can be seen as the networks of interrelated decisions which together form an
approach or strategy in relation to practical issues concerning health care delivery" (Barker C
(1996) The health care policy process. London. Sage Publications p.6)
Levels of operation of health care policies
• Systemic policies deal with the overall health system, such as

the public-/private mix, the role of donors, or decentralisation
• Programmatic level policies determine for example the

priorities for health care, resource allocation, what health
programmes should include, pharmaceuticals procurement
and availability
• Organisational level policies are concerned with the systems

and processes to ensure best use of resources and deliver a
high quality service, such as policies on district transport or
community participation
• Instrumental policies deal with the management of the

instruments of good organisation, such as the information
system or human resources planning
212
HRH policy formulation process
• The rational planning approach would suggest a

logical and linear approach to policy formulation,
but in practice the process is usually very complex
• Policies are usually developed in response to a

specific situation, often with competing demands
for attention, and accompanied by lobbying,
campaigning and tradeoffs
• The influence of donors, multinational corporations,

professional associations and other powerful
groups may have to be accommodated
HRH Policy implementation
“Operationalising” policy requires the

introduction of systems and procedures and
includes the following steps:
• Communication and publicity
• Piloting the policy
• Consultations
• Purchase of hardware
• Hiring staff
• Training staff
213
UNIT 3
HUMAN RESOURCE FOR HEALTH PLANNING
HRH planning
• Planning is deciding in advance what and how it is to be
done in the future, and establishing whether it has been
done
• HRH planning is a function and a task of every manager
• It is the ongoing process of systematic planning to

achieve optimum use of personnel. It is done to ensure
the best fit between employees and jobs while avoiding
manpower shortages or surpluses
• The key elements are: forecasting labour demands,

analysing present labour supply and balancing projected
labour demand and supply
214
HRH planning…
• Situation analysis
§ Disease Burden
§ Skills gaps
§ Norms and standards - Workload Indicators
of Staffing Needs (WISN)
§ Numbers of health workers and distribution
§ Catchment area
§ Labour market
§ Projection and forecasting
HRH planning…
• Stakeholder analysis
§ Multi-sectoral collaboration
§ Public-Private Parternerships (PPP)
§ Long and Short term plans (strategic and
operational plans)
§ Costing of the human resource plan
§ Monitoring and evaluating the plan
215
HRH staffing …
• HRM-staffing is the process through which an

organisation ensures that it always has the
proper number of employees, with appropriate
skills, in the right jobs at the right time to
achieve organisation’s objectives
• It involves:
§ Job analysis, e.g. determining skills duties
and knowledge required for job performance in
the organisation/community
HRH staffing …
• Human resource planning - systematic

reviewing human resource requirements to
ensure that the required numbers of
employees with the required skills are
available when needed
• Recruitment - the process of attracting

qualified individuals and encouraging them
to apply for work with the organisation
216
HRH staffing …
• Selection : process through which organisation

chooses, from a group of applicants, those
individuals best suited both for open positions and
the organisation itself
• Placement: the act of offering the job to a finally
selected candidate, and hence is the end of
recruitment-selection process
• According to Pigors and Myres, “placement has an
experimental element, for its initial stages is termed
as probation period, pending confirmation”
• But for most employees it is a decisive step and
should consist in matching what the job demands
(e.g. job requirement), what it imposes (working
conditions) and what it offers (compensation)
HRH staffing …
It also affects the rest of the human resources

functions:
• Human resource development
• Compensation and benefits
• Safety and health
• Employee and labour relations
NB: Successful accomplishment of these tasks

is vital for the organisation to effectively fulfill its
mission and vision
217
Human Resources Development

and Management (HRDM)
Human Resources Development (HRD) deals

with:
• Training and development of staff

§ process of equipping learners with the
needed skills, knowledge and attitude for
the present job
• Career planning and development activities

• Performance appraisal
• Counseling
HRDM…
• Career planning- an ongoing process

whereby an individuals sets career goal and
identify the means to achieve them
• Development- learning that goes beyond

today’s current job needs, hence preparing
them for future challenges
218
HRDM…
• Career development- formal approach used

by organisations to ensure that people with
proper qualification and experiences are
available when needed
• Performance appraisal & counseling- a

process whereby employees and teams are
evaluated to determine how well they are
performing their tasks and how to overcome
their shortfalls
Human resource financing
• Human resource financing involves a process

where budget funds are made available using
a position or person as a point of departure
• Financing must be linked to all the functions of

human resources
219
Human resource financing
Source: World Bank Institute (2001)
HRHM planning tools
• Workload Indicators of Staffing Need (WISN)

§ Determine how many health workers are
required to undertake the actual workload
§ Estimate staffing requirements to deliver
expected services
§ Calculate workload and time required to
accomplish tasks
§ Compare staffing between health facilities
and administrative areas
220
Why WISN?
• Used to determine how best to improve

current staffing
• Plan future staffing
• Assess current performance gaps
• Examine Impact of different employment
conditions and staffing
• Assess workload pressure
Steps in using WISN
• Determine priorities for WISN application

• Estimate available working time
• Define workload components
• Set activity standards
• Establish standard workloads
• Calculate allowance factors
• Determine WISN –based staff requirements,
analyse and interpret results
221
Activity: 5.3 (30 minutes)
With the help of a case study, participants are

taken through an exercise on how to use WISN
in analysing facility workload to determine:
• The difference between the actual and

required number of staff
• The ratio of actual required number of staff
Indicators of HRH
• Number of new health care workers who

annually graduate from pre-service training
institutions
• Number of community health and para-social

workers who successfully completed a pre-
service training programme
• Ratio of graduates of pre-service training

programmes to projected demand (or current
vacancies)
222
Indicators of HRH…
• Number of health workers recruited at

primary health care facilities in past 12
months by cadre (e.g. as percentage of
planned recruitment target)
• Staff vacancy rate (or % of vacancies filled)
• National HRIS system in place with key
elements
• Percentage of cadre registrations annually
through relevant regulatory bodies
Indicators of HRH…
• Number of health care workers (by category)

who successfully completed an in-service
training programme (by type and length
according to an accredited curriculum/national
curriculum
• Standards and SOPS are in place for all new and
established cadres
• Percentage of community, primary, secondary
and tertiary facilities and administrative units at
district level and up with a competent human
resource professionals and/or operations
managers
223
UNIT 4
PERFORMANCE MANAGEMENT FOR

HUMAN RESOURCES FOR HEALTH
Ask participants to brainstorm on the following

and share in plenary:
• Performance management
• Performance appraisal
224
Definition of performance management
• Performance management is a means of getting

better results from the organisation, teams and
individuals by understanding and managing
performance within an agreed framework of planned
goals, standards and competence requirements
• It is a process of establishing shared understanding

about what is to be achieved and an approach to
managing and developing people in a way that
increases probability that goals will be achieved in the
long and shorter term and in the most efficient way
(Source: AMREF)
Performance management
The Goal of performance management is to:

• Maximise productivity
• Provide conducive environment for individual

employee growth and development
• Reward for his or her contribution

225
Steps in performance management

• Role definition
§ Agreeing on key result areas and competency requirements (Job
descriptions)
• Performance agreement (contract) or work plan
§ Objectives
§ Mechanism for measuring performance
§ Competencies needed to deliver required results
• Personal development plan
§ Intended actions for competency improvement for performance
• Managing performance throughout the year
§ Taking action to implement performance agreement and personal
development plan (continuous feedback, informal progress reviews,
updating objectives and counseling and remedial measures)
• Performance review or appraisal
§ Formal evaluation stage (achievement, progress and problem/challenges)
§ If need be revision of performance agreements and personal development
plans
226
Ask participants to brainstorm on various

performance appraisal tools and discuss the
outcomes in plenary
Effective performance appraisals
• Apart from formal traditional (annual, six-

monthly, quarterly, or monthly) performance
appraisals, there are many different methods
of performance appraisal
• The use of any of these methods depends on

the purpose of the appraisal, the individual,
the assessor, and the environment
227
What is 360º assessment

• Assessment of an Individual from multiple perspectives
§ Supervisor
§ Peers
§ Subordinates
§ External – customers/suppliers/colleagues
§ Self
• Assessments made by people who are familiar with
behaviour of the person being rated
• Integrated reporting of information
§ Computer-based (you are free to print the forms)
§ Composite Information
§ Identifies convergence and divergence of perspectives
• Information organised around “competencies”
Why 360 degrees
• To maximise employee potential

• Higher accuracy
• Overcomes issues/problems of top-down
assessment
• Reinforces organisational values/vision
• Empowerment (taking responsibility for own
development)
• Team culture (elimination of “silos”)
• New perspectives on competencies
• Permits self vs. others comparisons of
effectiveness
228
Advantages
To the Individual: To the Team:

•Helps individuals to understand • Increases communication
how others perceive them • Higher levels of trust
•Uncover blind spots • Better team environment
•Quantifiable data on soft skills • Supports teamwork
• Increased team effectiveness
To the Organisation:
•Reinforced corporate culture by linking survey items to
organisational leadership competencies and company
values
•Better career development for employees
•Promote and growth from within
•Improves customer service
•Conduct relevant training
The 360º assessment process
M. Edwards & A. Ewen, "360 Degree Feedback:

The Powerful New Model for Employee Assessment & Performance Improvement," 1994, New York: AMACOM
229
The 360º assessment concept
M. Edwards & A. Ewen, "360 Degree Feedback:

The Powerful New Model for Employee Assessment & Performance Improvement," 1994, New York: AMACOM
Other types of performance appraisals
• Formal annual performance appraisals

• Probationary reviews
• Informal one-to-one review discussions
• Counseling meetings
• Observation on the job
• Skill- or job-related tests
• Assignment or task followed by review,
including secondments (temporary job cover
or transfer)
230
Other types of performance appraisals…
• Assessment centres, including observed

group exercises, tests presentations
• Survey of opinion of others who have
dealings with the individual
• Psychometric tests and other behavioural
assessments
• Graphology (handwriting analysis)
What is motivation?
Motivation is:
• The driving force by which people achieve
their goals. It is either intrinsic or extrinsic
• The individual internal process that energises,

directs and sustains behaviour
• Willingness to exert high levels of effort to

achieve organisational goals, conditioned by
the ability to satisfy some individual needs
231
Staff motivation
• People are attracted to organisations that

have the means of satisfying their needs
• Organisations use rewards and incentives to

motivate people to contribute towards
achieving organisational goals
• Rewards may contribute to good performance
Approaches to motivation
• Content/Need-Based Theories
• Process Theories
• Reinforcement Theories
• Contemporary Approaches
• Perspectives not mutually exclusive BUT are

complementary
• Theories based on fundamental assumptions about the

nature of work and how human beings perceive their
responsibilities
232
Content/need-based theories
Emphasise specific human needs/desires/

factors within a person that energise, direct
and stop behaviour, what makes people tick,
what turns them on or off
• Maslow's Hierarchy of Needs Theory A. Maslow

(1908 - 1970)
• Hertzberg’s Two Factor Theory
Content/need-based theories…
Maslow’s hierarchy of needs:
• Self-actualisation
• Self-esteem
• Affiliation
• Safety and security
• Physiological
233
Maslow’s hierarchy of needs…
• Esteem needs: internal esteem factors such

as self respect, autonomy and
achievement; and external esteem factors
such as status, recognition and attention
from others
• Self-actualisation: growth, achieving one’s

potential and self-fulfillment; the drive to
become what one is capable of becoming
Content/need based theories…
Hertzberg’s two factor theory
Motivator Factors Hygiene factors
Achievement Company policy
Recognition Administration
The work itself Supervision
Responsibility Salary
Advancement Working conditions/environment
Interpersonal
234
Content/need based theories…
McClelland's acquired needs theory:

Achievement Affiliation
Drive to excel, accomplish Desire for friendly and close
challenging tasks and achieve a interpersonal relationships
standard of excellence
Achievement motivation depends Employees high on this need

on childhood, personal and are likely to gravitate towards
occupational experience and the professions that involve high
type of organisation levels of interaction with
others and work well in
Power
teams
Desire to influence and control
one’s environment
Healthy work environment
• A healthy work environment is one in which

there is not only absence of harmful conditions
but an abundance of health promoting condition
(derived from WHO 1986 definition of Health)
• How to ensure a healthy work environment

§ Continuous assessment of risks to health
§ Appropriate provision of information and
training on health issues
§ Availability of health promoting organisational
support practices
235
Positive work environment

• Work autonomy and clarity of roles and
responsibilities
• Work autonomy and clarity of roles and

responsibilities sufficient resources
• Recognition of work and achievement
• Supportive management and peer structures
• Manageable workload and effective workload

management
Positive work environment…
• Effective management of occupational health

and safety risks including a safe and clean
workplace
• Effective employee representation and
communication
• Enforced equal opportunity policy
• Maternity/paternity leave
• Sustainable employment (security of tenure)
• Personal security
• Professional identity
236
Improving work environment
• Tools for assessing work climate

§ Monkey surveys
§ Work climate surveys
§ Discreet choice experiment
Improving work environment …
• Organisational strengths, best practices and

areas of improvement
§ Supervisor/manager relationships
§ Co-worker relationships
§ Job satisfaction
§ Job security
§ Work-life balance
§ Health and safety awareness and
enforcement of policies
237
Incentives
• The World Health Organisation defines incentives as “all the

rewards and punishments that providers face as a consequence
of the organisations in which they work, the institutions under
which they operate and the specific interventions they provide”
(WHO 2000 p.61)
• Mathauer and Imhoff (2006) define an incentive as “an available

means applied with the intention to influence the willingness of
physicians and nurses to exert and maintain an effort towards
attaining organisational goals”
• Incentives can also be viewed as the factors and/or conditions

within health professionals’ work environments that enable,
encourage and motivate them to stay in their jobs, in their
profession and in their countries
Role of Incentives
• An effective workforce strategy will address the

core challenges of:
§ improving recruitment
§ improving the performance of the existing
workforce
§ Slowing the rate at which workers leave the
health workforce
(WHO, 2006)
Incentives can play a role in all these areas by

providing a means through which health systems
can attract and retain essential and highly
sought-after health care professionals
238
Role of Incentives …
• Effective incentive schemes also help build a

better motivated, more satisfied and better
performing workforce
• Incentives are important levers that

organisations can use to attract, retain,
motivate, satisfy and improve the
performance of staff
Types of incentives
• Incentives can be positive or negative, financial or
non-financial, tangible or intangible
• Financial incentives are integral to the employment

contract. Financial incentives involve “direct
monetary payment from employer to
employee” (Kingma, 2003) such as wages,
bonuses or loans
• Non-financial incentives include provision of work

autonomy, flexibility Adapted
in working time and recognition
from Buchan et al. (cited in Adams & Hicks 2001);
of work Caldwell & Kingma 2007; Dambisya 2007)
239
Types of incentives …
Financial incentives Non financial incentives
Terms and conditions of employment Positive work environment

• Salary/wage • Work autonomy and clarity of
• Pension roles and responsibilities
• Insurance (e.g. health)
• Sufficient resources
• Allowances (e.g. housing, clothing,
child care, transportation, parking) • Recognition of work and
• Paid leave achievement
• Supportive management and
peer structures
• Manageable workload and
effective workload management
Positive work environment

• Effective management of occupational
health and safety risks including a safe
and clean workplace
• Effective employee representation and
communication
• Enforced equal opportunity policy
• Maternity/paternity leave
• Sustainable employment
240
Performance payments Flexibility in employment

• Achievement of performance arrangements
targets • Flexible work hours
• Length of service • Planned career breaks
• Location or type of work (eg.
remote locations)
Other financial support Support for career and professional

• Fellowships development
• Loans: approval, discounting • Effective supervision
• Coaching and mentoring structures
• Access to/support for training and
education
• Sabbatical and study leave
Financial Incentives Non Financial incentives
Access to services such as

• Health
• Child care and schools
• Recreational facilities
• Housing
• Transport
Intrinsic rewards
• Job satisfaction
• Personal achievement
• Commitment to shared values
• Respect of colleagues and
community
• Membership of team, belonging
241
Characteristics of effective incentive schemes
• have clear objectives

• are realistic and deliverable
• reflect health professionals’ needs and
preferences
• are well designed, strategic and fit-for-
purpose
• are contextually appropriate
• are fair, equitable and transparent
• are measurable
• incorporate financial and non-financial
elements
An approach for developing incentive package
An example:
Scoping and strategic What are we trying to achieve?
objective Who will have access to the package?
What problem are we trying to solve?
Assembling the What are the key issues to be addressed?
evidence: research and What kind of incentives will be meaningful to
consultation staff?
What are the organisation’s staff development
needs and priorities?
What has worked in other comparable
circumstances?
What hasn’t?
242
An approach for developing incentive

package …
An example…
Construct the What options do we have?
alternatives: designing a Can we provide financial incentives? What kind?
package What non-financial incentives can we provide?
Who will implement?
What financial and non-financial resources do
we have to support the programme?
How will we secure the support of staff and
managers?
What resources will be required to develop and
implement?
An approach for developing incentive

package…
Select the criteria: How will we choose which option is best?

how to define success What outcomes are we seeking?
How will we measure success?
Is the proposal fair and reasonable?
Is it sustainable?
Project the outcomes How long will it take to implement?

What will it cost?
Is it fair, reasonable and transparent?
How will key stakeholders react?
Will there be any negative effects?
Is there a different impact in the short term
and the long term?
243
Supportive supervision
It is the creation of an environment that allows

staff to develop professionally and enhances
performance of staff regardless of current
level of performance or professional expertise
Supervision and support
Reflect on the following questions:

• Do you think you had the resources and
support necessary to properly do your
job? If the answer is no, what were the gaps?
• What kind of relationship did you have with
your manager?
• What could your supervisor do to improve his
management style and skills?
• In your work, did you have specific goals
and did you know what was expected of you?
244
Supervision and Support…
• Was the training you received sufficient

to allow you to do your job effectively?
• Did you receive adequate support for your job?
• Did you receive adequate feedback about

your daily performance and the planning
process to improve your performance?
UNIT 5
HUMAN RESOURCE DEVELOPMENT,

RETENTION AND EXIT MANAGEMENT
245
Definitions and concepts
• HRD is a set of systematic and planned

activities designed to provide HRH with the
necessary skills to meet personal and
organisational goals as well as current and
future job demand
• Reasons for human resources for health
development
§ Renewed understanding of HRH as the
most critical asset
§ Due to human resources for health crisis
§ Evolution from personnel to human
resources management
Training and career development
• Training /Performance Needs Assessment (T/PNA)

§ Identification of competency (technical & overarching,
system) gaps
• Methodology and tools of T/PNA
§ Multiple methods (qualitative and quantitative)
§ Questionnaires (electronic or paper forms), key informant
interviews, focus groups, desk reviews, observations
• Purpose of T/PNA is to rationalise interventions gaps in:
§ training
§ work environment
§ performance,
§ numbers of staff and their competencies
§ system linkages
§ skills inventory
246
Training and career development…
The following are important considerations in the

development of training plan:
• Types of training (long and short); pre-service
and in-service training; Continuing Professional
Development (CPD)
• Methods of training
§ On the job training for CPD
§ Mentoring and coaching
§ Distance learning (e.g. E/m-learning and other
ICT-based trainings)
Training & career development …
§ Seminars, workshops and conference
§ Face to face learning especially in pre-

service
§ Apprenticeships (internship, attachments)
• Training institutions/facilities
• Costing of the implementation plan
• Monitoring and evaluation framework

247
Ask the participants to brainstorm on the

following question and share in plenary:
What is career pathing?
Career pathing
• Career path is a succession of different jobs

through which an employee may move within
an organisation. People move through their
careers either upwards through promotion or
by enriching their roles to utilise more skills
• Career expectations of employees may differ

significantly and therefore career paths should
identify realistic options available within an
organisation
248
Career pathing…
• A career path provides guidance on the steps

individuals can take as they progress through
their career in a job family (scientists,
engineers, accountants, etc.)
• Traditional view of defining careers in terms of

remuneration, status and upward mobility is
being questioned
Career pathing…
Career management policies and procedures

generally aim to:
• help employees identify skills required
• align and integrate personal aspirations
with organisational objectives
• identify career paths that points in all
directions, not only upwards
• provide employees with the opportunity to
develop themselves and their career
• provide mutual benefits for both the
organisation and individual
249
Professional accreditation
Development of career path should be in:
• Harmony between regulatory bodies, employers

and training institutions
Divide participants into groups and ask them to

discuss the following questions and present in
plenary:
•What is succession planning?

•Why succession planning is important?
•Who is responsible for succession planning?
250
Succession planning and management
• Succession planning and management implies

the use of an integrated and systematic
approach to identify, develop and retain talent
for the function and positions in key sectors, in
line with current business objectives and future
• The emphasis is on employee development, so

that the organisation has a pool of qualified
candidates who are willing to participate and
contest for key positions or positions in key
areas , if they become vacant
Succession planning and management …
• There are not many organisations that attach

importance to the planning
• Here are many reasons why organisations need
to think about succession planning
• The main one being, of course, they need a staff

to accomplish their mission, provide services
and achieve their goals
• We must consider what would happen if a key staff

member left office:
§ What would happen to the services offered by the
organisation?
§ How it would succeed in its mission?
251
• A succession plan is a component of good HR

planning and management
• The planning takes into account the fact that

employees will not remain indefinitely in the
service of the organisation and provides a plan
and process to deal with changes
that occur when employees leave
• When the size and organisational

resources permit, the succession plan should
provide guidance and development of those
already employed by the organisation
• Employees, management believes have the

skills, knowledge, skills and experience
and who wish to have more responsibility, can
be trained to fill key positions specific
252
Organisations should:
• assess their present and future needs based

on their plans, strategic goals and
objectives, or their priority programmes and
projects
• use the capabilities of existing employees to

meet those needs
• develop a plan to fill the vacancies of those in

authority who leave or are promoted
Linking succession planning and management with

integrated HR and Business Planning
Source: http://www.tbs-sct.gc.ca/gui/sps-eng.asp
253
Who is responsible for succession planning?
• The manager is responsible for succession

planning
• The manager is responsible for setting up a

succession plan for other critical positions in
the organisation
• The plan is likely to be developed with the

help of the management team, employees
concerned will also give their suggestions
Steps to consider in succession planning
Step 1 Identify key areas and key positions
Step 2 Identify capabilities for key areas and

key positions
Step 3 Identify interested employees and

assess them against capabilities
Step 4 Develop and implement succession

and knowledge transfer plans
Step 5 Evaluate effectiveness

254
Benefits of good succession planning

and management
• Increases the level of employee engagement through

career planning, a challenging work, training and
development, career advancement and development
horizontal
• Improves the capacity of the organisation to achieve

its business objectives through pools of qualified
candidates for positions and key sectors
• Allows managers to better appreciate the capabilities

and skills, experience, diversity, language skills and
interest in learning of their employees
Benefits of good succession planning

and management…
• Prevents the loss of institutional memory when
employees leave the organisation
• Facilitates the achievement of the goals of official

languages and employment equity through
targeted development initiatives
• Allows for cost savings through the creation of a

more committed and productive workforce
• Creates a public service more efficient and effective

in the long run
255
Challenges of good succession planning
• The size of the organisation: Some organisations

have so few positions they may not have the ability to
offer advancement
• Lack of financial resources: employees can look

elsewhere for better wages and benefits
• Nature of funding: more and more organisations

receive funding based on their projects rather than
their basic operations
• Staff hired for projects is constantly changing
Challenges of good succession planning…
• Lack of discernment in the succession plan, we rely

on employees who are not interested or motivated,
and who have not qualified
• A lack of training and development will ensure that an

employee will not be ready to get a promotion
• A plan that does not promote employees in a timely

manner
• Poor communication of the succession plan could

lead to confusion and turmoil within the organisation
and staff
256
Ask participants to brainstorm and discuss in

plenary on how to retain human resources for
health
Retention of HRH
The following are the five questions that staff

ask themselves about their work:
• Am I being treated fairly?
• Do I know what I’m supposed to do?
• How do I know how well I’m doing?
• Who cares?
• Do I have a future in this organisation?
257
Definition of retention
Retention is a systematic effort by employers

to create and foster an environment that
encourages to remain employed by having
policies and practices in place that address
their needs
(Mckeown, 2009)
Levels of retention
• Global level
§ Economic development aspects (out migration)
§ International regulations that guide movement of
health workers from country to country
• Country level
§ Geographical aspects
§ Cadre specific
§ Demographics
§ Policies/laws
• Organisational level
258
Essence of retaining staff
• Country level retaining institutional memory
• Avoids interruption of customer service
• Turn over leads to more turn over
• Goodwill of institution/company
• Enhancing efficiency
• Limited pool of competent workers
Strategies to improve retention
• Education interventions
§ aligning curricula along most challenging areas in most
disadvantaged regions
§ CPDs
§ Orientation programmes for students in disadvantaged
areas (internships/practicum)
• Regulatory interventions (compulsory services /bonding,
tying educational subsidies to mandatory placements)
• Financial incentives
• Personal (welfare needs, living conditions) professional
(career ladder, profile and visibility*) support
* professional recognition
• Interactions between rural and urban health workers
259
Exit interviews
• The exit interview is an important tool for HR
• All employees who leave the service should

be able to pass this interview, but
we must leave them free to participate or
not in an exit interview
Exit interviews…
Possible questions in the exit interview to

assess employees reasons for departure range
from general areas, job satisfaction,
supervision and support, and others
General areas:
• Why did you decide to leave the service?
• Is there something that inspired you to make
the decision to leave?
• Is there a particular event that motivates your
decision to leave?
260
Exit interviews …
• What was the most satisfying aspect of your

work?
• What was the least interesting aspect of your

work?
• What would you change your job?
• What did you like most about the service?
Exit interviews …
• To improve our work environment, what

changes would you make?
• Do the duties of your work were consistent

with what expected?
• Has your work been more difficult to achieve due

to organisational policies or procedures (or any
other obstacle)?
• And what do you like least?

261
Exit interviews …
• Do you have any advice for us to help

us find a good candidate for your job?
• You have a good experience in organising, in
your opinion, what are the qualities one must
possess to succeed in the workplace?
• Would you be willing to work for the
organisation again in the future?
• Do you recommend to your family and
friends to get a job in the organisation?
Exit interviews …
• Based on your experience, how would you rate the

morale and motivation of employees in the
organisation?
• You have decided to leave after accepting the job

offer from another organisation, what the
organisation had to offer more?
• Can we do something to make you stay with us?
• Do you have any other comments?

262
Exit interviews …
Good Practice
• At a personal interview, you can retrieve the
objects loaned to the employee by the
organisation; keys, badges, equipment, etc.
• End the interview on a positive note. Thank the

employee for his/her years of service within the
organisation
• Tell him/her the information s/he has given will be

very useful and wish the interviewee good luck for
the future
Ask participants to role play an exit

interview session
263

MODULE SIX
HEALTH MANAGEMENT
INFORMATION SYSTEMS (HMIS)
Objectives
By the end of this module, the participant should be able

to:
• Define the concepts of HMIS
• Describe the role and function of HMIS in the context
of health system strengthening
• Discuss the contribution of HMIS policies and legal
frameworks in systems strengthening
• Discuss the role of HMIS in knowledge management
in the context of health systems strengthening
• Describe the process of evaluating and improving
HMIS
• Describe the role of ICT in HMIS strengthening
264
UNIT 1
INTRODUCTION TO HMIS
Definition of information systems
• Set of information elements or components

that
§ collect (input)
§ manipulate (process)
§ disseminate (output) data and information
§ store (save) data for future reference; and
§ provide a feedback mechanism to meet an
organisational objective and mandate
265
Definition of information systems…
• Inputs
§ The capture or collection of raw data from
within the organisation or from its external
environment for processing in an information
system
• Outputs
§ Useful information, usually in the form of
documents and/or reports
• Feedback
§ Output that is used to make changes to input
or processing activities
Definitions: data and information

• Data: data are input raw materials from which
information is produced. These are facts obtained
by reading, observation, counting, measuring,
weighing, which are then recorded
• Data Sources: health facilities, community, other

government agencies (e.g. Registration of births
and deaths, National Bureaus of Statistics)
• Information: data that have been analysed,

interpreted, presented and understood by the
recipient of the communication
266
Definition of HMIS
Health Management Information System:

A comprehensive and integrated structure that
collects, collates, analyses, evaluates, stores,
disseminates, health and health-related data and
information for use by all stakeholders
(MoH Kenya, 2008)
Typically HMIS is made of two broad parts

• Facility/institution based
• Population based
Broad parts of HMIS

267
Sub-systems of HMIS
• Human Resources Information System (HRIS): an

information system used to capture data, manipulate,
analyse, store, retrieve, and disseminate information
regarding an organisation’s human resources
• Financial Information System (FIS): an information system

used to capture data, manipulate, analyse, store, retrieve,
and disseminate information regarding an organisation’s
financial management
• Logistic and Supplies Management Information System

(LMIS): an information system used to capture data,
manipulate, analyse, store, retrieve, and disseminate
information regarding an organisation’s commodity supply
chain management
The elements and components of

the HMIS system
Resources: Legislative, personnel, financial,

logistical, ICT
Indicators: Related targets
Data sources: Population based/institution
based
Data management: Collection, analysis, storage,
compilation at timely intervals
Information products: To turn data into relevant
information
Dissemination & use: Information is shared and used
to inform decision-making
Source: Health Metrics Network Framework and Standards for Country HIS 2nd edition, 2008
268
HMIS: system elements and components
• System Elements
§ Systems have three principal elements:
- Inputs: Data from different sources – including
facility and community)
- Processing mechanisms (analysis):
Processing or manipulation can include
performing calculations, making comparisons,
selecting alternative actions, or merely storing
data for future use.
- Outputs: Output is defined as the product
produced from information system processes
• Feedback provided by the system influences future

inputs
HMIS: system elements and components …
• Feedback
§ It is important that every information system has
a feedback process
§ Feedback can take the form of assessing outputs

of system processes and determining whether or
not adjustments or changes to input or
processing activities are required
§ Feedback is used to influence future inputs into

the system
269
Determinants of effectiveness of HMIS
• Three key information domains determine the

effectiveness of HMIS in a country
§ Health determinants
§ Health systems performance
§ Health status
Data driven management
• Information systems support a range of

management decisions and actions:
§ Planning programmes & obtaining resources
§ Enhancing population’s access to services
§ Quality measurement & improvement
§ Productivity/efficiency
§ Benchmark to national or global standards
§ Accounting for resources
§ Financial as well as physical resources (e.g.
drugs, supplies)
270
Participants work in country groups to:
• Briefly describe the evolution of HMIS in

respective countries
• Summaries are shared in plenary
Evolution of HMIS
Data Repository & Data Repository & Data Repository & Data Repository &
Statistical offices Statistical offices Statistical offices Statistical offices
• Collation and • Increase • Increased need for

• Routine inclusion analysis across
archiving of of records of investments in
health by various information
service delivery births and systems (e.g.
deaths. funding agencies
data & Hospital and governments presentation of
administrative • Emergence of called for improved Human resource
statistics offices of vital reporting systems vacancy rates by
statistics and for accountability different
demographic epidemiologic
surveillance sites profiles).
• Development &
integration of the
Community based
information System
(CBHIS)
Note: Kenya experience

271
Implications of evolution
• Increased need for quality and timely data

• Increase in the complexity of operational, policy and
strategic information requirements
• Changes in the roles and responsibilities of health
records information officers
§ Need to re-tool this cadre of health workers
§ Need to revise the training curriculum in tertiary institutions.
• Increased need to employ use of ICT for automation
and integration
• Exposure of gaps in policy and legislation around
information management in health
PRISM approach to HMIS strengthening
Source: Oxford journal “Health Policy and Planning” http://heapol.oxfordjournals.org/content/24/3/217.full

272
UNIT 2
ROLES AND FUNCTIONS OF HMIS
Role of HMIS in policy and decision making
• Management of routine information

• Link between plans and implementation
• Link between strategy, approach, intervention
and outcomes, impact
§ Operational research
§ Programme evaluation
§ Rapid surveys
§ Trend and time series analysis
• Surveillance systems
273
Role of HMIS in Health Systems Strengthening (HSS)
• Support of effective health sector planning

• Support of effective health sector
performance monitoring
• Management information system for
§ financing
§ HRM
§ logistics and supplies
§ infrastructure
• Support for correlational analytics
• Establishment of institutional memory
Role of HMIS for policy and decision making
Source: Health Metrics Network Framework and Standards for Country HIS 2nd edition, 2008
274
275
Results chain: outcomes
Input Activity Output Outcome Impact
• Changes observed among clients of the programme

• Changes in behaviour or skills (e.g. improved handling
of VAW cases, decrease in incidence of early
pregnancies)
• Usually have an action word associated with them, e.g.
increased, improved and represent the
consequences of the activities and the outputs
• Focus on: prevalence, risk reduction and behaviour
change
Results chain: outcomes
• Changes observed among clients of the programme

• Changes in behaviour or skills (e.g. improved handling
of VAW cases, decrease in incidence of early
pregnancies)
• Usually have an action word associated with them, e.g.
increased, improved and represent the
consequences of the activities and the outputs
• Focus on: prevalence, risk reduction and behaviour
change
276
Results chain: impact
• Changes in the longer term that occur at the

community level as a result of a given programme
• Usually observed in community or population level
• The focus is on: improved health outcomes,
equity, social and financial risk protection,and
responsiveness
Health impact
HMIS is the sole tool for monitoring trends of impact

indicators at population level. These are commonly
measured through population surveys:
• Improved health outcomes: Mortality rates

• Equity: Fairness in the output and outcome
indicators
• Social and financial risk protection: Cushioning
individuals and families from impoverishment from ill
health and costs of seeking health services
• Responsiveness: Meeting the felt and expressed
health needs of communities, families and individuals
277
Resource mobilisation and allocation
HMIS is key in producing the information to

guide resource mobilisation and allocation by:
• Equity analysis
• Efficiency ratios
UNIT 3
POLICIES, LEGAL FRAMEWORKS AND

ETHICAL ISSUES IN HSS
278
Need for HMIS policy & legal framework
• Address the country institutional HMIS

framework
• Need to streamline the functions of HMIS
• Guarantee availability and accessibility of
quality data as a public good for decision
making
• Need to establish and maintain a simple,
coherent, scientifically sound, easily
understandable and compatible information
system
Need for HMIS policy & legal framework ...
• Need for a robust system to track

achievements of the health sector objectives
at all levels, taking into account the national
values of universal coverage, equity, quality
and social justice
• Need for ethical considerations guiding

information sharing
279
Gaps in policy and legislation
• Reporting obligation by all service providers

§ public vs. private actors
§ government vs. development partners in health
§ implementing partners
• Data structure standards
• Data exchange standards
• Data confidentiality and privacy
• Public access to health information
• Direct financing of HMIS activities as % of THE
and GEH
Process of policy formulation
Problem
Identification
Policy
Prioritisation
Evaluation
Policy
Implementation
Formulation
Adoption
280
• In groups, participants discuss objectives

of HMIS policies and legal framework in
health system strengthening
• Group report in plenary
Objectives of HMIS policies
Promote:
• unified and integrated HMIS used by all actors
• incentivised data demand and information use
• functional linkage among all statistical
constituencies
• continual improvement in data quality
• individual and institutional learning
• knowledge creation and management
• public access to health information in user
friendly formats
281
UNIT 4
INFORMATION AND KNOWLEDGE

MANAGEMENT
282
Knowledge Management
q Is knowledge an object OR a process?
Knowledge=Object Knowledge=Process
(Invest in IT) (Invest in people)
Knowledge is:
• A process
• Dynamic
• Personal/organisational
• Different from data
• Different from Information.
Knowledge = A Capacity to Act
Knowledge Management: Fact or Myth?
• KM is the same thing as learning

No, learning is a means to an end – KM must have a
business focus
• KM is a series of procedures which are to be
implemented
No, KM is a fundamental shift in strategic paradigm
• KM is to capture knowledge kept in the heads of people
No, KM concerns how to create environments for people
to create, leverage and share knowledge
• KM is a question of ensuring information is sent to
everyone
No, central push tends to fail. Catering for demand is
much more effective
283
Knowledge Management: Fact or Myth?
• KM is a simple add-on to business as usual

No, KM requires deep rooted behavioural and
strategic change
• KM is a function to be delegated to HR or IT
No, KM requires top management
involvement; it is a fundamental shift in
strategic perspective
• KM is just a matter of investing in IT
No, IT is a tool for information exchange, but
can never drive change
Cycle of information management

284
Identification of information needs

of the user
• Information system managers must answer

questions such as:
§ What information is needed at what level?

§ How much of it is needed?
§ How, when, and by whom will it be used?
§ In what form is it needed?
Identification of information needs

of the user …
• Output requirements
Management must begin with an examination of the
output requirement e.g. by classifying information based
on the level (strategic, tactical and operational) in the
organisation at which it will be used
• Data gathering and information processing

The purpose is to improve the overall quality of
information
Components:
Evaluation – determining how much confidence can be
based in a particular piece of information. The credibility
of the source and reliability and validity of the data must
be determined
285
Data collection and information processing
• Abstraction – involves editing and reducing

incoming information in order to provide
managers with only the information that is
relevant to their particular tasks
• Indexing – classifying information for storage

and retrieval purposes
• Storage – provide for storage of information

to permit its use again in needed
Information dissemination and use

• Dissemination:
Getting the right information to right manager at
the right time. This is the overriding purpose of
an HMIS
Information use depends on:

Quality (accuracy)
Form – how it is presented
Timeliness
Relevance
• Major goal of HMIS:

Provide the right information to the right decision-
maker at the right time
286
Aspects of data quality
• Data must be:

§ Complete
§ Accurate
§ Standardised
§ Timely
§ Verifiable
§ Accessible
§ Secure
UNIT 5
DESIGN IMPLEMENTATION
287
Components for design
Components for design
• Define the data elements needed from each

data source
• Design standard data capture tools
• Build the capacity of the health care workers
on data capture
• Make electronic formats of the tools
• Design a IT interactive interface and a robust
database
288
Components for design…
• Determine essential dataset needed from each

data source
• Design IT interface to mine data from priority
databases
• Develop an integrated data repository relevant
to the organisational specific needs
• Build capacity for data analysis and data

presentation
• Determine the appropriate decision support
tools required
• Dashboards
• Messaging services
• Flash alerts
• Adopt appropriate technology to support the
data presentation requirements
289
• Effectively profile the end-user data and

information needs
• Determine their preferred presentation format
and platform/media
• Determine their preferred frequencies of
dissemination
• Adopt appropriate technology to meet
dissemination requirements
• Adopt appropriate technology to archive the
data and information
UNIT 6
ROLE OF ICT IN HMIS STRENGTHENING

290
Data transformation
Priorities for information technology

investment
• Fundamental question: Is infrastructure to
support IT available?
§ If not, focus on staff training, detailed
procedures, team building, regular audits
• Focus IT investment on activities where it can

provide greatest benefits
§ Many first line facilities can use paper records
§ IT is most powerful for communicating and
aggregating data, doing complex analyses
291
Infrastructure requirements to support

information technology
• Staff trained to use computers and software

• Maintenance for computers and software
• Data backup capability
§ In case of computer loss or failure
• Physical security
§ To prevent theft or damage to hardware
• Data security
§ To prevent unauthorised access
Information technology selection

and implementation criteria
• Software: standardisation, ease of use,

stability, upgradeability
§ Open source software is free but requires
knowledgeable staff to install and maintain
• Hardware: reliability, support from vendor

• Network: reliability, cost
• Staff: ability to retain staff with critical IT skills
292
Data through an information system
Vertical view of an enterprise architecture

293
Integrating information system
Information sharing and feedback

294
Glossary of terms
• Archiving – Archiving is a process for backing up data that may not be
routinely accessed, but to which an organisation wants to retain the ability
to access should the need arise. By archiving data, database queries
become faster and more efficient, translating into faster, more responsive
experiences for the end users
• Data dictionary – A data dictionary, or metadata repository, as defined in
the IBM Dictionary of Computing, is a "centralised repository of information
about data such as meaning, relationships to other data, origin, usage, and
format." In other words, a data dictionary helps describe the data in the
system, and help translate the data of one system into terms acceptable in
another system
• Data dissemination – Once data has been integrated into the national HIS,
stored in the data warehouse, sent to the various data marts for data mining
and visualisation, the “results” should be accessible by the decision
makers. The method of dissemination depends on what the results look like
and who needs them; however, data dissemination could occur by web
page, email, RSS, SMS text message, paper report, voice phone call, a
briefing, or another method
Glossary of terms…
• Data governance – Data governance embodies a convergence of data

quality, data management, data policies, business process management,
and risk management surrounding the handling of data in an organisation.
Through data governance, organisations are looking to exercise positive
control over the processes and methods used by their data stewards and
data custodians to handle data
• Data mart – A data mart (DM) is the access layer of the data warehouse
(DW) environment that is used to get data out to the users. The DM is a
subset of the DW, usually oriented to a specific business line or team.
There can be multiple data marts inside a single HIS system; each one
relevant to one or more business units for which it was designed
• Data mining – Data mining is the process of extracting patterns from large
data sets by combining methods from statistics and artificial intelligence
with database management. Data mining is a process of inspecting,
cleaning, transforming, and modeling data with the goal of highlighting
useful information, suggesting conclusions, and supporting decision making
295
Glossary of terms …
• Data Services layer (DSL) – The DSL provides a layer for data
access that is independent of the physical schema. The purpose
is to provide a consistent interface for accessing data,
independent of the structure of the databases attempting to
make the connection
• Data warehouse – A data warehouse is a subset of the overall
data available in a system, collected over large periods of time,
and needed to process a relatively small number of very large
data requests. It is an interim database that lies somewhere
between the source databases and the reporting platform. Data
warehousing is used for archiving, data mining, and analytics or
some combination of all three. A data warehouse maintains its
functions in three layers: staging, integration, and access.
Staging is used to store raw data for use by developers
(analysis and support). The integration layer is used to integrate
data and to have a level of abstraction from users. The access
layer is for getting data out for users
• What challenges can you foresee if you are

to implement information system in your
organisation?
• What are you going to do to overcome these

challenges?
296

MODULE SEVEN
HEALTH FINANCING
Objectives
By the end this module, the participant should

be able to:
• Define health financing and related concepts

• Discuss the mechanisms of financing health
• Describe the processes of financial
management
• Discuss the use of financial expenditure
monitoring tools
297
UNIT 1
OVERVIEW OF HEALTH FINANCING
Ask participants to brainstorm on the

concept of health financing in plenary
• What is health financing?
• How does health financing differ from

financial management?
298
Definition of concepts related to health financial
• Health financing is much more than a matter of raising

money for health. It is also a matter of who is asked to pay,
when they pay and how the money raised is spent
• It includes raising adequate funds for health, in ways that

ensure people can use needed services, and are protected
from financial catastrophe or impoverishment associated
with having to pay for them. It provides incentives for
providers and users to be efficient
• Financial management is the process of achieving the

organisation’s objectives in an efficient manner through
planning (budgeting), acquiring, organising, directing,
monitoring, controlling and reporting
Definition of concepts...
• Revenue collection
§ is the way money is raised to pay health system costs
• Risk pooling
§ is accumulation and management of financial resources to
ensure that the financial risk of having to pay for healthcare is
borne by all members of the pool and not by the individuals who
fall ill. The primary purpose is to spread the financial risk
associated with the need to use health services
• Purchasing
§ is the process of paying for health services
• Moving towards universal coverage
§ means working out how best to expand or maintain coverage in
three critical dimensions:
- Who is covered from pooled funds?
- What services are covered?
- How much of the cost is covered?
299
Definition of concepts...
• Financial accounting
§ External reporting which emphasises historical, custodial and
stewardship
• Management accounting
§ Identification, measurement, accumulation, analysis, preparation,
interpretation and communication of information that assists
managers in fulfilling organisational objectives
• Auditing
§ Is a systematic process of objectively obtaining and evaluating
evidence regarding assertions about economic actions and events
to ascertain the degree of correspondence between those
assertions and established criteria and communicating results to
interested users
• Financial auditing
§ This is seeking objective evidence relating to reliability and integrity
of financial and occasionally operating information
Health financing system
• Health financing system covers three basic functions

a) Collecting revenues
b) Pooling resources
c) Purchasing services
• These three functions have the capacity to improve

health outcomes, provide financial protection, move
towards universal coverage and ensure customer
satisfaction in an equitable, efficient and financially
sustainable manner
300

Based on the concept of ‘Moving Towards Universal Coverage’ use
your country specific experiences to discuss the criteria used to
allocate resources at national and/or institutional levels keeping in
mind the following principles:
• Equity
• Efficiency and
• Effectiveness
Expected Group discussion Outputs

• List of the allocation criteria used in your county
• List of appropriate principles guiding the allocation criteria
• Examples of challenges and emerging issues on any of the
principles including glaring inequities and inefficiencies
In plenary, ask participants to:
• Brainstorm on the key roles of a health

manager in health financing and report in
plenary
301
Roles of health managers in health

financing and financial management
• Specific roles in mobilisation, allocation and

efficient use of financial resources include
§ Oversight (policies and regulations relevant to
financial systems, structures)
§ Planning (including proposal development,
budgeting)
§ Implementation
§ Monitoring
§ Reporting and use of information for planning
and decision making
UNIT 2
MECHANISMS OF HEALTH FINANCING

302
• Participants watch the short video clip on

various sources of health financing titled
‘Health System Overview’ from youtube
• Each participants to list and discuss the

different roles of key actors in health
financing in their countries
• In plenary, highlight differences in the list

of actors and give reasons
Health financing mechanisms
Revenue Sources of revenue include: households, organisations

collection or companies, and sometimes from contributors
outside the country (called “external sources”)
Risk Pooling For funds to be pooled, they have to be prepaid,
before the illness occurs – through taxes and/or
insurance, for example. Most health financing systems
include an element of pooling funded by prepayment,
combined with direct payments from individuals to
service providers, sometimes called cost-sharing
Purchasing There are three main ways to purchase health
services: government, institutions (separate
purchasing agency) and individuals
303
Basic principles to health financing mechanisms
• Principle 1: Raise enough revenues to provide

individuals with a basic package of essential
services and financial protection against
catastrophic medical expenses caused by illness
and injury in an equitable, efficient and
sustainable manner
• Principle 2: Manage these revenues to pool

health risks equitably and efficiently
• Principle 3: Ensure the purchase of health

services in ways that are efficient in terms of
allocation and technicality
Framework for health financing mechanisms

304
Sources of health financing
Resources can be collected through

• General or specific state taxation
• Compulsory or voluntary health insurance contributions
• Direct out-of-pocket payments, such as user fees
• Global financial mechanisms including proposal/grant

funding
• Trust funds - types and coverage
• Donations including bilateral, multilateral, philanthropic and

private individuals
Risk pooling mechanisms
• National health service systems -

funded from the exchequer
• Social health insurance
• Private voluntary health insurance
• Community based health insurance
• Direct purchases by the consumers
• Community health financing
• Trust funds
305
Purchasing mechanisms
Many countries use a combination of these purchasing
mechanisms:
• Government provides budgets directly to its own
health service providers (integration of purchasing and
provision which covers health promotion, disease
prevention, care and rehabilitation) using general
government revenues and, sometimes, insurance
contributions; HMOs
• An institutionally separate purchasing agency (e.g. a
health insurance fund or government authority) to
purchase services on behalf of a population (a
purchaser-provider split)
• Individuals pay a provider directly for services
Participants work in groups to discuss the

nature and challenges of the following types
of Insurance:
• Social Health Insurance

• Private Voluntary Health Insurance
• Community-Based Health Insurance
306
Community Based Health Financing

(CBHF)
• Mechanism for community-level risk pooling in
relation to sickness, and burial societies
• More user-friendly for the rural and informal sector as
they pay in kind – agricultural products or livestock
• Small-scale and cover limited geographical areas and
may even be clan or religion based
• Have worked well where external ‘seed money’ and
availability of sustainable out-patient services
• Weak in coverage of the most vulnerable, schemes
are vulnerable without external support and
especially in drought or other disaster prone areas,
when conditions requires extended hospitalization or
in cases of chronic illnesses
Trust funds
• These are set up at various levels including

family, corporate or Multi Donor Trust Funds
(MDFT) for vulnerable groups
• The purpose may vary but goal is flexibility
health package customised to the needs of the
beneficiary
• MDTF is often used to fund post-conflict health
activities
• ICC trust fund for victims of human rights
abuse in various African countries
307
Capacity development in health systems management

to improve social and financial risk protection (Kenya case)
Auditing
Mechanism
Health Sector National Hospital

Service Fund Insurance Fund
(HSSF) (NHIF)
Health Systems Capacity

Supply Management Development Demand
Side Side
Performance Based Financing (PBF)
• Performance Based Financing (PBF) refers to the transfer of

money or material goods conditional on taking a measurable
action or achieving a predetermined performance target (Eichler,
2006)
• Alternative names: results-based financing, performance-based
contracting, performance-based incentives and output-based aid
• World Bank defines Results-Based Financing for health (RBF-H)
as any program that rewards the delivery of one or more health
outputs or outcomes through financial incentives, upon
verification that the agreed-upon result has actually been
delivered
• A new perspective on service delivery? Or donor-speak for new
forms of development assistance?
• The nature of “results” vary by Lower Income Countries (LICs)/
Higher Income Countries (HICs)
308
Stylized facts about “Results”

in different contexts
• Large increase in global aid for MDGs interventions – now
LICs
flatening; unclear impact on MDGs
• Expanded supply infrastructure, but there may be under-
utilisation
• Donors now emphasize “Results” on MDGs
• Search for results led first to Vertical programs now RBF?
• 30 high growth MICs launched “UC programs”
MICs
• Most already had good access to “MDG package”
• UC seeks to expand benefits and financial protection
• Financed, increasingly by general taxes (instead of payroll
tax),
MoFs demand “Results” – refuse to finance traditional
systems…
HICs
• Rapid expenditure growth linked to new technologies and
increasing needs linked to NCDs
• Big fiscal pressures and concern over population aging
• Emphasis on “Results” - “value for money” and “quality”
What RBF Debate?
Donor
Policy Loans, other budget support;
“Performance Disbursements” (e.g. GAVI)
Central
Government Performance-‐Based BudgeJng
Performance Contracts
Local
Government DecentralizaJon
Purchaser Purchaser-‐provider split; provider payments linked

to results, benefit package; validaJon of results
Clinic Autonomy; freedom to hire/fire; community

parJcipaJon
Health Worker Monetary carrots and sJcks; intrinsic values;

other professional consideraJon
309
Result-based health financing

While in higher income countries, PBF has been mainly
aimed at improving quality of care, in LMICs, the
objectives have been wider, including:
• to increase the allocative efficiency of health services
(by encouraging the provision of high priority and cost
effective services)
• to increase their technical efficiency (by making
better use of existing resources such as health staff);
• to improve equity of outcomes (for example, by
encouraging expansion of services to hard-to-reach
groups)
• some have also argued that PBF has the potential to
transform health systems
Levels of results based health financing
• Different levels of payment:

§ to governments
§ local governments
§ NGOs
§ facilities
§ individual health workers
§ often, combinations of these levels
• Variety of targeted processes/outputs/

outcomes, as well as payment systems and
magnitude of transfers
310
Conceptual framework for RBF analysis
Assumptions: results-based health financing
• Aligning incentives of providers with public goals relies on:

§ Being able to define key attributes of performance
§ Being able to measure them
§ Being able to reward them without causing adverse
consequences
• Risks
§ distortion – encouraging staff to ignore key services which
are not rewarded with incentives,
§ financial dependency – problematic if RBF is not sustained
and has raised expectations from staff; also hard to reform,
once introduced
§ fiduciary risks – if funds are poorly controlled, then leakage
and corruption may be increased
311
RBF: Project summaries

• National level: GFATM and GAVI (HSS grants)
• Provinces: Argentina’s Plan Nacer; Family Health Project,
Brazil
• NGOs: USAID project in Haiti; performance-based
contracting in Afghanistan, Cambodia, DRC, South
Sudan; IFPP India
• Facilities: national schemes in Rwanda and Burundi;
pilots in Tanzania, Zambia and Uganda
• Health workers: incentive payments in India (JSY); Nepal
(SDIP); Tanzania; Cambodia; Philippines; Pakistan (most
national but some more localised)
Participants can give examples of results outputs, impact
and sustainability from RBF projects
UNIT 3
FINANCIAL MANAGEMENT
312
Principles of financial management
Guides to ensure that the organisation is using funds

effectively and that staff are working appropriately.
They include:
• Consistency
• Accountability
• Transparency
• Viability
• Integrity
• Stewardship
• Accounting standards
Building blocks of financial management
Basic building blocks which must be in place to

achieve good practice in financial management
include:
• Accounting records
• Financial planning
• Financial organising
• Financial monitoring
• Internal controls
313
Tools of financial management
1. Planning
• Relevant policies
• Strategic plan
• Business plan
• Budgets
• Work plans
• Cash flow forecast
• Feasibility studies
Financial policies and regulations
• Oversight by the Board of Directors

§ Roles and responsibilities?
• Policies on internal controls which are the key to
fiscal responsibility
§ Examples include segregation of duties
§ Provide other examples...
• Policies for financial issues and to comply with
government regulations
§ Examples policies on cash reserves, fixed
assets
§ Provide other examples...
314
Health financing planning and decision process
Tools of financial management…
2. Organising
• Constitution
• Organisational charts
• Flow diagrams
• Job descriptions
• Chart of accounts (expenditure codes)
• Finance manuals
• Finance regulations
• Budgets
315
3. Controlling
• Budgets
• Delegated authority
• Procurement procedures
• Reconciliation
• Internal and external audits
• Fixed assets register
• Vehicle policy
• Insurance
4. Monitoring
• Evaluation reports
• Budget monitoring reports
• Cash flow reports
• Financial statements
• Project reports
• Donor reports
• Audit reports
316

5. Record keeping
In a computerised system, all the books are automated, in
the system and only the initial records for data entry are
required
• Supporting documents
These include: receipt of money received and paid,
invoices, paying-in vouchers for bank deposits, bank
statements, journal vouchers, payments vouchers, Local
Purchase and Service Orders (LPOs/LSOs) and Goods
Received Notes (GRNs)
• Books of accounts
These include: cash book for each bank account, petty
cash book, general ledger, journal book, wages book,
assets register and stock control book
Financial accounting vs. management accounting
Financial accounting Management Accounting

• Compares results against
• Records transactions
goals
• Classifies transactions • Determines reasons for
• Reconciles records variations
• Helps identify collective
• Summarises transactions action
• Forecasting and planning
• Presents financial data
• Analyses information
42
317
Financial reports
• Trial balance
• Income and expenditure account
• Balance sheet
• Cash flow statement
• Donor reports
• Government related reports
Interpreting the accounts
Two types of financial analysis
a) Trend analysis
• Comparison over a period of time
b) Ratio analysis: helps answer 3 Qs

• Financial sustainability
• Efficiency
• Effectiveness
318
Using the reports

Aim: To assess the health of the organisation and to
reassure yourself that the organisation’s objective are
being met
• Identify problems, look for solutions
§ Budget overspent
§ Budget under spent
§ Linked line items show different figures
• Predicting the future
• Managing cash flow
§ Examine options available for managing cash flow
Reporting to donors
• Accountability
• Check terms and conditions of grant aid
• Reporting to other beneficiaries
Financial audit
• According to the (WHR, 2010), an estimated 20 - 40%

of health resources are being wasted
• Financial audit is the review of books of accounts and
related documentation at the administrative office
• The main purpose is to
§ Detect compliance
§ Fraud
§ Waste
§ Abuse
• These areas that are looked into are at strategic and
operational level
319

Participants work in groups to answer the
following questions:
• Discuss your role in financial management in your

work place?
• Discuss some of the challenges you experience in
your work place in executing the financial
management role?
• List five recommendations to improve financial
management in your work place?
• Using the financial statement provided, identify the
key problems
• Report in plenary
Financial statements
• A financial statement should reflect true and fair view of the
business affairs of the organisation
• They typically include four basic financial statements,
accompanied by a management discussion and analysis:
§ Statement of financial position: a balance sheet, reports on
a company's assets, liabilities, and ownership equity at a given
point in time
§ Statement of comprehensive income: profit and Loss
statement reports on a company's income, expenses, and
profits over a period of time
§ Statement of changes in equity: explains the changes of the
company's equity throughout the reporting period
§ Statement of cash flows: reports on a company's cash flow
activities, particularly its operating, investing and financing
activities
• Electronic financial statements
320
• Participants to review a prepared financial

statement for Hospital XYZ
• Using the financial statement, list the things to

look out for when reading a financial
statement
UNIT 4
EXPENDITURE TRACKING AND REPORTING

321
Definition of National Health Accounts

• National Health Accounts (NHA) constitute a
systematic, comprehensive and consistent
monitoring of the resource flows in a country’s
health system for a given period
• A tool designed to assist policy makers in the effort
to understand their health system and to improve
health system performance
• National health accounts provides evidence to
monitor trends in health spending in all sectors
(public and private), different health care activities,
providers, diseases, population groups and regions
in a country
Importance of NHAs
• Provide policy-makers with information on the
volume and sources of financial resources for the
health sector
• It helps in developing national strategies for effective
health financing and in raising additional funds
• Regular updates of the NHA facilitate reviews of
public and private health expenditure trends over
time and help to monitor and evaluate the country's
health system
• Information can be used to make medium term
financial projection of a country’s health system
requirement with the past or with those of other
countries
322
Ask participants to brainstorm on other uses

of NHAs in their respective countries
Challenges of NHAs
• Danger of having parallel health accounts where

harmonisation with national frameworks is difficult
• Building disease-based NHAs due to donor funding
• Estimating cost of illnesses especially out-patient and
chronic conditions
• Challenges of estimating household expenditures
• Differences in modes of delivery making comparisons
difficult
• Differences between fiscal and calendar year records
• Distinctions between types of insurance is not very clear
• Difficult to capture international trade in healthcare
• Sustainability of NHAs – only done because donors fund it
323
Mid-term Expenditure Framework

(MTEF)
• This is a national framework for mid-term

financing and monitoring of resources
(usually 3 - 5 year rolling plan)
• The plan is usually linked to national

development plan, used to finance the health
sector strategic plan and used to monitor the
Annual Operation Plan (AOP)
Participants work in groups to discuss the

uses and challenges of the following reports
• Budget monitoring reports
• Cash flow reports
• Financial statements
• Project reports
• Donor reports
• Audit reports
324
Linking health financing and financial management
• To achieve MDGs by 2015, countries need sustainable

mechanisms of financing health as well as strategic and
efficient financial management of the allocated resources
• Financing principles define the goals equity, efficiency and
effectiveness vs. financial management principles which
define the process consistency, accountability,
transparency, viability, integrity, stewardship, accounting
standards
• Appropriate disbursement and control of funds will
improve the implementation of health financing
mechanisms
• Various levels of financial management effectiveness can
result from incentives in health financing mechanisms
Review questions
• Distinguish between health financing and

financial management?
• List the mechanisms of financing health in your
country?
• Describe key challenges of financial
management in health?
• How is financial expenditures tracked in your
Country?
• What is the role of National Health Accounts?
• How can we improve universal coverage in our
countries?
325

STRENGTHENING N AFRICA
MODULE EIGHT
SERVICE DELIVERY
Objectives
By the end of this module, the participant

should be able to:
• Define the concepts and models of

service delivery
• Discuss the characteristics of effective
service delivery
• Describe an effective referral system
• Discuss the concepts and approaches in
accreditation
326
UNIT 1
CONCEPTS AND MODELS

OF SERVICE DELIVERY

questions:
• What do you understand by service

delivery?
• What service delivery models are in
existence in your country towards achieving
improved health systems?
• What are the bottlenecks of people-centred
care?
327
Definition of service delivery
Service delivery is a process for meeting

health needs of a population (customers
or patients) through deliberate promotive,
preventive, curative and rehabilitative
programmes
Service delivery concepts and models
• Service delivery models including: medical model,

people centred model
• Linkages with other health system components
§ Governance and leadership: policies, oversight and
regulation for universal health coverage (UHC)
§ Health financing: revenue collection, pooling, purchasing
services and transparency for UHC
§ Health information: comprehensive collection, collation,
analysis, interpretation and use to monitor and evaluate
progress towards UHC
§ Health workforce: adequacy (number and competence) and
equitable deployment guided by policy to achieve UHC
§ Medicines and health technologies: prudent selection,
procurement and distribution for UHC
328
UNIT 2
CHARACTERISTICS
OF
EFFECTIVE SERVICE DELIVERY
329
Participants brainstorm on the characteristics

of an effective service delivery
Characteristics of effective service delivery
• Comprehensiveness
• Continuity of care
• Person centered
330
Other approaches of effective service delivery
• Demand creation (knowing health needs,

affordability accessibility, quality, behaviours
of the health workers towards clients)
• Re-engineering based on primary health

care principles including: equity, universal
access, solidarity, social justice community
participation, intersectoral action, human
rights approach
331
332

questions in plenary
• What quality management systems are

there in your organisation?
• What is the legislation on quality in your

country?
333
Quality management system
Ten characteristics of quality systems:

1. A process in place to ensure the needs and
expectations of clients and other interested parties
2. The quality policy and quality objective are defined
and deployed throughout the organisation
3. Processes are documented in simple to use
procedures
4. Resources to meet objectives are identified and
provided
5. Metrics are established and monitored for each
process
6. Management is committed to using the metrics for
process improvements
Quality management system …
7. A process is in place for preventing non-conforming

product or services
8. Continual improvement is a priority
9. A framework for verification of processes and

products is in place
10. Management is involved in the system and reviews

the entire system
334
Introducing 5S-Kaizen principles
• "5S" originally developed in the Japanese manufacturing

industry in the 1960s
• Used as a tool for product quality control
• Stands for five (5) Japanese words that start with the
letter 'S‘ with English/French/Swahili equivalents:
Sort/Séparer /Sasambua
Set/Systématiser/Seti
Shine/Salubrité/Safisha
Standardize/Standardiser/Sanifisha
Sustain/Se discipliner/Shikilia
Introducing 5S-Kaizen principles…
• Structured processes to systematically achieve

total organisation, cleanliness, and
standardisation in the workplace
• It boosts the morale of the workers, promoting a
sense of pride in their work and ownership of
their responsibilities
• A gateway to Total Quality Management (TQM)
• A well-organised workplace results in a safer,
more efficient, and more productive operation
335
Kaizen- Continuous Quality Improvement/CQI - TQM
• Kai = further
• Zen = good
• Improvement for better – Ongoing:
Continuous quality improvement (CQI)
• Total quality management: a management
philosophy that focuses on doing business to
§ satisfy the customer – the person paying for the
product (demand side)
§ satisfy the supplier (of goods and services)
§ continuously improve the business processes
OPD reception at a
Set
health centre in Lusaka
Retrieval time reduced from 10min to 10 seconds 22

336
Medical ward after 5S
Introducing 5S-Kaizen principles…
<1> Sort: Remove unused stuff from your place of

work and reduce clutter (Separation/Removal)
<2> Set: Organise everything needed in proper order for

easy operation (Orderliness)
<3> Shine: Maintain high standard of cleanliness

(Cleanliness)
<4> Standardise: Set up the above three 5s as a part of the

routine at every section in your work place
(Sort, Set and Shine as a system)
<5> Sustain: Train and maintain discipline of the

personnel involved (Discipline)
337
Concept of Service Quality Assurance (SQA)
• It is normally on comparison approach
• The perceptions compared to expectations

(using mean scores)
• A comparison of service providers with

customers is also used to find out if the
difference is statistically significant
Phrase by Parasuraman et al (1988)
• In 1985 they suggested 10 determinants

(Tangible, Reliability, Responsiveness,
Competence, Courtesy, Credibility,
Security, Access, Communication and
Understanding)
• After conducting some researches, in 1988,

they refined them to 5 major determinants
with a total of 22 factors to describe all the
said ten
338
5 major determinant of
quality of service
• Tangibility (4 factors)
• Reliability (5 factors)
• Responsiveness (4 factors)
• Assurance (4 factors)
• Empathy (5 factors)
Tangibility
• Equipment
• Appealing H/F
• Neat human resource for health (HRH)
• Organised documents for customers
( Patients and employees)

339
Tangibility…
Waste Segregation equipment
Tangibility…
Human Resource for Health Appealing H/F

340
Organised documents for customers
Reliability
• Keep promises
• Sincere interest
• Perform right first time
• Serve at the time prescribed
• Do not mix name of patient

(mistake patients identity)
341
Responsiveness
• Give update of what is happening
• Provide prompt services
• Willingness to help
• Readily available (Never too busy to respond

to the requests of customers - internal and
external)
Assurance
• Instill confidence to a patient even when s/he
under critical condition
• Safe transaction on medication
• Consistency of courtesy
• Adequate knowledge on health care services

(don’t ask the patient if the correct
medication is Betadine or HCL?...)
342
Empathy
• Individual attention when attending one
customer/patient (avoid phones on service)
• Convenient operating hours (if possible 24

hours even in public health centres)
• Empathetic employees in the health system,

irrespective of the function (TQM)
• Having interest of the patient at heart
• Understand the specific needs of the

customer
Quality assurance definition
A planned and systematic actions necessary to

provide adequate confidence that goods/
services will satisfy the customers needs
• The right result, at the
• Right time on the
• Right specimen, from the
• Right patient, with result interpretation
based on correct reference data at the
• Right price
343
Quality Assurance Cycle
Patient/Client Prep
Sample Collection
Personnel
Reporting Competency
•Data and Lab Test Evaluations
Management
•Safety
•Customer
Service Sample Receipt
and Accessioning
Record
Keeping Sample
Transport
Quality Control
Testing
http://wwwn.cdc.gov/mpep/labquality.aspx
What is Customer Relationship Management

(CRM)?
• This is a social process of managing all

networks of communication to ensure mutual
understanding between the service provider
(health worker) and the customer (e.g. patient
from OPD or nurse in the ward)
• Relationships are preceded by social

communication for both internal and external
customers
344
Internal and external customers
Internal customer
Includes all individuals, departments, sections
within the organisation who use the output of
your job (e.g. pharmacist and the accountant of
the hospital)
• This is a crucial part of CRM as when it fails it

gives room for gossips and the image of the
organisation diminishes
Internal and external customers …
External customer
• Includes individuals, organisations, and anybody
outside the organisation who buy, use/may use
the goods and services provided
• In the case of health service; suppliers, patients,

regulatory bodies, community,
stakeholders ,business people, etc.
• Integrated marketing combines (employees,

employer and external customers)
345
Integrated system
ORGANISATION
Triangular
model
HIGH PERFORMANCE
WITHOUT STRIKES
Interactive marketing
EMPLOYEES +ve or -ve EXT. CUSTOMERS
• In your respective groups, indentify three

internal and external customers
• How do they expect you to serve them to

maintain CRM?
• What are your current CRM strategy to meet

these expectations?
346
What do customers(clients) expect from health

service providers?
• Timeliness in delivery of services/

punctuality
• Courtesy and helpfulness
• Service reliability
• Consistency in service delivery
• Positive attitude from staff
• User-friendly systems
• Less bureaucracy
• Quality service
• Aesthetic environment
How can I improve CRM in my team?
• Know your customers well
• Know the customer needs
• Know their expectations
• Be clear about what your role entails

347
The value of relationships
• Increased loyalty of the customers

• Reduced resource and development costs
• Customers become part time marketers of
the organisation
• Reduced unnecessary criticism
• Improved performance and synergy as the
team spirit will be strong
• No gossips
Internal relationship management
• One crucial aspect is the employer’s

engagement with those who create value
• Organisations need to positively brand

themselves both inside and outside
• The function of customer service is a

systematic requirement
348
Internal relationship management system
• Recognises the application of networking in

working relationships between the
organisation and its customers
• All employees are customers of managers

who wish to carry out the departments’
objectives
• Internal marketing can be compared to the

process management concept within Total
Quality Management (TQM)
Internal relationship marketing system …
• Personnel are the first market of the service

business
• Managers must ensure that staff understand

what is expected of them
• Staff must be mentally prepared for, and

accept the stipulated approach to service
provision
349
Internal relationship marketing system …
• The service must be fully developed and

accepted by employees before it is launched
• Internal information channels must work, and

personal selling is needed within the
corporation’s operations
• Managing a corporation’s human resources

equates with managing its customer services
• Good employee relations is essential for good

customer relations
How to ensure CRM in health sector
• Trust amongst stakeholders

• Visionary leaders
• Strategic talk and communication
• Accurate information with application of ICT
• Professionalism of the health experts
• Commitment of service providers and
customers to the CRM System
350
Types of customers and strategies

to handle them
Categories of customers
• Internal vs. External

• Industrial vs. Individual
• Existing vs. New
• Physical Product Customers vs. Service
Customers
• Short term vs. Long term
• General vs. Prestigious (VIP)
351
Types of customers
• Silent (uncommunicative) customer

• Talkative customer
• Sarcastic (over-familiar) customer
• Good-nurtured customer
• Angry-bad tempered customer
• Hostile, rude, argumentative customer
• Aloof/disinterested customer
Types of customers …
• Busy customer
• Dictatorial customer
• Hesitant/suspicious/uncertain customer
• ‘Woman’ type customer

352
In groups, identify three common types of

customers and explain the strategy used to
handle them
The silent customer
• Is shy, quiet or deliberately uncommunicative
• Scarcely talks (e.g. a patient with a STD)
Strategy
• Show interest, use open - ended questions,
ask simple questions, ask his opinion
353
The talkative customer
• is friendly and has a good sense of humour
• willing to talk about different issues
Strategy
• Keep listening, try to direct and not to order
on issues when one briefly pauses, be careful
not to be misled by the customer
The sarcastic (over-familiar) customer
• talks a lot, often fast, without stop, could be

the most difficult customer (e.g. a doctor who
is a patient)
Strategy
• Ask him politely to repeat what he has said,
ask him to give attention to you so that you
can direct him to the service you are offering
354
The good nurtured customer
• says yes to almost every thing but will not

make a decision (e.g. a nurse who fears a
doctor or a driver with his boss)
Strategy
• Use a good sense of humour to direct him to
make a decision
Bad tempered
• is irritated with something small (trivial)
Strategy
• Just apologise however difficult it might be,
establish the cause for anger, act as a
counselor, ask for his help/opinion
355
The hostile/rude/argumentative
customer
• Very difficult customer - interjects when you

talk to challenge your position (a pharmacist
when procuring the drugs)
Strategy
• Do not be involved in the argument, remain
polite, listen attentively and try to establish
the basis for his argument
Aloof/disinterested customer
• Similar to the silent customer
• Very reserved
Strategy
• Be firm but polite, show that his behaviour is
not putting you off, use visual aids to draw
his attention (pictures, a pen, samples, etc.)
356
The bluffer
• talks big and often says things which suggest

that he has influential connection with highly
placed individuals
Strategy
• Asses his particular needs, recommend a
realistic initial solution, Associate his buying
habits with big customers possibly known to
him
The busy customer (impulse customer)
• appears busy
• have hurried movements and anxiety
• cannot concentrate on service offered at the

counter
Strategy
• Advise him to follow the set procedure
357
Dictatorial customer
• has a power complex and wishes to put you

at a disadvantage
• is not courteous and is intolerable
Strategy
• Listen carefully and friendly, however difficult
it might be. Share the procedures of operation
and stick to them
Hesitant/suspicious/uncertain customer
• is challengeable, uncertain and lacks

confidence
Strategy
• Provide clear guidance, remove doubt and
assure him your support
358
The invisible/telephone customer
• is a customer you cannot see
• must handle him/her carefully, has never

complained, could behave just like the afore-
mentioned types
Strategy
• Listen carefully, deal with his problem to
satisfaction, assess his personality and guide
him accordingly. From the voice tone, you
can determine the ‘personality’
Some facts about a customer
• A customer is the most important person in an

organisation’s business and your life
• A customer is not an interruption of your work,

but he is the purpose of your work
• A customer does you a favour by visiting you;

you are not doing him or her a favour by
serving him
359
Some facts about a customer …

• A customer is a person who brings us
his needs. It is our job to handle him
ethically for him and for ourselves
• A customer is not someone to argue

with. Nobody ever won an argument
with a customer
• A customer is a person with feelings

and emotions. Treat him better than
you would want to be treated
Some facts about a customer …
• A customer is not a stranger, he is part of

your business
• A customer deserves the most attentive,

courteous and professional treatment you
can provide
Remember: Customers are different and their

needs are different
360
UNIT 3
EFFECTIVE REFERRAL SYSTEMS
Ask participants to discuss the following questions in

groups and report back in plenary
• What are the levels of health service in your

country?
• On what model is your referral system based?
• How can you redesign an effective referral
system?
• What obstacles do you envisage in redesigning the
referral system?
• What are the main outcomes of an effective
referral system?
361
Definition and principles of

a health referral system
• Definition
§ A system of advising and directing clients upwards
to the tertiary level or downwards to the community
level to ensure continuity of people-centred health
care
• Principles
§ Adaptability
§ Urgency
§ Diagnostic consistency
§ Ability to provide required care
§ Reliability of the provider
§ Availability of required services
Types of referral system
• Medical model – upward progressive

(provider and patients)
• Disease control model – (provider and

specialised services)
• People centred model – (contract)

362
Steps in designing a referral system
• Review the service delivery model
• Assess the system using a SWOT analysis
• Design strategies to improve the referral

system
• Advocate to all relevant stakeholders and if

necessary recommend for legislation
Developing a successful referral system
• Work with clients to decide what their immediate needs

are
• Outline the health and social service options available
• Help the client choose the most suitable in terms of

distance, cost, culture, language, gender and sexual
orientation and age
• In consultation with the client, assess which factors

may make it difficult for the client to complete the
referral. (e.g. lack of transportation, child care, work
schedule, costs, stigma) and try to address them
363
Developing a successful referral system …
• Discuss shared confidentiality with clients and

support them as they make the decision
• Make a note of the referral in the client’s file
• Ask the client to give feedback on the quality

of services to which he or she is referred
UNIT 4
CONCEPTS AND APPROACHES

IN ACCREDITATION
364
Definition of accreditation
Accreditation is the process in which an

entity, separate and distinct from the health
care organisation usually non-governmental,
assesses the health care organisation to
determine if it meets a set of requirements
(standards) designed to improve the safety
and quality of care
Accreditation standards for health care

• Accreditation standards for health care include:
§ Patient-centred standards
§ facility management standards
• What is the purpose of accreditation?

§ To improve and sustain quality of services
§ To protect the public from harmful practices within
the health facilities
§ To ensure consistent use of standards across both
the pubic and private health providers
• There are several bodies but should all have

harmonised standards
365
People-centred standards
S/N GOAL STANDARD
1 Identify Patients correctly The organisation develops an approach to
improve accuracy of patients identifications
2 Improve effective communication The organisation develops an approach to

improve effectiveness of communication
among care givers
3 Improve the safety of high alert The organisation develops an approach to
medications improve the safety of high alert medications
4 Ensure correct –site, correct- The organisation develops an approach to

procedure, correct-patient ensuring correct –site, correct- procedure,
surgery (why surgery only?) correct-patient surgery
5 Reduce the risk of health care The organisation develops an approach to

associated Infections reduce the risk of health care associated
infections
6 Reduce the risk of patient harm The organisation develops an approach to

resulting from falls reduce the risk of patient harm resulting from
falls
Facility standards
S/N GOAL STANDARD
1 Leadership and planning Relevant laws, regulations, facility inspection requirements,
written plans, and qualified workers to manage risks
2 Safety and security The organisation plans and implements a programme to

provide a safe and secure physical environment
3 Hazardous materials A plan for handling hazardous materials and waste
4 Disaster preparedness The organisation has and implements an emergency

management plan to respond to likely emergency,
epidemic and natural or other disasters
5 Fire safety A plan to ensure that all occupants are safe from fire ,
smoke and other emergencies in the facility
6 Medical equipment A plan a programme for inspecting, testing and maintaining
medical equipment and documenting their results
7 Utility system Potable water and electrical power are available 24 hours a
day 7 days a week through regular or alternative sources
to meet a essential patient t care needs
8 Staff education The organisation educates and trains all staff about their
role in providing a safe and effective patient care facility
366
Benefits of accreditation
• The accreditation process is designed to create a

culture of safety and quality between an organisation
that strives to continually improve care processes and
results
• Benefits include:
§ improved public trust that the organisation is
concerned for patient safety and quality of care
§ a safe and efficient work environment that
contributes to worker satisfaction
§ ability to negotiate on the quality of care
Benefits of accreditation …
• Listen to patients and their families, respect

their rights and involve them in the care
process as partners
• Create a culture that is open to learning from

timely reporting of adverse events and safety
concerns
• Establish collaborative leadership that sets

priorities for and continues leadership for
quality and patient safety at all levels
367
Participants are divided into two groups to

discuss the following:
Group 1: Client-centred standards

Group 2: Health facility standards
• Assess the status of one of the countries or

institutions represented in the group
• Discuss how you can advocate for fast
tracking the accreditation process
Establishing accreditation mechanisms
• Legal framework
• Establish regulatory bodies and
professional associations
• Develop guidelines for accreditation
• Ensuring compliance
368

MODULE NINE
SUPPLY CHAIN MANAGEMENT
Objectives
By the end of this module, the participant should be able to:
• Define the concepts in supply chain management

• Discuss the contribution of existing policies, laws
and regulations in strengthening supply chain
management
• Describe procurement management practices in
health
• Describe an effective distribution and stock control
system for supply chain management
• Discuss appropriate quality control measures to
enhance service delivery
369
UNIT 1
OVERVIEW OF SUPPLY CHAIN MANAGEMENT
Ask participants to discuss supply chain

management definitions, concepts, objectives
and roles
370
Definition of supply chain
• A supply chain encompasses all

activities in fulfilling customer demands
and requests
• Activities are associated with flow and

transformation of goods from raw
materials to end user as well as flow of
information and funds
Definition of supply chain …

Supply chain management:
• is a set of synchronised decisions and activities
utilised to efficiently integrate suppliers,
manufacturers, warehouses, transporters, retailers
and customers
• is all the tasks involved in deciding what to buy,
where, when and how much and how to manage
the stock
• is the process of ensuring the delivery of the right
product at the right time in the right place
• also entails regularly ascertaining customers’
satisfaction as to the services offered
371
The supply chain
Suppliers Manufacturers Warehouses & Customers

Distribution Centers
Transportation Transportation
Costs Costs
Material Costs Transportation
Manufacturing Costs Inventory Costs Costs
Source: http://216.54.19.111/~mountaintop/log102/scopage dir/mod09/elo2.html
What is a supply chain?
• Also referred to as the logistics network

• Suppliers, manufacturers, warehouses,
distribution centers and retail outlets –
“facilities”
• Raw materials
• Work-in-process (WIP)
• Finished products that flow between the
facilities
• Inventory
372
Objectives of supply chain
• To keep the prices at a reasonable level

• Efficient ordering, receiving, handling and storage
to avoid losses and waste
• To supply goods and services of a type and
quality which are to the best advantage of the
customers
• To educate and train customers in the effective
use of inputs and necessary protection needed to
safeguard the health of farmers
• Shortening the supply chain through direct
purchases from factories or importers
Concepts of supply chain management
• Sourcing
• Counterfeits
• Production
• Distribution
• Enterprise resource planning
• Push and pull systems
• Efficient and responsive supply chain
• Bidding
SUPPLY CHAIN MANAGEMENT: CONCEPTS, TECHNIQUES AND PRACTICES –

Enhancing Value Through Collaboration
© World Scientific Publishing Co. Pte. Ltd.
373
Stages of supply chain
Supply chain includes four stages:

• Supply network (material flow)
• The internal flow (service flow)
• Distribution systems
(information and funds flow)
• The end users
The supply chain – another view
Plan Source Make Deliver Buy
Suppliers Manufacturers Warehouses & Customers

Distribution Centers
Transportation Transportation
Material Costs Costs Costs Transportation
Manufacturing Costs Inventory Costs
Costs
374
What is Supply Chain Management (SCM)?
Plan Source Make Deliver Buy

• A set of approaches used to efficiently integrate
§ Suppliers
§ Manufacturers
§ Warehouses
§ Distribution centres
• So that the product is produced and distributed
§ In the right quantities
§ To the right locations
§ And at the right time
• System-wide costs are minimised and
• Service level requirements are satisfied
Supply chain management approach

• Three items that flow through the supply chain:
§ Information
§ Money
§ Materials
• Three areas of decision-making:
§ Materials
§ Processes
§ Logistics
• Two types of tools:
§ Information technology
§ Operational analysis
375
Importance of supply chain management

• Dealing with uncertain environments – matching
supply and demand
§ Boeing announced a $2.6 billion write-off in 1997 due to
“raw materials shortages, internal and supplier parts
shortages and productivity inefficiencies”
§ U.S Surgical Corporation announced a $22 million loss in
1993 due to “larger than anticipated inventories on the
shelves of hospitals”
§ IBM sold out its supply of its new Aptiva PC in 1994 costing
it millions in potential revenue
§ Hewlett-Packard and Dell found it difficult to obtain important
components for its PCs from Taiwanese suppliers in 1999
due to a massive earthquake
U.S. firms spent $898 billion (10% of GDP) on supply-
chain related activities in 1998
Importance of supply chain management…
• Shorter product life cycles of high-technology products

§ Less opportunity to accumulate historical data on
customer demand
§ Wide choice of competing products makes it difficult to
predict demand
• The growth of technologies such as the Internet enable
greater collaboration between supply chain trading partners
§ If you don’t do it, your competitor will
§ Major buyers such as Wal-Mart demand a level of “supply
chain maturity” of its suppliers
• Availability of SCM technologies on the market
§ Firms have access to multiple products (e.g. ERPsSAP,
Baan, Oracle, JD Edwards) with which to integrate
internal processes
376
Uncertainty in supply chain management

• Inventory and back-order levels fluctuate considerably
across the supply chain even when customer demand
doesn’t vary
• The variability worsens as we travel “up” the supply chain
• Forecasting doesn’t help!
Multi-tier Manufacturer Wholesale Retailers Consumers

Suppliers Distributors
Sales
Sales
Sales
Sales
Time Time Time Time
Bullwhip Effect
Factors contributing to the bullwhip

• Demand forecasting practices
§ Min-max inventory management (reorder points to bring
inventory up to predicted levels)
• Lead time
§ Longer lead times lead to greater variability in estimates of
average demand, thus increasing variability and safety
stock costs
§ Batch ordering
§ Peaks and valleys in orders
§ Fixed ordering costs
§ Impact of transportation costs (e.g. fuel costs)
§ Sales quotas
• Price fluctuations
§ Promotion and discount policies
• Lack of centralised information
377
Today’s marketplace requires
• Personalised content and services for their

customers
• Collaborative planning with design partners,
distributors, and suppliers
• Real-time commitments for design, production,
inventory, and transportation capacity
• Flexible logistics options to ensure timely
fulfillment
• Order tracking and reporting across multiple
vendors and carriers
Shared visibility for
trading partners
Supply chain management – key issues

• Forecasts are never right
§ Very unlikely that actual demand will exactly equal forecast
demand
• The longer the forecast horizon, the worse the forecast

§ A forecast for a year from now will never be as accurate as a
forecast for 3 months from now
• Aggregate forecasts are more accurate

§ A demand forecast for all CV therapeutics will be more
accurate than a forecast for a specific CV-related product
Nevertheless, forecasts (or plans, if you prefer) are

important management tools when some methods
are applied to reduce uncertainty
378
Supply Chain Management – key issues
ISSUE CONSIDERATIONS
Network Planning • Warehouse locations and capacities
• Plant locations and production levels
• Transportation flows between facilities to minimise cost and time
Inventory Control • How should inventory be managed?
• Why does inventory fluctuate and what strategies minimise this?
Supply Contracts • Impact of volume discount and revenue sharing
• Pricing strategies to reduce order-shipment variability
Distribution Strategies • Selection of distribution strategies (e.g. direct ship vs. cross-docking)
• How many cross-dock points are needed?
• Cost/benefits of different strategies
Integration and Strategic • How can integration with partners be achieved?
Partnering • What level of integration is best?
• What information and processes can be shared?
• What partnerships should be implemented and in which situations?
Outsourcing & Procurement • What are our core supply chain capabilities and which are not?
Strategies • Does our product design mandate different outsourcing approaches?
• Risk management
Product Design • How are inventory holding and transportation costs affected by product
design?
• How does product design enable mass customisation?
Source: Simchi-Levi
Supply chain management operations strategies
STRATEGY WHEN TO CHOOSE BENEFITS
Make to Stock Standardised products, Low manufacturing costs;

relatively predictable demand meet customer demands
quickly
Make to Order Customised products, many Customisation; reduced

variations inventory; improved service
levels
Configure to Order Many variations on finished Low inventory levels; wide
product; infrequent demand range of product offerings;
simplified planning
Engineer to Order Complex products, unique Enables response to

customer specifications specific customer
requirements
Source: Simchi-Levi
379
Supply chain management – benefits
• A 1997 PRTM Integrated Supply Chain

Benchmarking Survey of 331 firms found significant
benefits to integrating the supply chain
Delivery Performance 16%-28% Improvement

Inventory Reduction 25%-60% Improvement
Fulfillment Cycle Time 30%-50% Improvement
Forecast Accuracy 25%-80% Improvement
Overall Productivity 10%-16% Improvement
Lower Supply-Chain Costs 25%-50% Improvement
Fill Rates 20%-30% Improvement
Improved Capacity Realization 10%-20% Improvement
Source: Cohen & Roussel
Supply chain imperatives for success
• View the supply chain as a strategic asset and a differentiator

§ Wal-Mart’s partnership with Proctor & Gamble to automatically
replenish inventory
§ Dell’s innovative direct-to-consumer sales and build-to-order
manufacturing
• Create unique supply chain configurations that align with your
company’s strategic objectives
§ Operations strategy
§ Outsourcing strategy
§ Channel strategy
§ Customer service strategy Supply chain configuration components
§ Asset network
• Reduce uncertainty
§ Forecasting
§ Collaboration
§ Integration
380
Push and Pull processes
Supply chain integration – push/pull

strategies
• Hybrid of “push” and “pull” strategies to overcome
disadvantages of each
• Early stages of product assembly are done in a “push” manner
§ Partial assembly of product based on aggregate demand
forecasts (which are more accurate than individual product
demand forecasts)
§ Uncertainty is reduced so safety stock inventory is lower
• Final product assembly is done based on customer demand
for specific product configurations
• Supply chain timeline determines “push-pull boundary”
Push-
Pull
Boundary
“Generic” Product “Customized” Product
Push Strategy Pull Strategy

Raw End
Materials Supply Chain Timeline Consumer
381
Choosing between push/pull strategies
Pull High Where do the following

Industries where: Industries where:
industries fit in this
• Customization is High • Demand is uncertain model:
• Demand is uncertain • Scale economies are High
• Scale economies are Low • Low economies of scale
• Automobile?
• Aircraft?
Demand Uncertainty
Computer Furniture
equipment • Fashion?
• Petroleum refining?
• Pharmaceuticals?
Industries where: Industries where:
• Biotechnology?
• Uncertainty is low • Standard processes are the • Medical Devices?
• Low economies of scale norm
• Push-pull supply chain • Demand is stable
• Scale economies are High
Books, CD’s Grocery,

Beverages Source: Simchi-Levi
Push Low
Low Economies of Scale High
Pull Push
Supply chain collaboration

• Cornerstone of effective SCM
• The focus of many of today’s SCM initiatives
• The only method that has the potential to eliminate
or minimise the Bullwhip effect Retailers
Suppliers Synchronized Manufacturer

Production
Scheduling Collaborative Distributors/
Demand Wholesalers
Collaborative Planning
Product
Development
Collaborative Logistics Planning

•Transportation services
•Distribution center services
Logistics Providers
382
Benefits of supply chain collaboration
CUSTOMERS MATERIAL SUPPLIERS SERVICE

SUPPLIERS
• Reduced inventory • Reduced inventory • Lower freight costs
• Increased revenue • Lower warehousing • Faster and more
• Lower order costs reliable delivery
management costs • Lower material • Lower capital costs
• Higher Gross acquisi?on costs • Reduced
Margin • Fewer stockout deprecia?on
• Be=er forecast condi?ons • Lower fixed costs
accuracy
• Be=er alloca?on of
promo?onal budgets
• Improved customer service
• More efficient use of human resources
Source: Cohen & Roussel

In your opinion, what are the expectations of

clients from the health supply service?
383
Additional costs health service organisations

should pay to satisfy clients
S/N Type of service Costs

1 Wide stock variety Administrative and stock
holding costs
2 Generous credit Interest costs and risk of bad
debts
3 All items available at all times Stocking and finance costs,
and risk of deterioration
4 Convenient locations and Transport costs

individual delivery
4 Wide range of package sizes Storage and administrative
costs
5 Full personal information about all Staff training and wage costs
products
6 Lowest prices Small surplus to cover supply
service costs
Models of supply chain: efficient and

responsive
384
Supply chain in an e-Business environment
SUPPLY CHAIN MANAGEMENT: CONCEPTS, TECHNIQUES AND PRACTICES

- Enhancing Value Through Collaboration © World Scientific Publishing Co. Pte. Ltd.
http://www.worldscibooks.com/business/6273.html
UNIT 2
POLICIES, LAWS AND REGULATIONS IN

SUPPLY CHAIN MANAGEMENT
385
Ask participants to discuss in groups the

following questions and present in plenary
• What specific policies exist in your

organization governing manufacture,
procurement, distribution and use of
pharmaceutical and medical supplies in your
organisation, country?
• What laws and regulations exist in your
country for the above?
Policies, laws and regulations in

supply chain management
• Policies provide guidance on what supply

chain systems may be established
• Laws and regulations provide a framework

for the efficient management of supply
chains
386
Legal Environment in Kenya
The medicines regulatory Authority in Kenya has had

its legislation Cap 244 since 1957 hence colonial.
Other conflicting Acts exist e.g.
• Cap 254 – The Food Drug Chemical Substances
Act.
• Cap 253 - The Medical Practitioners & Dentists Act.
• Cap 260 – Clinical Officers Act
• Cap 346 – The Pest Control Act
• The Narcotic Drugs & Psychotropic substances
Act1994
• The Medical Laboratory Act 1999
• Cap 242 – The Public Health Act
• The Veterinary Surgeons Act Cap 366
The Pharmacy and Poisons Board
• Established in Kenya as a Regulatory

Authority under the Pharmacy and Poisons
Act, Chapter 244 of the Laws of Kenya
• Commenced operation on the 1st of May 1957
• The Board regulates the Practice of

Pharmacy and the Manufacture and Trade in
drugs and poisons
387
Regulatory activities
Registration
• Receipt of applications
• Market agency authorisation
• Manufacturers and manufacturing sites
• NQCL (National Quality Control Laboratory)
• CDR (Committee on Drug Registration)
recommendation
• Practice committee
• Full Board approval
• Gazettement
Regulatory activities…
Drug Information
• Centre for drug information for public and board use
• Regulating aspects of advertisement on
Pharmaceuticals
Pharmacovigilance
• Surveillance of drugs in the distribution channels to
monitor drug failures in treatment
• Toxicity aspects reports on new molecules
• Counterfeits in the market
Trade in pharmaceuticals
• The control of entry and exit of drugs by import and
export of drugs to ensure that only authorised drugs
enter or leave the country
388
Inspectorate
• The enforcement wing of the regulatory authority
• It inspects and enforces proper quality services
(pharmaceuticals) in the distribution channels
• GMP (Good Manufacturing Practices) inspections
of manufacturing plants to establish their
compliance with GMP as per WHO guidelines
• Enforcement through courts of law (e.g.
enforcement of the Regulating Act Cap 244)
Special permits
• Special permits are given for narcotics and
psychotropic substances for their control
International treaties
• The international community has had concerns in
narcotics/psychotropics and Kenya is a signatory to
some of these treaties. While there is no law- but the
regulatory authority is required to report to INCB in
Vienna – on seizures and precursor control which are
being used to manufacture narcotics
• It also regulates by not granting import or export
permits to suspicious applicants
389
Regulation of Herbal/food supplements
• The regulatory authority has been issuing

permit for export/import of this product in the
form of a no objection letter for process of
clearance at the ports of entry/exit
• However when the said herbal preparation
has a medical claim as to what it treats then
it’s a requirement that the same be registered
with the regulatory body
Limitation of herbal/food supplements
• Most herbal preparations though bearing medical

claim, the parties owning and claiming the same
cannot register them since the registration
process requires active ingredients to be declared
and many scientific information including clinical
trails, pharmacological activities etc which is too
sophisticated for the herbalist
• There is a proposal that the same should be
considered under traditional knowledge for
protection and registration – a tricky area
• A proposal for partnership between scientists and
herbalist is shrouded in suspicion
390
Policy on pharmaceuticals
• The patent protection of pharmaceuticals in Kenya is

based on the African Regional Industrial Property
Organisation (ARIPO) patent system, which was
created by the Lusaka agreement in 1976. ARIPO is
based in Harare, Zimbabwe
• The organisation was mainly established to pool the
resources of its member countries in industrial
property matters together in order to avoid duplication
of financial and human resources
• Additionally, the Kenyan government passed the
Kenya Industrial Property Bill in 2001 which allows
Kenya to import and to produce more affordable
medicines for HIV/AIDS and other diseases
Requirements for importers
Importers are expected to meet respective

national legal requirements, which include:
• Essential drugs list, using WHO guidelines,
whose objective is to promote the availability
of quality pharmaceutical products at
affordable prices
• Passing regulatory quality control, monitoring
and market surveillance as stipulated by
respective national pharmacy and poisons
board and national drug quality control
laboratory
391
Multidimensionality of requirements
Pillars of Environmental, Health and Food Safety Requirements
Food Safety Plant/Animal Product Environment Social

Health Quality
MRLs Surveillance Product Control of Labour

Heavy metal Quaran=ne composi=on water and env standards
limits Pest risk Product contamina=on Fair trade
Food assessment cleanliness Protec=on of standards
addi=ves Sanita=on Grading biodiversity
Labeling Protec=on of
Hygiene
requirements endangered
requirements
Control of species
Traceability nutri=onal Recycling
HACCP claims Organic prod
ISO 9002 requirements
Pharmaceutical value chain

• The pharmaceutical “value chain” is only partially synonymous
with the pharmaceutical “supply chain”
Discovery / Development / Commercialization
Target Lead Def & Candidate Phase Phase Phase Regulatory REALIZED VALUE
Selection Expression Selection Pre-Clinical I-II a II b III Launch
Review
Mfg., Marketing / Sales / …
• The “value chain” describes how the addition of knowledge to a

specific molecule through transformational processes of R&D, pre-
clinical, clinical trial, manufacture, marketing and sales activities
generates commercial value to a pharma/biotech company
• The “supply chain” refers to the activities involved with planning,
sourcing, manufacturing and distributing your products as it does
for any other company
– There is also a “clinical supply chain” which addresses sourcing and
provision of materials to clinical trail investigators
– It’s still “Source”, “Make” and “Distribute” with “Plan” at the head of
each major supply chain domain
392
Pharma supply chain considerations

What business requirements differentiate pharmaceutical SCM
from other manufacturers?
• End-user (patient) safety
§ Anti-counterfeiting requirements
§ Product integrity
§ Quality assurance
• Fraud prevention and detection
• Electronic signature requirements
§ Records access and retention requirements
• Product tracking
§ Class 2 pharmaceuticals must carry unique identifiers at the
item level
§ “Chain of custody” tracking from manufacturer to distributors
and point-of-use (“pedigree” requirements)
• End-consumers are not the principal product customers
§ CRM doesn’t focus on the patient (yet)
Source - End-User Safety considerations
• Foremost of all the considerations in the

Define the
pharma supply chain
Material – Are the materials provided by our suppliers
safe?
– Are the products manufactured by our
company safe?
Qualify the – Are all the products being manufactured
Material
reaching the distributors?
– Are any of our products being adulterated or
Audit the Supply Chain
counterfeited?
Approved • The supply chain begins with the material
Vendor List
supplied for product manufacture
– Key ingredients need to be covered by
Major Problems?
Delist the Vendor
Supply Agreements
Qualify the • Price, Source, Quantity, Quality, Delivery
Vendor
– Quality Agreements
• Defined Specification Control, Change Control,
Complain Resolution
Monitor the – Pre-purchase Usability Tests
Vendor – Toxicity Requirements
– Know where starter materials are
manufactured
– Know who tests it and how 50
393
UNIT 3
PROCUREMENT MANAGEMENT
Procurement management

questions and report in plenary
• What critical steps would be involved in the

procurement of pharmaceuticals and
medical supplies?
• What should be the normal flow in
implementation of these steps?
394
Objectives of Public
Procurement and Disposal Act
• Maximise economy and efficiency

§ Aggregation
§ Value for money
§ Contracts to be made with qualified
suppliers
• Promote competition and ensure competitors

are treated fairly
§ Open tendering
Procurement and Disposal Act...
• Promote integrity and fairness of

procurement procedures
§ Corrupt and fraudulent practices and collusion
among bidders made offences
§ Technical requirements based on required
performance and on national or international
standards
§ Evaluation based on criteria in tender
documents
• Increase transparency and accountability
§ Advertisement of bid opportunities
§ Public opening of bids
§ Disclosure of grounds for contract award
395
Procurement and Disposal Act ...
• Increase public confidence in procurement

procedures
• Promote local industry and economic

development
§ Preference and reservation schemes
Four pillars of a good public procurement system
• Developed in 2005 by OECD and the World

Bank
§ Pillar I: Legislative and regulatory framework
§ Pillar II: Institutional framework and
management capacity
§ Pillar III: Procurement operations and market
practices
§ Pillar IV: The integrity of the public
procurement system
396
Pillar I: Legislative and regulatory framework
• For example in Kenya, legislative and regulatory

documentation and supporting tools
§ Public Procurement and Disposal Regulations, 2006
§ Act and Regulations came into effect on 1st January 2007
§ Public Procurement and Disposal General Manual issued
March 2009
§ Various sector manuals (including Public Procurement
Manual for Health Sector), User Guide and Bidders’
Guidelines issued
§ Standard Tender Documents and Forms
§ Guidelines on particular requirements, e.g. use of framework
contracting
Ask participants to share examples from their countries
Pillar II: Institutional framework and

management capacity
• Public Procurement Oversight Authority (PPOA)

§ Ensures compliance
§ Monitors procurement system and reports to Minister of
Finance
§ Supports operations by:
ü- preparing manuals and standard documents
o - providing advice and assistance
o - supporting training and professional development
o - issuing directions to procuring entities
o - ensuring PE staffed by procurement professionals
§ Initiates policy and propose amendments to Act and
Regulations
• Mainstreaming and integration into Public Financial
Management System
397

management capacity
Ask participants to discuss structures and

enforcement mechanisms and present in
plenary

management capacity
• Accounting Officer (Head of Procurement) primarily

responsible for ensuring procurement entities fulfil
their obligations
• Procurement Unit staffed by qualified professionals
• Institutional development capacity
§ Capacity building strategy
§ Training and capacity development for PE staff
and potential bidders
§ Supplies Management Practitioners Act, 2007
§ High value contracts to reported to PPOA
§ PPOA’s monitoring function being stepped up
398
Pillar III: Procurement operations and

market practices
• Functionality of the public procurement market

§ List of registered suppliers updated annually
§ Fair and equal rotation
§ Debarment of unsatisfactory bidders and
contractors
§ Regulations on Public Private Partnerships issued
in 2009
• Contract administration and dispute resolution
§ Contract management procedures set out in
General manual
§ Late payments
§ Control of contract variations
Pillar IV: The integrity of the public

procurement system
• Existence of effective control and audit systems

§ Monitoring of performance through procurement reviews
and assessments
§ Internal audits
§ Audits by Controller and Auditor-General
§ Enforcement/sanctions against breach
• Efficient appeals mechanism

§ Notification of contract award sent simultaneously to
successful and unsuccessful bidders
§ Dissatisfied bidders may appeal to Public Procurement
Administrative Review Board before written contract made
§ Appeal from Review Board to High Court
399
Pillar IV: The integrity of the public

procurement system…
• Access to information
§ Procurement review reports published on PPOA
website www.ppoa.go.ke
§ Community monitoring
• Ethics and anti-corruption measures
§ Public Officer Ethics Act, 2003
§ Anti-Corruption and Economic Crimes Act, 2003
- Kenya Anti-Corruption Commission
§ Code of Ethics for procurement
§ Integrity declaration for bidders
What differentiates health from other areas of

public procurement?
• Value and range of procurements
• Specialised products with limited sources of supply
• Patented products may necessitate high use of

direct procurement
• Doctors’ professional preferences
• Emergencies give rise to unplanned requirements

that change budgeted priorities:
§ Natural disasters
§ Epidemics
400
Hospital and clinic requirements
• Pharmaceuticals
• Medical devices
• Specialised equipment
• General non-medical supplies
Pharmaceuticals
• One of largest items in health budget

§ Accounts for about one-fifth of health
spending, on average, in OECD countries
• Kenya
§ Total pharmaceutical expenditure KES15.9bn
(US$229mn) in 2008
§ Estimated to rise to KES31bn (US$522mn) by
2013
Source: Business Monitor International Kenya Pharmaceuticals and Healthcare Report Q4

(2009)
401
Counterfeit medicines
• The (2005) random survey by the National Quality

Control Laboratories (NQCL) and the Pharmacy and
Poisons Board found that almost 30% of drugs in
Kenya were counterfeit
§ Some of the drugs were no more than chalk or

water marketed as legitimate pharmaceutical
products
§ According to Kenyan Association of
Pharmaceutical Industry, counterfeit
pharmaceutical products account for sales of
approximately $130 million annually
Access to medicines
Access to medicines depends on:
• Regulation:
§ Transparent licensing
§ Affordable prices
§ Control of spurious/sub-
standard drugs
• Good procurement practices
• Sustainable financing
• Reliable supply chain systems,
including efficient transportation
networks
• Rational selection and use of
medicines (branded/generic)
402
Medical devices
• Broad range of products

including:
§ Examination gloves
§ Bandages
§ Oxygen
§ Intravenous products
§ Infusion devices
§ Peritoneal dialysis
solutions
• Often bought in
specialised pre-packed
standard kits 69
Medical devices...
• Medical devices also susceptible to

counterfeiting
§ 6%-8% of the total medical device market
comprised of counterfeit goods (WHO)
§ Fake medical devices may have incorrect

components or materials or be made from
cheaper, inferior quality or even toxic
materials
403
Medical devices...
• Procured through competition

but certain problem areas:
Oxygen
• Modes of delivery
§ Compressed oxygen gas
cylinders
§ Liquid oxygen cylinders
§ Bulk oxygen delivered to
Vacuum Insulated
Evaporator (VIE) high
pressure cryogenic liquid
storage tank
§ On-site oxygen generation
Specialised medical equipment
Broad range of products

including:
• Laboratory equipment
• Diagnostic equipment
• Defibrillators
• Electrocardiography
• Operating theatre
equipment
• Hospital furniture
• Radiology equipment
404
Specialised medical equipment
• Issues of concern:
§ Limited number
of manufacturers
§ Doctor
preferences for
familiar product
may preclude
proper product
evaluation
Procurement of specialised medical equipment
• Treat high-value exceptional purchases

differently from low-value and routine
purchases
• Maximise competition subject to supplier
capabilities
• Build installation, servicing and annual
maintenance for high value/complex
equipment
• If sourcing from overseas sources, ensure
local service and maintenance capabilities
405
General non-medical supplies
• Vary in cost and sophistication:

§ IT hardware and software
§ Vehicles
§ Office supplies
• Normal procurement principles should apply
Effective procurement for the health sector
 Same principles apply as for general procurement

§ Plan requirements and ensure availability of budget
§ Use open competition wherever practicable
§ Seek value for money with particular focus on high
value items
§ Fairness, transparency and right to redress
 Rationalise drug procurement based on WHO list and
generics
 Develop contingency plans for emergency
procurements
§ Framework contracts can cover unexpected needs
and ensure quality and price for decentralised
procurement
406
Supply chain stages
• The internal supply chain

§ Sourcing
§ Production
§ Distribution
§ Enterprise Resource Planning (ERP)
• The supply network
• The distribution network
• E-commerce (business to business; business to
customer and customer to customer)
Components of the selection process in a

public health system
407
Steps in the procurement cycle
UNIT 4
DISTRIBUTION AND STOCK CONTROL

408
Distribution and stock control
Ask the participants to discuss the following

questions in groups and present in plenary
• Discuss what could be an ideal distribution

system for your institution or country outlining key
steps and their linkages
• Outline challenges that face the supply chain
management for pharmaceuticals in your
countries
Distribute – Current Supply Chain Models
Three principal models of distribu=ng drugs today

Model 1
Manufacturer Repackager
Retailer
Wholesaler
Model 2
Manufacturer
Retailer
Repackager
Wholesaler Wholesaler
Model 3
Manufacturer Retailer
Other Sources of Drugs
(foreign, private mfrs)
“Secondary Market” – Major source of counterfeit drugs

409
Typical country distribution System
Challenges: Kickbacks, leaks and schemes
Manufacturer
Kickbacks
Bribes Favors, cash for Rx
Free goods
Sales rep
Theft,
Regulator
Diversion
Kickbacks
Patient
Wholesaler Retailer
Counterfeits
410
Direct delivery model for distribution
Distribution cycle
411
UNIT 5
QUALITY ASSURANCE AND CONTROL
Quality assurance and control
If there is no Quality assurance and control:
Counterfe
it drug sal
reach $75 es will
billion glo
2010 bally in
412
Use health systems controls to ENHANCE

the procurement and supply chain cycle
Regulation &
Quality control
Effect of lack of regulation and enforcement of rules
• Creates dysfunction and undermines quality

• In a lawless environment, personal relationships and
interdependence become the stabilising factor
• Economic efficiency becomes secondary – first is safety:
I did something for you, now you owe me
• Political power and economic power are closely linked –
politicians need to provide for their followers to maintain
their powerbase
• “Tribal” thinking: keeping power and resources within
the “family” is rational behaviour in a hostile environment
– creation of monopolies (e.g. drug gangs)
• Cartels become a way to split the market and keep the
peace among competitors
413
Regulation: Strength in numbers?

Impact of harmonisation of the registration process
Today's current environment A harmonized future environment
§ ~ 50 National Medicines Regulatory § 8 regional economic communities (RECs)

Authorities (NMRAs) governing drug covering the entire African continent
registration across Africa
§ Common documentation, procedure, and
§ Paperwork, technical requirements, and decision-making framework across all
other registration steps differ across NMRAs RECs
§ Manufacturers must invest significant time § Low cost to register in each additional
and effort in each registration, so a limited country, so coverage is more broad and
set of countries are targeted equitable
§ No clear timelines for a drug to clear § Streamlined process that is faster and
registration and be ready for the marketplace easier... starting first with generics
§ Little transparency before or during the § Clear understanding of the process by all
process parties involved
Quality assurance and control
Storage of medicine and must be systematised in order to avoid

duplication of storage, lapses and destruction
Do this:
• Apply the system FEFO (first to expire, first out)
• The sheets should be stored near stocks of products
• Check expiry dates
• Meet the standards of conservation
NB:
• Quality control is normally done from the stage of acquisition
of drugs at the national level by the accredited laboratory
• At the operational level, we must especially emphasize
proper storage and compliance with standards and
procedures for conservation
414
Quality assurance and control...
• Use FIFO or FEFO

Those must be fresh,
they have just arrived
• Keep track of
expiration dates
• Return excess
stock to the
warehouse for
redistribution
Destruction of expired drugs
• Take quantitative and qualitative inventory of

obsolete products
• The inventory value at cost to the PNA / PRA
• Send this inventory to the Department of
Pharmacy to analyse how it can destroy
different types of products
• Wait for instructions and authorisation from
the Department of Pharmacy
415
Procedures for destruction of expired drugs
• Develop a PV destruction with notification

of inventory value
• Do the destruction in the presence of
representatives of the (prefect, mayor,
police, RM, Head PRA or CS (CS
members), responsible for district (MCD or
manager)
• To sign the PV by all parties involved and
maintain the PV and send a copy to the
Department of Pharmacy
416

MODULE TEN
MONITORING AND EVALUATION
Objectives
By the end this module, the participant should be able to:
• Define the concepts of monitoring and evaluation

in the context of health systems strengthening
• Describe the frameworks for monitoring and
evaluation systems
• Discuss tools and methods for monitoring and
evaluation
• Describe the role of evaluative research in health
systems strengthening
417
UNIT 1
OVERVIEW OF MONITORING AND EVALUATION
Ask participants to discuss the following in

plenary
• Define the concepts of monitoring and

evaluation
• Distinguish between monitoring and
evaluation concepts
• What is your role in monitoring and
evaluation at your workplace?
418
Definition of monitoring
• Monitoring is a systematic and continuous
process for data collection and
assessment of activity progress over time
• Monitoring is the regular collection and

analysis of information to assist timely
decision-making, ensure accountability
and provide the basis for evaluation and
learning
Definition of evaluation
• Evaluation is a systematic and objective

assessment of an ongoing or completed
project, programme or policy and its design,
implementation, and results, in order to
improve planning and implementation of
current and future activities
• Evaluation covers context, input, process,

output and impact to assess whether the
objectives were achieved
419
Purpose of monitoring
• Monitoring is concerned with the following
§ Progress – whether activities are being /or

have been accomplished
§ Whether objectives are being met
§ It provides opportunity for re-assessment,
re-aligning and re-designing
Purpose of evaluation
Overall, evaluations are critical for evidence-

based decision making on the following
attributes:
• Relevance
• Performance
• Efficiency
• Effectiveness
• Impact
• Sustainability
• Institutional learning
420
Comparison of M&E
• While Monitoring is an ongoing activity,

evaluation is done periodically, typically at
mid-term and at the end of the project/
programme
• Evaluation is the process of gathering

information to inform judgments about a
project’s achievements and value
• Some evaluations are conducted to

determine whether a project has met (is
meeting) its goals
Comparison of M&E…
Monitoring Evaluation
§ Observe, check Why? Judge value, merit, worth
§ Record, account Assess
§ Day-to-day decision Major decisions
§ Provide info for evaluation Provide info for planning
When?
§ Throughout all phases Before , during or after
§ Continuous – routine. regular Periodic – time-bound
§ Systematic How? Systematic

§ Process Process
§ Internal Who? Internal & External
§ Participatory Participatory
§ Data used in Evaluation Data used in decision making
§ Quantitative & Qualitative Quantitative & Qualitative
421
Comparison of M&E...
Monitoring Evaluation
• Continuous process • Periodic
• Focuses on the activities being • Focuses on the process and
implemented according to plan the results
• Answers questions on what, • Answers questions on how
when, how well and why
• Acts as an early warning • Identifies lessons for new
system projects
• Done internally by the project • Done internally or externally
staff
Context of M&E
• M&E system must be context sensitive because:
§ Determine how the context affects the M&E
§ Enable accurate interpretation of the M&E results
§ Assess extent to which findings can be generalised
• Context includes among others
§ Political
§ Social and economic – gender, empowerment, poverty, equity
§ Economic
§ Environment
§ Legislative
• Contextualising M&E through
§ Participatory approaches to M&E
§ Measuring less known aspects (e.g. governance & empowerment)
§ Systems approach
422

Ask participants to work in groups to define the
following common terms used in M&E
• Efficiency
• Effectiveness
• Inputs
• Outputs
• Outcome
• Impact
• Effects
• Sustainability
• Relevance
• Replication
Manager roles in M&E

• Refer to definition of management in Module 4
‘Monitoring and evaluation is a key function of a
manager under the ‘leading and managing results
model’
• To perform this function, a health manager assumes

• Interpersonal roles: involve coordination and
interaction with employees – figure-head, leader, liaison
• Informational roles: involve handling, sharing and
analysing information – monitoring, dissemination
• Decisional roles: require decision making –
entrepreneurial, disturbance handler, resource allocator,
negotiator
423
Manager skills in M&E

A health manager needs the following skills to conduct M&E:
• Technical skills
1. Technical expertise
2. Clarification of goals and objectives
3. Problem solving
4. Imagination and creativity
• Team Approach
5. Listening for insights.
6. Directing and coaching
7. Solving problems as teams
8. Coordinating and cooperating
• Drive
9. Standards of performance
10. Control of details
11. Energy
12. Exerting pressure
UNIT 2
MONITORING AND EVALUATION

SYSTEMS AND FRAMEWORKS
424
Framework for Monitoring & Evaluation System
Determining OUTCOMES Are collective efforts being implemented on a large

Collective & IMPACTS enough scale to impact the epidemic (coverage;
Effectiveness MONITORING impact)? Surveys & Surveillance
Monitoring & Are interventions working/making a difference?
Evaluating OUTCOMES
Outcome Evaluation Studies
National
Programs
OUTPUTS
Are we implementing the program as planned?
Outputs Monitoring
What are we doing? Are we doing it right?

ACTIVITIES
Process Monitoring & Evaluation, Quality Assessments
What interventions and resources are needed?
INPUTS
Needs, Resource, Response Analysis & Input Monitoring
Understanding
Potential What interventions can work (efficacy & effectiveness)? Are we doing the right things?
Responses Special studies, Operations res., Formative res. & Research synthesis
What are the contributing factors? Determinants Research
Problem
Identification What is the problem? Situation Analysis and Surveillance
Fill in the M&E matrix below

425
M&E system matrix

M&E INFORMATION METHODS TOOLS FOR METHODS FOR TOOLS FOR DATA
INDICATORS TO BE FOR COLLECTING DATA ANALYSIS ANALYSIS
PROGRAMME
PROFILE COLLECTED COLLECTING INFORMATION
(QUESTIONS) INFORMATION
PROGRAMME’S IMPACT
GOAL(S) INDICATORS: (State broad
M&E questions
for each
indicator)
PURPOSE EFFECT/OUT-
(Immediate COME
Objectives) INDICATORS:
SPECIFIC
OBECTIVE(S)
OUTPUT
INDICATORS:
PROGRAMME’S PROGRESS
ACTIVITIES INDICATORS:
INPUT
!"#$%!&"# ' INDICATORS
PERSONNEL:
SUPPLIES &
EQUIPMENT:
Ten steps to develop a performance based

monitoring and evaluation system
1. Conducting a readiness assessment
2. Agree on performance outcomes to monitor and
evaluate
3. Developing key indicators to monitor outcomes
4. Gathering baseline data
5. Planning for improvements with setting realistic
targets
6. Building a mentoring system
7. Analysing and reporting findings
8. Collecting and providing evaluative information
9. Using the findings
10. Sustaining the monitoring and evaluation system
426
M&E system and how it links to the project

strategy and operations
http://www.ifad.org/evaluation/guide/4/4.htm
Example of annual planning & monitoring cycle -

Kenya
427
UNIT 3
TOOLS AND METHODS FOR M&E
Process of monitoring
The monitoring process entails:

• Recording data on key indicators
• Analysing and processing data
• Storing and retrieving information
• Reporting activity results
• Providing feedback to appropriate managers
and stakeholders
428
Monitoring mechanisms
• Periodic reporting
• Field supervisory visits
• Seminars/meetings
• Internal programme review during which
Health Management Teams meet to review
planned activities, identify achievements/
deficiencies, establish future directions
Data sources
• Primary
§ Surveys such as DSS, DHS,
§ HMIS
• Secondary
§ Check in meetings – to review successes and
lessons learnt since the last meeting
§ Activity report forms – to record what happened,
who attended, successes
§ Filling in the registers
§ Quarterly meetings – teams meet to ensure they
are on track in achieving the desired outcomes
and summarises lessons learnt
§ Reports – monthly and quarterly
429
Monitoring Indicators
Participants to work in groups to:
• Define an indicator
• List types of indicators
• Outline the importance of indicators
• Give characteristics of a good indicator
Report back in plenary
Indictors: Definitions
• Indicators are either qualitative or quantitative criteria

used to check whether the planned changes have
taken place as intended
• Indicators are variables with which we can measure

changes either directly or indirectly
• Indicators are performance standards that allow

project outputs to be verified and eventual project
impacts measured i.e. they help in determining how
to measure the extent to which the objectives have
been achieved at different times
430
Indicators: Classification
• Result-based:
§ Input
§ Process
§ Output
§ Outcomes
§ Impact
• Effect:
§ Direct
§ Indirect
• Measurement type:
§ Qualitative
§ Quantitative
Indicators: Definition by type

• Input indicators: that will track the means allocated for
implementation of the activities either financial, personnel
(technical assistance volunteers) facilities, equipment &
supplies
• Process indicators: that will track the activities in which the
inputs are utilised for instance in training, in establishment of a
logistic system, in planning of the service delivery
• Performance indicators: measures that show how well a
project/programme is achieving its set objectives
• Output indicators: track the direct and immediate results of
input and processes at project level
• Outcome indicators: refer to the intermediate results at the
target population level that are closely linked to the project
• Impact indicators: long-term results of interventions on the
health of individuals, households, communities
431
Indicators: Importance
• Better decision-making, lower risks and costs, identify limits

and opportunities
• Identification of emerging risks - prevention
• Identification of impacts - corrective action
• Performance measurement of the implementation of
development plans and management actions
• Greater public accountability, better communication
• As “signs” or “signals” of progress, indicators can be
observed, assessed or measured. Yet, in reality, indicators
show only a partial view of a rather complex reality. In other
words, change in real life is far more complex, and may be
beyond the capacity of one indicator to capture
Characteristics of a good indicator

• When selecting indicators, ensure that they are:
§ Specific
§ Measurable
§ Achievable
§ Realistic & Reliable
§ Time-bound
• A quality indicator is:
§ needed and useful
§ has technical merit
§ fully-defined
§ has been field-test or used operationally
§ set is coherent and balanced
432
UNIT 4
EVALUATIVE RESEARCH
IN HEALTH SYSTEMS STRENGTHENING
Evaluation Approaches
There are several approaches to evaluation
They include:
• The results chain approach

• The expert driven approach
• The participatory approach
• The peer approach
433
Results Chain Approach
• The results-based M&E is designed to address

a range of interventions and strategies, taking
a systemic view of the wider developmental
environment and outcomes to which such
interventions contribute
• The results chain depicts logical relationships

between inputs, activities, outputs, outcomes,
and impacts of a given policy, programme, or
initiative
Result chain model

434
Evaluation approaches …
• Expert-driven approach
§ One or more outside evaluators are given
full responsibility for conducting the
evaluation
• Participatory approach
§ An evaluation coordinator, often from
outside the programme or organisation,
works in partnership with programme
“stakeholders” in all phases of the
evaluation process
• Peer approach
§ Professional or teams assess each other
Tools for data collection
These are the common tools for data collection

for M&E:
§ Checklists
§ Questionnaires
§ Interview guides
§ Focus group discussion guides
§ Observation guides
§ Secondary data from internet
435
Characteristics of a good evaluation design
Types of evaluation
§ Baseline/Formative: conducted before
implementation to assess needs and potentials and
to determine feasibility of the plan
§ Midterm evaluation: conducted during
implementation to identify areas for change or
modifications; to detect deficiencies and ensure
immediate redesign of intervention strategies
§ Summative/end term evaluation: conducted at
the end of programme to assess outcomes
§ Ex-post evaluation: conducted to measure the
programme sustainability afters its closure
436

• Participants work in groups to discuss the case
study provided and answer the following questions
• Which type of research does this case study
represent?
• Define the following terms
§ Operations Research
§ Action Research
§ Evaluation Research
§ Economic Evaluation
§ Health Systems Research
• Share in plenary
Research: Types and Distinctions

• Operations Research
– is intervention oriented and use of advanced methods such as
simulations and optimization of performance to make better
decisions
• Action Research
– is problem oriented participatory approach to ‘learning by doing”
• Evaluation Research
– is applied research defined as ‘Evaluation research is the
systematic application of social research procedures for
assessing the conceptualization, design, implementation, and
utility of social intervention programs.’
(Clarke and Dawson 1999‎)
• Economic evaluation
– use applied analytical techniques to identify, measure, value,
and compare the costs and outcomes of alternative
interventions. Types of economic evaluations include cost-
benefit, cost-effectiveness, and cost-efficiency evaluations
437
Evaluation research
• Evaluation research use of social research methods;

requires study design, a control or comparison
group; involves measurements over time; and
special studies
• Why Evaluation Research?

§ Cost – effectiveness
§ Institutional learning
§ Sustainability
§ Need to be accountable
Evaluation research Models
For each of the models describe its application and

limitations using country-specific examples:
• True experimental model (RCTs)

• Quasi-experimental model
• Non-experimental models
• Management oriented models
Logical Framework, the Programme Evaluation and
Review Technique (PERT), the Critical Path Method
(CPM), and the Context, Input, Output and Product
(CIPP)
• Qualitative models
438
Definition of health systems research
• “Health Systems Research (HSR) is interdisciplinary in

nature and aims to provide policy and practice relevant
information, so as to improve the health system as a
whole by addressing the goals of equity, efficiency,
effectiveness, sustainability - ultimately leading to
improved health status”
• HSRis problem-oriented, it tends to focus on factors that
help to explain and solve the problem being examined
• It is therefore seldom that all components of the health
system are included in one study, although HSR studies
should cover all the six components
Domains and dimensions of health systems research
Source: IDRC
439
Process of proposal development for

evaluative research
Criteria for selecting health systems problem
• Analysis of the problem statement
• Formulation of research objectives and hypotheses
• Research design
• Design of research instruments/tools
• Sampling
• Data collection
• Systems approach to data processes and
management
• Ethical considerations
• Budget
Nangami Mabel sept 2010

440
Closing the gap between researchers and

policy makers
• Researchers should harvest, synthesise, re-package,
and communicate the policy-relevant evidence of
their studies in user-friendly terms that stakeholders
at many different levels can interact with and
understand
• Similarly, policymakers and other stakeholders

should share information on identified gaps, set
priorities, and express their policy needs in the form
of questions that can be investigated scientifically
Participants brainstorm in plenary on:
• Who are the actors in dissemination of M&E

information?
• Who are the audience?
• What are the challenges?
441
Gap between research, policy and practice
Source: Reach Policy Initiative, 2006
Evaluation: Common terminologies

• Concept note
§ Is a brief description of the idea of the project and the objectives
to be pursued
• Terms of Reference (TORs)
§ Structured description of the scope of work to be undertaken by
person or company undertaking an evaluation
• Expression of Interest (EOI)
§ A statement of intent by a company of their intent to get
involved in a project and responds to an advertisement; method
of short listing
• Inception report
§ A detailed and formal response of external reviewer interpreting
their understanding of the TORs and is often part of the letter of
agreement. The common components are technical and
financial plans
442
Conducting evaluations: Terms of reference
• Terms of Reference (TOR) also known as a Scope of

Work, is a plan outlining the key elements of the
purpose, scope, process and products of an
evaluation, including management and technical
aspects as necessary
• TOR sets the formal agreements about the evaluation
• These include the scope of the evaluation, its purpose,

the methods to be used and the specific tasks of the
evaluator and the client
Importance of TOR
• For the stakeholders:

TOR explains the agreed expectations in terms of
parameters and process of the exercise and are a guide
to each stakeholders’ specific role
• For the evaluation team:
TOR ensures that expectations are clear
• For external and internal teams:
External teams may require more details on the
background context and on intended audiences and
uses. Internal teams may simply need to clarify the
parameters of the assignment
443
Components of TOR
• Title
• Background
• Objectives
• Scope of work
• Expected deliverables/outputs
• Evaluation methodology
• Timeline /duration
• Team/personnel
• Budget
Ask participants to work in group to discuss

adequacy of the TORs provided, and present
in plenary
444
Effective Writing
Senior managers and policy makers at national level as
well as middle-level managers at county /district level
have the responsibility and obligation to assist in the
formulation of policy and ensuring that decisions on
policy are transmitted to the proper quarters for
execution
• The mechanisms of effective communication to policy

makers include:
§ Technical reports
§ Policy brief
§ Cabinet memo

Policy Brief
Ask participants to use the case study provided to:

§ Prepare a brief cabinet memo
§ Write a one page policy brief
§ Present in plenary to a panel consisting of the
minister for health and senior officials from the
Ministry of Health and Ministry of Finance
445
Dissemination: Communicating research findings
• Know your message

• Know your audience
§ Analysis –Who is the audience?
§ Understanding –What is the audience’s knowledge of the issue?
§ Demographics –What is their age, gender, educational
background ?
§ Interest –What is the reason for the information? (real or
perceived)
§ Environment – How will the message be sent?
§ Needs –What are the audience’s needs?
§ Customization –What specific needs / interests should you
address?
§ Expectations –What the audience expects to learn from your
work?
• Know your location
Possible challengers and weaknesses

• Weak M&E leadership
• Un-harmonised data collection tools
• Poor attitude towards data management
• Non-participatory and consultant-driven evaluation studies
• Poor skills and competencies in data analysis, dissemination,
and use of M&E data
• Weak infrastructure
• Inadequate financial allocations for M&E
• Weak management support, especially supportive
supervision for M&E
• Weak M&E partnerships to achieve the goal of 'one
harmonised M&E system’ for reporting procedures of
government, civil society, the private sector, and development
partners
446
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LIST OF CONTRIBUTORS
1. Mr Paul Tebatso 31. Dr Naftali Agata
2. Dr. Amani Koffi 32. Dr. Linet Nyapada Oyucho
3. Prof. Sano Daman 33. Mr. Mikihiro Toda
4. Dr Katche Jacques 34. Mr. Eiichi Shimizu
5. Dr. Ranga Taruvinga 35. Dr Tomohiko Sugishita
6. Ms. Faith Tombale 36. Dr. Peter Ngatia
7. Dr Maty DIAGNE CAMARA 37. Mr. Nzomo Mwita
8. Mrs. Jenniffer Kaahwa 38. Francic Namisi
9. Ms. Audrey Kgosidintsi 39. Ms. Wairimu Njoroge
10. Prof Stephen Hendricks 40. Mr. Nicholas Kiambi
11. Mr. Chaltone Munene 41. Ms. Betty Omore
12. Dr. Afua Kufuor 42. Miss. Sarah Naeku
13. Dr. spéro-guy COMLAN 43. Mr. Antony Kimani
14. Dr G. Koryoe Anim-Wright 44. Mr. Augustine Mwangi
15. Mrs. Jennifer Nyoni 45. Ms. Betty Rabar
16. Prof. Kiyombo Mbela 46. Mr. Fred Mandi
17. Dr. Habib Somanje
18. Prof. Jotham Micheni
19. Dr. Abel Nyakiangora
20. Prof Simon Kang’ethe
21. Dr. Anastasia Kimeu
22. Mr. David Njoroge
23. Dr. Mollent Okech
24. Dr. Fred Newa
25. Dr. Martin Osumba
26. Dr. Mabel Nangami
27. Dr. Florence Kithinji
28. Dr Josephine Mbiyu
29. Mrs.Margaret Karangatha
30. Prof. George Odhiambo-Otieno

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Pg G O V E R N A N C E , L E A D E R S H I P & M A N AG E M E N T F O R H E A LT H S YS T E M S T R E N G T H E N I N G

The Publications Editor

Directorate of Capacity Building

P.O Box 27691-00506, Nairobi, Kenya

Module 1: Overview and context of a health system 13

Module 2: Governance in health 37

Module 3: Leadership in health 64

Module 4: Management for health 125

Module 5: Human resources for health management (HRHM) 200

Module 6: Health management information systems 263

Module 7: Health financing 296

Module 8: Service delivery 325

Module 9: Supply chain management 368

Module 10: Monitoring and evaluation 416

Module 10: References 446 - 448

Module 10: List of Contributors 449

• Module 1: Overview and Context of the Health System

• Module 2: Governance in Health

• Module 3: Leadership in Health

• Module 4: Management for Health

• Module 5: Human Resources for Health Management

• Module 6: Health Management Information Systems

• Module 7: Health Financing

• Module 8: Service Delivery

• Module 9: Supply Chain Management

• Module 10: Monitoring and Evaluation

Dr. S.K. Sharif, MBS Dr. Peter Ngatia, EBS

Mr. Masaaki KATO

Acronyms and abbreviations

AHLMN Africa Health Leadership and Management Network

AMREF African Medical and Research Foundation

ANC African National Congress

AOP Annual Operation Plan

ART Antiretroviral Therapy

CBHF Community Based Health Financing

C/VHC Community or Village Health Committee

CEDAW Convention on the Elimination of All Forms of Discrimination against Women

CESAG Centre Africain d’Etudes Supérieures en Gestion

CORPS Community Resource Persons

CPD Continuing Professional Development

CRC Convention on the Rights of the Child

CRM Customer Relationship Management

DHS Demographic Health Survey

DSS Demographic Surveillance Sites

EHP Environmental Health Perspective

FCTC Framework Conventional on Tobacco Control

FEFO First to Expire, First Out

FGD Focus Group Discussion

FIFO First In First Out

FIS Financial Information Systems

GAVI Global Alliance for Vaccines and Immunization

GEH Government Expenditure on Health

GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria

GIMPA Ghana Institute of Management and Public Administration

GRNs Goods Received Notes

HAF Health Action Framework

HALE Health Adjusted Life Expectancy

HFC Health Facility committee