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Management Developm nt for Primary He Ith Care
Report of a Consultation 28 May - 1 June 1990 Geneva, Switzerland
TABLE OF CONTENTS
1.
Introduction 1.1. 1.2. Objectives Process
2. 3.
Opening Statement Management Development for PHC: A Framework for Analysis 3.1. 3.2. 3.3. 3.4. 3.5. 3.6. Management problems in PHC The role of management in PHC Approaches to health management development Outcomes and evaluation Expansion and extension Key questions
4. 5.
Findings and Conclusions Recommendations
Annexes A List of Papers B Schedule C Participants
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INTRODUCTION
There is increasing international concern about the actual implementation of Primary Health Care. Improved management is generally regarded as one of the most critical factors in bridging the gap that exists between the policy and its implementation. Efforts to strengthen the management process have always been among WHO's concerns. Considerable resources have been directed towards management training and the development of guidelines, but the results have often been disappointing. There is, therefore, a need for renewed attention to health management development, particularly at the district level.
1.1.
OBJECTIVES
Towards this end, WHO has organised a consultation on management development for Primary Health Care. The meeting brought together experts and practitioners from several countries and regions in order to o review the state of practice regarding health management development, based on experiences in countries with whom WHO has been collaborating; o build a consensus about what is known, what are the gaps in knowledge, and how these gaps should be investigated; o agree on an agenda for follow-up, including further investigation and preparation of country case studies. These objectives build on a number of principles and assumptions which were agreed upon during a small preparatory meeting in December 1989. The most important of these are: o Management development is not an end in itself. The aim of health management development is to improve PHC implementation. o There is not one best approach to management development. Rather, the effectiveness of management development strategies depends on a variety of factors, including the context in which they are applied and the desired outcomes. o Knowledge about evaluation of outcomes is inadequate, and there is little actual experience of assessing whether expected improvements in the performance of health and management systems are taking place.
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A paper, outlining a conceptual framework for analysing and discussing issues in management development for Primary Health Care, was prepared for the meeting. Three country papers were also prepared, according to a common set of guidelines for reviewing and documenting diverse management development interventions. Annex A lists the papers presented at the consultation.
1.2.
PROCESS The consultation took place over a period of five days. On the first day, following an
introduction and overview of issues in management development for Primary Health Care, several partiCipants gave country presentations: Papua New Guinea, Bangladesh and Ghana. The second and third days consisted of small group work and plenary reviews of group discussions. These sessions were guided by handouts with questions to address the major issues identified in the concept paper: approaches to management development; outcomes and evaluation of management development programmes; expansion, extension, and dissemination of management development; and institutionalisation and sustainability. On the fourth day, participants were asked to review draft notes of their discussions and presentations of group work. Based on their review, they suggested recommendations to be included in the consultation report. The final day consisted of a review of the draft report and finalisation of the recommendations.
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OPENING STATEMENT by Dr Jean-Paul Jardel, Assistant Director General, WHO
Weak management is often cited as a root cause of the failure to implement Primary Health Care effectively. Countries expend considerable resources on management training but, in most cases, without lasting impact. Why is this so? What can be done about it? What do we know about different approaches to management development? What works and what does not? How do we evaluate success in improving management performance? These are some of the fundamental questions that need to be addressed now. More than ever before we are faced with the challenge - how to do more with less. And we know that we need improved management in order to confront this challenge. Only a few weeks ago, the Director General's Consultative Committee on Primary Health Care met for wide-ranging discussions conceming ways to improve PHC implementation. Several of the issues that arose during that meeting were concerned with management. The need for effective decentralization and the need for strengthening district or local health systems were among the points which were raised repeatedly. In this meeting, we take as a starting point that the primary concern of management development is to establish, strengthen and sustain the infrastructure required for the effective implementation of strategies based on Primary Health Care. Towards this end, we need organisational structures and management systems which, in addition to performing traditional management functions, will help to o o o o o support the promotion of equitable distribution of resources available for health care; facilitate managerial and financial integration of health programmes; encourage the participation of other sectors and relevant public and private organisations in the implementation of health-related strategies; promote the scrutiny of all development initiatives for their impact on and relationship to health status; strengthen or establish sustainable institutions, with recognised channels of influence, in which dialogue and negotiation between health care providers and beneficiaries can take place. What then are the problems health managers at all levels have to face? Here are just a few: o There is the problem of coordination and integration which continues to haunt us -how can district health managers develop coordinated work plans and provide
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integrated services, when training courses, transport, supplies and information systems continue to be organised in programme-specific terms? o There is the problem of financial management -- management information and accounting systems are not oriented to facilitate review of cost and effectiveness. Most district managers simply do not have the information they need to make decisions which will improve efficiency. What can be done and who should do it? o There is the problem of low utilisation of health services. How can outreach programmes be better organised? How can we involve communities in the planning and management of services? Answers to these questions and concerted efforts by district health management teams are bound to improve this problem. o And what about the problem of human resource management? Job descriptions which provide clear roles and responsibilities are lacking in most places: yet another management problem. The traditional answer to this one is training -- but unless training takes into account the actual conditions under which people work it may not lead to the desired improvements in work practice. So what else is needed? All these questions point to the need for action on management development that is system-wide: covering all levels and programmes. Management development should deal with o o o o reforming organisational structures, strengthening support systems, improving skills of staff, and developing learning materials and guidelines.
These need to be the components of the 'management development package'. The agenda of this meeting includes discussion of such difficult issues as o o o sustainability - how can management development be institutionalised? evaluation - how do we know whether our management development interventions are succeeding? is team performance improving? are systems functioning better? structural reform - how can ministries approach the sensitive issue of re-organising so that PHC implementation can be improved? What will the discussions of this consultation lead to? We hope to achieve greater clarity about what management development can do, what support countries need, and how WHO can help. We expect that there will be intensified collaboration with WHO on this subject, leading to the preparation of country case studies and to further development of practical methods for analysis and evaluation of management initiatives.
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MANAGEMENT DEVELOPMENT FOR PRIMARY HEALTH CARE: A FRAMEWORK FOR ANALYSIS
3.1.
MANAGEMENT PROBLEMS IN PRIMARY HEALTH CARE
The most appropriate starting point for analysing management development programmes is a brief review of the problems with which health managers have to deal. The following examples illustrate the nature of the most frequent and persistent problems. o In District A, there is no common workplan for the outreach activities of the district health team. The district public health nurse does not know when the public health inspector is next going to village X. There is no system for sharing transport. o The job descriptions for the district health team are outdated and irrelevant. They do not describe the responsibilities detailed at a recent PHC workshop. The job description of the medical assistant running the health centre is 15 years old and has not been revised. o The public health nurse reports directly to the MCH Director at HQ about family planning results. A similar procedure exists for most other district officers. The district medical officer's role as team leader is, therefore, undermined. o Two different district officers are involved in EPI. Each uses a separate information system. The two systems are not reconciled. o The district medical officer does not know which of the health centres in the district operates more efficiently. Although he knows the number of outpatients seen at each faCility, the existing accounting system does not provide him with information on their operating cost. o Village health committees have been established at the request of the PHC coordinator at ministry headquarters. But the committees have never met, and utilisation of health services continues to be very low. o The director of MCH and the director of the EPI programme work in isolation of each other. Each programme is funded by a different donor. Each has a separate information and reporting system. Each has separate accounts and separate supply systems.
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The District Medical Officer has just attended a PHC management workshop in the regional capital. When she returns to the district, however, she finds it impossible to implement her plan to hold an intersectoral workshop because she has no discretionary funds at her disposal, all available funds being earmarked for specific programmes.
Some of these problems are due to lack of skills. Some are due to lack of resources, others to lack of information, to unclear procedures, to poorly motivated staff. Some can be solved by working more efficiently within existing systems and structures. Others require structural change. The move from baSic health services and traditional disease control programmes to health systems based on Primary Health Care requires not only reorientation and training of staff, but fundamental changes in the whole organisation. It is to this complex set of problems that management development must respond.
3.2.
THE ROLE OF MANAGEMENT IN PRIMARY HEALTH CARE
Many of the problems health managers have to face can be explained in terms of a lack of fit between the strategies of Primary Health Care and the existing organisational structures and management support systems through which these strategies are to be implemented. The effect of organisational structure is most acute in the case of vertical programmes. Virtually all training activities of vertical programmes contain management modules. Most programmes claim that these modules are generally applicable, and thus contribute to the improvement of health systems management in general. There are, however, two important flaws in this argument. Firstly, the number of existing programmes leads to considerable duplication of effort. Secondly, and most important in this context, their separate vertical organisational structure brings with it separate programme-specific systems -- for financial management, supplies, transport, information. Vertical programmes often make selected parts of the health system more efficient. But they do little or nothing towards developing structures and systems for cooperation with other similar programmes, or towards the development of a more responsive and integrated health system based on Primary Health Care. If there is a mismatch between strategy and structure, we can either change the structure and its management systems -- or we question the strategy, and implicitly the policy on which it is based. If, however, Primary Health Care as a strategy is non-negotiable, then structural change is required to facilitate its implementation.
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Therefore, management development for PHC must be concemed not only with improving implementation within the constraints of existing structures and systems, but also with changing structures and systems in relation to Primary Health Care policies. The potential of management development programmes to change structures and systems is, however, limited. If we agree that there are a number of different interested parties involved in shaping health systems, and that not all of these parties see the world in the same way, changes in organisational structures and management systems are not easy to affect. The results will depend on the power and position of those starting the programme, and the power and position of others who can hinder or help the process of implementation. The chances of success will be different, if a management development programme is started on the insistence of a donor agency as opposed, say, to one instigated by the Permanent Secretary of the MoH based on an internal management review. Management development also has a different potential when it is initiated by an intervention-specific programme, such as EPI, as compared to being supported by the planning or training division. There is a constellation of factors that make up what we have called the context within in which management development takes place. There is not always a great deal that can be done to change the context. However, a clear understanding of the opposing and supporting forces in the organisational environment help us distinguish between what kind of management development is desirable and what is actually possible.
3.3.
APPROACHES TO HEALTH MANAGEMENT DEVELOPMENT
In trying to define the characteristics of management development strategies, the first problem to overcome is one of terminology. Instead of providing a helpful structure, much of the current language in the field of management tends to confuse rather than clarify. Another challenge is to do justice to the wide variety of strategies which go under the name of management development and to ensure that the proposed framework encompasses the diversity which exists. Approaches to health management development may be defined in terms of scope; orientation; methods; and organisation.
There are three aspects which determine the scope of a health management development programme. They concem
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the level of operation: centre, region, province, district, sub-district, or any combination of these; the technical or programme focus: one or more specific technical programme, such as EPI, or a comprehensive integrated programme; the means of effecting change: structure; systems; staff; software. The choice of entry point in terms of structure, systems, staff and software will be determined by a variety of factors emanating from the programme context. It is often opportunistic and may involve anyone or all of the four 5s.
Structure refers to the organisational structure of ministries of health or health systems as a whole. Management development interventions may analyse and attempt to change organisational structures and linkages in order to make them more effective in supporting the implementation of the organisation's mission and policies.
Systems refers here to specific management and support systems (sub-systems of the overall health system), such as the information system, the transport system, the resource allocation system, the drug management system. Management development interventions may be concerned with reviewing, developing, reforming, re-designing these management sUb-systems.
Staff refers to managers and workers in the formal and informal health system. Management development interventions usually include a component concerned with the development of the people working in the system: providing them with skills; increasing confidence and competence; changing behaviour and attitudes
Software refers to learning and training materials, protocols, standardized procedures and guidelines, and is usually linked with attempts to change structure, systems and/or staff. Management development interventions may be concerned with developing and revising management training materials, reviewing existing guidelines,
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protocols and standard operating procedure and changing them in order to effect improved management. Whatever the initial scope and entry point opted for at the outset of a programme, it will usually need to broadened and extended later on.
Orientation
This has been the focus of much attention. Orientation tells us how the programme is conducted: who identifies and defines problems; what the relationship is or should be between those defining the problem and those implementing solutions; what methods and tools are appropriate to initiate and implement management development. A spectrum exists between two broad types.
Type 1 Key words: directive; blue print; ends rather than means-oriented; product-focussed; prescriptive; normative. o Problems are identified, analysed and solutions developed by persons other than the managers involved in programme implementation. The concern is less with the nature of the process and more with arriving the most efficient solution.
Type 2 Key words: participative; flexible; means rather than ends-oriented; processfocussed; learning model; adaptive; pragmatic; developmental. o Practicing managers are aSSisted by facilitators to analyse their own problems and develop relevant solutions. The concern is as much for the way the intervention is carried out as it is for the product.
Methods
Tools and methods will be chosen and/or developed primarily in accordance with the orientation, but also with the programme scope and, to some extent, the institutions involved. Materials development is an area in which much time and energy has been invested. However, there has sometimes been a tendency to put the cart before the horse, as evidenced by the vast quantity of learning materials produced without careful assessment of the need, without due regard for their appropriateness and usability in the field, and without sufficient attention to the context in which they are to be applied.
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Organisation: location and linkages In any programme it is important to consider the roles, responsibilities and relationships between the various organisations and institutions involved at different stages in the management development process. Roles and responsibilities will be influenced by the programme scope and the approach adopted. Resource institutions, such as university departments and training schools, may be better suited to participate in nationwide systems design or the orientation of key senior personnel. District-level strengthening, on the other hand, may only be possible on a large scale if it becomes the responsibility of the Ministry of Health itself.
3.4.
OUTCOMES AND EVALUATION
There are two main schools of thought conceming outcomes of health management intervention.
Group 1 holds the view that the only legitimate objective of any intervention in the health sector is improvement in health status. Interventions may include management development strategies, but these are purely a means to an end. Unless health status is positively affected, nothing of value has been achieved.
Group 2 holds the view that better health systems management is a necessary but not sufficient cause of improved health. Recognising that multiple factors influence both service delivery and health status, it is a legitimate objective to try and improve the performance of service managers per se. The corollary of this argument is that if the objective is to improve management performance, means must be developed for monitoring achievements. Clearly, the objectives and thus, the desired outcomes will be influenced by political and organisational factors and by the scope of the management development programme itself. However, intended outcomes are not always made explicit, leaving considerable room for divergent opinions as to what should be regarded as a success. The following categories represent a possible hierarchy of outcomes: increased competence should lead to improved managerial performance, which in turn should lead better service delivery, thereby positively influencing health status. In practice, however, there is likely to be an emphasis on certain primary objectives. Monitoring systems will be geared to asseSSing progress towards the achievement of these objectives and success, or otherwise, will be defined in these terms.
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Management competence In many programmes concern is limited to the development of management skills or the establishment of management systems. Competence objectives might be stated in terms of aquiring skills in health centre management or setting up a new information system, for example. Monitoring the development of competence is primarily the concern of the trainers: how many people have been trained, workshops held, manuals distributed, learning objectives achieved.
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Managementperionnance Developing the competence of systems or individuals does not guarantee that it will be translated into improved performance. Do managers work more effectively and actually use the systems that they or others have established? As a result of management development activities, do managers do what they are supposed to do better? Do they hold meetings, prepare workplans, act on new job descriptions? If objectives are stated in terms of improved managerial performance -- either of individuals or systems -- how will these be monitored? In reviewing any particular programme, there are several issues to consider. What are the most appropriate indicators of improved performance? How and by whom should these indicators be monitored? To what extent is appropriate information available from existing routine sources? Who will be the main consumer of this information?
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Service outputs The overall purpose of many management development programmes is defined in terms of improving health programme (as opposed to health policy) implementation. The concern of senior administrators is that an investment in management development will result in more efficient use of resources: either more outputs from available resources or lower unit costs for key outputs. It is often easier to monitor service outputs of programmes which are afforded a high priority, such as immunisation or family planning services. The difficulty, however, arises that measurable improvements in the delivery of priority programmes may result more from favourable resource allocation to those programmes, than from management strengthening per se. Measuring success in terms of specific service outputs also presupposes that the programme's objective was merely to enhance implementation of a specified set of tasks and not to develop general strategic or allocative skills.
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Health status Although the overall purpose of a management development programme may be directed to improving health status, health status objectives to be achieved directly are usually defined in terms of specific causes of mortality or morbidity. These in turn are usually related to a particular programme or programmes (reduction in maternal mortality, for example). Monitoring changes in health status is rarely possible with routine data and special surveys are likely to be required. Given the multiple factors associated with changes in health status (even in cause-specific mortality), it is unlikely that assessments of change would be carried out as a means of determining the success of a management development programme.
3.5.
EXPANSION AND EXTENSION
Expansion: broadening the scope Many PHC management development programmes begin with a single form of intervention: staff training being by far the most common starting point. If appropriate structures and systems are in place and functioning, staff development may be all that is required. More often than not, however, training alone is insufficient. This is particularly true in the case of the more prescriptive forms of management training for Primary Health Care. Either there are no functioning support systems, or the structures and systems that exist are at odds with the orientation of the training and the policies on which it was based. In either case, a more comprehensive approach is essential. Similarly, if organisational reform is the starting point of a management development strategy, the process will be incomplete unless support systems are reviewed and appropriate training is instigated. Thus, expansion of scope in some circumstances may enhance the overall effectiveness of management development, in others it may be required for any effect to be achieved at all. Our definition of scope recognises that some programmes are designed in a comprehensive way from the outset: they address the development of structures, systems, staff and software as part of an integrated package. In others, the scope of the programme may expand over time -both in response to demand, opportunity and changes in overall context. Implicit in this understanding of expansion is the fact that as the scope of management development broadens, so necessarily are more levels of the health system involved. Whereas staff development, for example, can take place at any level, structural reform must involve the centre.
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Extension: disseminating the products and Increasing the scale It is first important to distinguish different approaches by which management development initiatives can achieve an impact on a national or health system-wide scale, starting from a smallscale or localised base.
Product orientation By working in a discrete area, innovative strategies for addressing common problems can be tested and their effectiveness assessed. Field-tested solutions developed in the local situation can then be disseminated for system-wide implementation. Similarly, small-scale projects provide an opportunity for understanding and documenting complex problems, the solution to which may require national-level decisions. The assumption is that recommendations concerning change in organisational structures or management systems, or the implementation of innovative strategies for addressing operational problems, will be institutionalised on a large scale through existing channels. Extension, therefore, occurs by the dissemination of the products of management development.
Process orientation An alternative approach is to implement on a large scale that which has initially been done on a small scale. Starting on a small scale may be necessary and desirable for a variety of reasons: in order to test the methods used, assess the magnitude and extent of problems, stimulate demand for the process and gain political support, by dint of early success, for management development. The objective, however, is to extend the effect of management development by scaling up the management development process itseH. These approaches are not mutually exclusive, and both may be found as components of the same programme. They are differentiated here in order to draw attention to some of the problems associated with each. In the dissemination of the products of management development, the assumption is that what has been learned in the 'experimental situation', be it in the form of guidelines or manuals or a recommendation to a high-powered committee, will be adopted and institutionalised by others who have not been directly involved in the process of production. Clearly, this cannot always be assumed. The adoption of lessons that have been leamed in other parts of the system (or even other countries) will need to be linked with a process of adaptation to ensure that there is a fit between the management solution being disseminated and the context in which it is to be transplanted. As concerns the process approach, the difficulties of implementing small-scale experimental or pilot projects on a large scale have been widely documented. It is generally agreed, however, that problems arise as the context in which implementation occurs changes. Large-scale implementation requires that the structural and system-wide issues from which small-scale projects are effectively protected, have to be faced. Thus, planning for large-scale implementation requires
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a further careful analysis of new contextual factors which come into play. Specifically, the need for the parallel development of the support systems required to maintain the process of expansion, must be addressed.
3.6. KEY QUESTIONS
As stated at the outset, the purpose of this meeting is to review the current state of practice regarding management development for Primary Health Care, to identify and explore the main issues, and to agree on what is known, what are the gaps in our knowledge, and how might these gaps be investigated. To facilitate this process, we will focus on four areas of concern: approaches to health management development; outcomes and evaluation; expansion and extension; and institutionalisation and sustainability. For each area, we have set out a number of critical questions to structure the discussion.
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Approaches to health management development There is a wide variety of approaches to health management development. The choice of approach and of an appropriate entry point, as well as the ultimate effectiveness of the particular approach selected, depend on a variety of factors. These include the context in which the development and implementation of the programme takes place. o What are the most important elements that constitute management development? What activities need to be carried out? Why are these particular activities important? o o o What is the basis for selecting a particular approach, a particular entry point? What conditions are important to ensure success? What should be the role of vertical or intervention-specific programmes in relation to management development for Primary Health Care?
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Outcomes and evaluation There is a need to review and decide on what it is that we expect to change as a result of management development. Different assumptions are made as to what constitute the most important outcomes of management development programmes. o o What and who determines the emphasis given to different outcomes? What are the most important indicators for assessing the outcomes of management development? What makes these indicators important? If it is agreed that it is important to assess improved management practice in relation to PHC, how should this be done? What indicators should be used? Who should undertake this kind of evaluation? For whom? o What systems are required for the effective monitoring and evaluation of management development programmes?
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Expansion and extension Expansion: broadening the scope Irrespective of the initial entry point of a mangement development initiative, there is usually a need to expand the scope of programmes to encompass interventions in all four Ss: structure, systems, staff and software; to move from one to all levels of the health system; and from Single programmes to a comprehensive programme approach. o What obstacles have been experienced in trying to broaden the scope of programmes from their original entry point? What actions are required to facilitate and support expansion? What are the enabling conditions required to make expansion possible?
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Extension: Increasing the scale Many programmes start out with implementing management development interventions on a small scale, covering only a few districts or a selected part of a country. Once methods have been tested and the process gains momentum, there is a concern with extending the intervention on a larger scale.
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What obstacles have been experienced in trying to extend the scale of management development programmes? What actions are required to facilitate and support extension? What are the enabling conditions required to make extension possible? How can these conditions be ensured or created?
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Extension: disseminating the products There is an assumption that if lessons learned from innovative experiments in management development are well documented and disseminated, they will be readily adopted elsewhere. This method of extension is thought to work both within countries and internationally. o o Are these assumptions borne out by the experience of the participants? Apart from disseminating information, what needs to be done to ensure that lessons learned from successful programmes can be effectively adopted and adapted beyond the original area of implementation?
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Institutionalisation and sustainability There is a general concern to sustain the effective functioning of systems based on Primary Health Oare. Institutionalisation of improved management is considered a necessary step in making this is possible. o What aspects of management development programmes is it useful to institutionalise? Does the need for short-term improvement in programme implementation conflict with the need for the long-term development of sustainable health systems? o What obstacles have been experienced in trying to institutionalise elements of management development? What are the enabling conditions required to make institutionalisation possible? How might a focus on institutionalisation and sustainability change the way management development programmes are designed and implemented?
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FINDINGS AND CONCLUSIONS
4.1.
OVERVIEW There was overall agreement that management development is an essential tool to
transform the health system so that Primary Health Care can be implemented. Management development should not be a separate programme, however, but rather an integral part of health systems development. Although management development interventions may start in a limited way through a particular entry point, it is critical that management development is seen as a means to effecting system-wide change. Therefore, limited approaches, such as management training, are not likely to be effective in isolation. Strategic plans for management development facilitate a comprehensive approach. Such plans must have built-in flexibility to allow learning and adaptation during the course of implementation. The following sections summarise the deliberations of the working groups and the plenaries. They are organised according to the four key issues which provided the structure for the discussions.
4.2
APPROACHES TO MANAGEMENT DEVELOPMENT
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A critical stage in deciding on the approach to management development is an assessment of the social, political, economic and organisational context in which it is to be implemented. The idea of mapping the context as a means of deciding what can be done was discussed. This may point to particularly intractable problems (eg: changing civil service regulations) and thus help to answer the question: are the systems with which we are concerned capable of accepting change. Tools are required for carrying out an assessment of the context and circumstances in which programmes are to be implemented.
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Management development interventions, particularly at district level, need to be problemoriented. It was recognised, however, that different actors will see problems in their own way and that, following from this, the way problems are defined often points to a particular kind of solution.
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A number of specific activities were identified. Having gained a consensus that a problem exists, and secured commitment to support change, the next step is to consider the full range of available management development strategies. When it is determined who is to be involved in the management development process, roles and responsibilities of all concerned need to be clearly specified.
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It is not enough just to train people in management. It is also necessary to make organisational and management systems changes if management development is to realise its full potential. There is a need to address the 45's (structure, systems, staff, software) referred to in the background paper.
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Management development programmes must necessarily involve all levels of the health system. The choice of a particular point of entry is primarily a tactical decision. However, a focus on district or local systems is considered essential in the implementation of PHC and thus, in management development.
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There is widespread support, particularly from donor agencies, for management development in the context of vertical programmes. Despite the fact that this approach can help in skills development for individuals, it generally resuHs in programme-specific management systems, thereby reinforcing verticalisation.
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A number of conditions influencing the success of management development programmes were identified: o Commitment to management development has to be expressed by the allocation of adequate resources for the implementation of change, and to the process of management development itself. o To gain acceptance, management development needs to be perceived as an internally valued rather than externally imposed process. Early involvement in the process is therefore critical: on the part of policy makers and managers at all levels of the system o Management development is more likely to be successful if the focus is on problems of real and immediate concem to the managers involved. If managers agree to be accountable for resuHs, performance is more likely to improve. Opportunities for learning can be found in a variety of different settings.
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There is a need for greater clarity concerning the strengths, weaknesses, and potential role of the different institutions and organisations involved in management development. This is particularly the case for resource institutions, such as university departments and schools of public administration.
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Other development sectors (such as local government, agriculture and education) are also concerned with management development. The experience of these sectors may be of use in planning management development for PHC.
4.3
OUTCOMES AND EVALUATION
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Different actors will have different views as to what outcomes and indicators are most important. For example, health professionals, politicians, and clients all have different interests and, therefore, will not see all outcomes as equally important. The need for early and visible indications of success is critical.
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The 'rules of evidence' question must be addressed, namely, what will important actors accept as proof of outcomes? Because management development outcomes are difficult to quantify, there can be a problem in convincing decisionmakers about the utility of management development.
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It is easier to establish a link between management development interventions and improved management practice, than with changes in service outputs and health status.
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Given that management development outcomes are "soft" and effects are not always immediately visible, it can be difficult to use evaluation as a management tool. It is important to ask who is interested in evaluation, for certain actors evaluation is not a felt need.
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Both the technical and political aspects of outcomes, measurement, and evaluation are important. Management development programmes must be sensitive to both. The political dimension often outweighs the technical one, and managers must remain aware of the fact that key decisionmakers' information needs and demands will be predominant.
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System managers should initiate evaluations, key actors from all organizational levels and from outSide the system should participate in evaluation, and evaluations should be scheduled periodically throughout the management development process. The preconditions for effective evaluation include such factors as: stated objectives and action plans, clear roles and responsibilities, performance contracts and reviews, agreed value systems, and accountability.
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4.4
EXPANSION, EXTENSION AND DISSEMINATION
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As the scale and scope of programmes increase, they become more complex; require more coordination; greater commitment of resources; and have wider political implications. The context in which they operate, therefore, changes and new social, political, economic and organisational factors affect what can be done.
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There is often limited appreciation of the nature or potential benefits of management development programmes on the part of policy makers. This is particularly true in the health sector, where improvement is only perceived in terms of better health services. Without the commitment of those with power to effect system-wide change, the effects of management development initiatives may remain limited.
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The problems inherent in scaling-up from pilot projects to larger operations include: o pilot areas are often atypical of the larger setting for a variety of reasons (not least in the resources available), the small-scale project avoids system-wide structural issues that constrain largescale implementation of change, the culture of management development, acceptable on a small-scale, may be resisted if it conflicts with wider organisational or societal values, o the organisations initiating small-scale projects may not be capable or willing to take on a large-scale role, problems can also result if pilot areas are associated with particular donors -internationally well-known unreplicated pilot projects were cited as examples.
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Traditionally, pilot projects have been used for technical reasons -- in order to demonstrate, by careful evaluation, the effect of a particular intervention. An alternative approach, which still recognises the need for a small-scale start, is to use small-scale projects for tactical reasons -- to test out methods, to check that the strategy is acceptable, to gain political support and so forth. The tactical approach does not require evidence of effectiveness (which takes time to produce) or assume that a decision to continue will depend on this evidence. Rather, it assumes implicitly that large-scale implementation will go ahead anyway, but that sufficient flexibility is built-in to allow learning and adaptation along the way.
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As different levels in the health system become involved, conflicts can arise. This is particularly true when districts start to make demands for more autonomy on the region or
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province. Similarly, regions can begin to make demands on the centre which may well be resisted. The resistance may be partly due to inertia, but vested interests are often involved, for example, when stronger regional management requires concrete steps to be taken in terms of vertical programme integration. 6 It is important to build on success. This may require a modest start and gradual build-up. It also argues for identifying sub-systems that are amenable to change as a starting point. This, however, should not be interpreted as legitimising a single health programme focus. Rather, the concern is for management support sub-systems. 7 A number of strategies for widening the net of those committed to management development were discussed. The notion of "seeding" critical parts of the system with individuals known to be both able and committed to change -- has been shown to be effective. 8 Good documentation is a necessary but not sufficient step in the process of dissemination. A number of other factors can be equally critical: o strategies are unlikely to be adopted without being adapted to local circumstances, o o o gaining commitment by involving people in the process of adaptation, anticipating similar difficulties to those involved in large-scale extension, gaining first-hand knowledge through study tours and visits.
Resource institutions may play an important role in analytiC documentation of management development.
4.5
INSTITUTIONALISATION AND SUSTAINABILITY
1
Donor support for management development means that countries have resources to devote to management strengthening that otherwise would not be available, but poses certain dangers to institutionalisation. These include: the possibility that the intervention will respond more to donor than national interests, and the risk that vertical programmes will be reinforced. Solutions to be considered are: national plans into which donor funds may be inserted (as opposed to the reverse); strengthening of national capacity to manage donor funds, in particular to use funds strategically to accelerate the pace of change; and allocating control of funds directly to national governments.
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2
Institutions embody values that a society considers worthy of continuing, thus, the underlying dynamic of institutionalisation deals with fitting the intended changes with existing values, or creating new values around the changes. To institutionalise management development, therefore, some powerful actors must value it and provide the resources necessary to continue activities.
3
The overall concern is for sustainable health systems based on Primary Health Care. Thus, it is important to sustain the outcomes and effects of management development, as opposed to the intervention itself.
4
Enabling conditions for effective institutionalisation include: o o o o o recognition of a gap in performance, commitment to change, openness to learning, availability of resources, and involvement of actors at multiple levels.
In many situations it can be difficult to find or create a" the enabling conditions, which reduces the possibility for institutionalisation. 5 A concern for institutionalising the outcomes of management development for PHC leads to revisiting the original premises underlying PHC itself, namely: decentralisation, community involvement, increased productivity (qualitative and quantitative efficiency), and equity. The implementation of PHC requires wide-ranging reforms of the health system. If PHC has not moved beyond the level of understanding to action, it is difficult to envision how PHC management improvement can be sustained and institutionalised. 6 Sustainable management development programmes must pay much more attention to linkages with other sectors. As Ministries of Health are part of the national public administration and are subject to civil service rules and regulations, proposals for change in structures, systems, or procedures must consider the larger administrative environment. 7 Designing and implementing management development programmes with an eye toward institutionalisation implies having an overall strategiC framework, within which individual interventions fit. 8 The pressure for short-term results often leads to the creation of separate programme units; this conflicts with longer-term strategies for capacity building and institutionalisation of improved performance.
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5
RECOMMENDATIONS
ACTION BY WHO IN COLLABORATION WITH COUNTRIES
1
More knowledge of what constitutes effective health management is needed. WHO should collaborate with countries in analysing. documenting and disseminating information about experiences in management development for PHC. The concept paper prepared for this consultation should be further developed and adopted to provide a basis for such analyses.
2
WHO should support efforts to create interest and demand for management development by health policymakers and other powerful actors, through providing documentation, holding workshops and meetings, and sponsoring study tours. New ways of disseminating information should also be explored.
3
WHO should collaborate with Ministries of
H~alth
in carrying out contextual assessments to
support the development of appropriate management development strategies. 4 WHO should collaborate with Ministries of Health in developing appropriate indicators and monitoring systems for assessing improved management performance in relation to Primary Health Care. 5 Investigation into the important issue of institutionalisation of management development processes and outcomes should be undertaken by countries with WHO support. 6 WHO should work with countries in building up their capacity for effective management through providing learning materials and guidelines. 7 The role of local and international resource institutions (for training, research, consultancy) in support of management development for PHC should be reviewed, and linkages with and between these institutions strengthened. 8 The resource implications of different types of management development approaches should be investigated with WHO support.
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ACTION BY COUNTRIES
9
Strategic plans are needed to coordinate both diverse management development efforts and external inputs in support of them. Ministries of Health should collaborate with local government and with other sectors in planning and implementing management development for PHC.
10
11
Training for management needs to be appropriately oriented and closely linked with other management development activities.
ACTION BY WHO
12
WHO should review and strengthen coordination of its own supPOrt for management development for PHC, with particular emphasis on integration at the district level.
13
WHO should review and catalogue existing materials (learning materials, country case studies, guidelines) concerned with health management development at all levels of the system. The resulting inventory should include not only WHO materials but also those of other agencies and from countries. WHO should also assist in the adaptation of different materials to specific country contexts.
14
WHO should continue to scrutinize the changing context and concerns of ministries of health to ensure that issues of efficiency, quality, cost control and staff performance are linked with the original tenets and principles of Primary Health Care.
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ANNEX A: LIST OF PAPERS PRESENTED 1
Cassels A, Janovsky K Management Development for Primary Health Care: A Framework for Analysis 2 Currey M Management Development in Bangladesh: The Management Development Unit Enyimayew K A An Overview of a Strategy for Health Management Development in Ghana Thomason J Management Development in Papua New Guinea.
3
4
These papers are available upon request from WHO, Division of Strengthening Health Services, Geneva, Switzerland.
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ANNEX B: PROGRAMME Monday, 28 May 1990 morning
09.30 - 10.00 10.00 - 10.15 10.15 - 10.30 10.30 - 10.45 10.45 - 12.00 12.00 - 14.00 afternoon
Registration Opening by Dr Jean-Paul Jardel, Assistant Director General Introduction and Overview of Consultation Coffee Break Presentation: Issues in Management Development for Primary Health Care Lunch Break
14.00 14.45 15.30
- 14.45 - 15.30 - 15.45
Country Presentation: Papua New Guinea Country Presentation: Bangladesh Tea Break Country Presentation: Ghana
15.45 - 16.30 evening
17.15 Tuesday, 29 May 1990 morning
Welcome Drinks & Buffet in the WHO Restaurant
09.30 - 09.45 09.45 - 12.00 10.30 - 10.45
Plenary Presentation of Issues to be discussed in Groups 1 Work in Groups Issue 1: Approaches to Health Management Development Coffee Break Plenary Presentation of Conclusions by Groups Lunch Break
11.30 -12.00 12.00 - 14.00 afternoon
14.00 - 16.00 15.30 - 15.45 16.15 - 17.00
Work in Groups Issue 2: Outcomes and Evaluation of Management Development for PHC Tea Break Plenary Presentation of Conclusions by Groups
For each issue to be discussed a short briefing note will be provided to the partiCipants.
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Wednesday, 30 May 1990
morning 09.30 - 09.45 . 09.45 - 12.00'
Plenary Presentation of Issues to be disaJssed in Groups Work in Groups Issue 3: Expansion and Extension of PHC Management Development Programmes Coffee Break Lunch Break
10.30 - 10.45' 12.00 - 14.00 afternoon 13.30 - 14.15'
14.15 - 15.30
Plenary Presentation of Conclusions by Groups Work in Groups Issue 4: Institutionalisation and Sustainability of Management Development for PHC Tea Break Plenary Presentation of Conclusions by Groups
15.30 - 16.00 16.00 - 17.00
Thursday, 31 May 1990
morning 09.30 - 10.30 10.30 - 10.45. 10.45 - 13.00 afternoon
Secretariat preparing Draft Notes of Rndings and Conclusions Coffee Break Discussion of Recommendations based on Rndings and Conclusions.
Informal discussions. Secretariat preparing draft report.
Friday, 1 June 1990
morning 09.30 - 12.00 10.30 - 10.45 12.00 - 12.15
Plenary Presentation and Discussion of Draft Report Coffee Break Closing of the Consultation
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ANNEX C: LIST OF PARTICIPANTS COUNTRY PARTICIPANTS
Bangladesh Dr Mehtabunisa Curreyl Coordinator, Management Development Unit Third Population and Family Health Project Ministry of Health & Family Planning Dhaka Ethiopia Dr Gebreselassie Okubagzhi Associate Professor in Community Health Ras Imru Training Centre Addis Ababa Ghana Dr K. A. Enyimayew2 Regional Director of Health Services Ministry of Health Ho Indonesia Dr Soeharto Wirjowidagdo Director Provincial Health Office Jakarta Kenya Dr James Maneno3 Project Officer, Primary Health Care UNICEF Nairobi
Lao PDR Dr Philaysack Naphyavong Deputy Director of Cabinet and Head, Health Planning & Coordination Ministry of Public Health Vientiane
Group Rapporteur 2 3
Group Rapporteur Chairperson
29
Papua New Guinea Dr L. Sialis First Assistant Secretary Primary Health Care Department of Health Boroko
Zimbabwe Dr Walter Muchenje Director, Health Services Management Ministry of Health Harare
WHO REGIONAL OFFICES Dr Miguel Segovia, Regional Advisor, Management of Health Services, AMRO, Washington, DC, USA Dr Mario Pinho da Silva, Regional Advisor, Health Services Development, WPRO, Manila, Philippines
SECRETARIAT
Consultants Dr Derrick Brinkerhoff International Development Management Centre University of Maryland College Park, MD USA Dr Andrew Cassels Liverpool School of Tropical Medicine Department of International Community Health Liverpool UK Professor Arie Rotem Head, School of Medical Education KenSington, New South Wales Australia
30
WHO Staff Mr Andrew Creese SHS, Geneva Dr John Martin SHS, Geneva Dr WilHam Newbrander Management OffICer, Thailand Dr Katja Jaoovsky4 SHS, Geneva Dr Jean-Paul Menu HRH, Geneva Dr Steve Sapirie FHE, Geneva
4 5
Secretary Rapporteur
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