Shared by Prof Moosa 1

TRAINING MANUAL IN

LEADERSHIP
MANAGEMENT
& GOVERNANCE
FOR HEALTH SYSTEM STRENGTHENING IN AFRICA

VOLUME 1
TRA IN ING MANUAL O N LEADERSHIP, MANAGEMENT AND GOVERNANCE FOR HEALTH SYSTEM STRENGTHEN ING I N AFRICA

Amref Health Africa Copyright

Any part of this material including the illustrations, may be copied, reproduced to meet the needs of local
health contexts including, for teaching or training purposes provided that these materials or excerpts are
distributed free of charge. Appropriate referencing and citation would be highly appreciated whenever you
make use of the materials or any of the illustrations (Figures, tables, photographs or quotes) from this Manual.
Amref Health Africa is a learning organisation and would be grateful to get your constructive comments and
suggestions on how to further improve the materials presented in this manual. Please address any
correspondence to:

The Publications Editor

Institute of Capacity Development
Amref Health Africa Headquarters
P.O Box 27691-00506, Nairobi, Kenya
Email: phssa@[Link]
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TABLE OF CONTENTS

ACKNOWLEDGEMENTS

MODULE 1: OVERVIEW AND CONTEXT OF A HEALTH SYSTEM 1

Unit 1: Sustainable Development Goals 2
Unit 2: Context of Health System 7
Unit 3: Components of the Health System 15
Unit 4: Holistic Thinking in Health System Strengthening 18
Unit 5: Characteristics of functioning health systems 24
Unit 6: Challenges Facing Health Systems in Africa 28
Unit 7: Best Practices of Healthcare System in Africa 31

MODULE 2: GOVERNANCE AND ETHICS IN HEALTH 35

Unit 1: Overview of Governance and Ethics 36
Unit 2: Professional Ethics, Morals, Rules and Standards in Health care Service Delivery 47
Unit 3: Principles, Characteristics and Practice of Good Governance 60
Unit 4: Governance Structures and Functions in Health 72
Unit 5: Health Laws, Agreements and Regulations in Governance 77

100
101
114
136
149

MODULE 4: MANAGEMENT IN HEALTH 170

Unit 1: Concepts and principles 171
Unit 2: Functions and Roles of a Manager 177
Unit 3: Operations Management 184
Unit 4: Strategic Planning 190
Unit 5: Management of Effective Teams 208
Unit 6: Risk Management In Health 217

MODULE 5: HUMAN RESOURCES FOR HEALTH 224

Unit 1: Context and Evolution of Human Resources For Health 225
Unit 2: Human Resources Statutes, Policies 237
Unit 3: Planning for Human Resources for Health 244
Unit 4: Functions in Health Resources for Health Management 252
Unit 5: Human Resources for Health Training and Development 271
Unit 6: Risk Management In Health 285
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REFER TO VOLUME II

MODULE 6: HEALTH MANAGEMENT INFORMATION SYSTEM 1

Unit 1: Overview of HIS & HMIS 6
Unit 2: Functions and Roles of HMIS in HSS 10
Unit 3: Elements and Components of the HMIS 14
Unit 4: Design & Implementation of HMIS 22
Unit 5: Role of ICT in HMIS 26

MODULE 7: HEALTH FINANCING AND FINANCIAL MANAGEMENT 33

Unit 1: Concept of Health Financing and Financial Management 37
Unit 2: Health Financing Policy Framework & Mechanisms 39
Unit 3: Financial Management 53
Unit 4: Expenditure Tracking and Reporting 59

MODULE 8: SERVICE DELIVERY 62

Unit 1: Principles and Concept of Health Service Delivery 65
Unit 2: Essential Elements to Improve Service Delivery 69
Unit 3: Referral Health System 79
Unit 4: Quality Accreditation 88

MODULE 9: PROCUREMENT AND SUPPLY CHAIN MANAGEMENT 98

Unit 1: Procurement Laws, Regulations and Policies 101
Unit 2: Procurement and Disposal Process 108
Unit 3: Supply Chain Management 125
Unit 4: Inventory Management 134
Unit 5: Supply Chain Management Relationship 143

MODULE 10: MONITORING AND EVALUATION FOR HEALTH SYSTEM 158

Unit 1: Overview and Context of Monitoring and Evaluation for Health System 159
Unit 2: Linking M&E Frameworks to Strategic and Operational Plans 167
Unit 3: Measuring Project and Programme Outcome and Impact 175
Unit 4: Translating Available M&E Knowledge to Influence Policy and Practice 181
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ABBREVIATIONS AND ACRONYMS

3D 3-Dimensional
ABC Always better control
AIDS Acquired Immuno Deficiency Syndrome
ANC Antenatal Clinic
ART Antiretroviral Therapy
BMI Body Mass Index
CCF Country Coordination and Facilitation (process)
C/VHT Community/ Village Health Teams
CODAP Comprehensive Occupational Data Analysis Program
CPD Continuing Professional Development
CREAM Clear, Relevant, Economic, Adequate and Monitorable.
CRM Customer Relationship Management
CSOs Civil Society Organisations
DDDM Data Driven Decision Making
DHT District Health Teams
DIKW Data Information Knowledge Wisdom
ECSA-HC East, Central and Southern Africa Health Community
EOQ Economic Order Quantity
ERP Enterprise Resource Planning
EWG Experts Working Group
FCTC Framework Convention for Tobacco Control
FEFO First Expired First Out
FIFO First In First Out
GDP Gross Domestic Product
GHWA Global Health Workforce Alliance
GNI Gross National Income
GPI Gender Parity Index
GRN Goods Received Note
HCW Health Community Workers
HFC Health Facility Committee
HIS Health Information System
HIV/AIDS Human Immunideficiency Virus/ Acquired Immune Deficiency Virus
HMIS Health Management Information System
HMN Health Metric Network
HR Human Resources
HR(T)D Human Resources (Training and) Development
HRH Human Resources for Health
HRHIS Human Resources for Health Information System
HRIS Human Resources Information System
HSS Health System Strengthening
ICD (Amref Health Africa’s) Institute of Capacity Development
ICT Information and Communication Technologies
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IDRC International Development Research Centre

ILO International Labour Organisation
IMF International Monetary Fund
ISCM Internal supply chain management
JICA Japan International Cooperation Agency
LMG Leadership, Management and Governance
LMG-HSS Leadership, Management and Governance for Health Systems Strengthening
LPOs/LSOs Local Purchase and Service Orders
MBO Management By Objectives
M&E Monitoring and Evaluation
MDGs Millenium Development Goals
MDI Management Development Institute
MOH Ministry of Health
MTEF Mid-Term Expenditure Framework
NGOs Non-Governmental Organisations
NHA National Health Accounts
NHS National Health System
NPD New Product Development
OECD Organisation for Economic Co-operation and Development
OOPS Out-of-Pocket Payments
PBF Performance Based Financing
PC Personal Computer
PDU Procurement and Disposal Units
PESTEL Political, Economic, Social-cultural, Technological, Environmental as well as Legislative
PHC Primary Health Care
PISA Programme for International Student Index
PMTCT Prevention of Mother to Child Transmission
PPP Public Private Partnership
RB Results-Based Financing
RFID Radio Frequency Identification
RFP Request For Proposals
RFQ Request for quotations
RHS Referral Health System
SADC Southern Africa Development Community
SCM Supply Chain Management
SDGs Sustainable Development Goals
SDSN Sustainable Development Solutions Network
STDs Sexually Transmitted Diseases
SWOT Strengths, Weaknesses, Opportunities, Threats
TNA Training Needs Assessment
TRIPS Trade-Related Aspects of Intellectual Property Rights
TWG Technical Working Group
UCLA University of California at Los Angeles
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UHC Universal Health Coverage

UN United Nations
UNDP United Nations Development Program
VCT Voluntary Counselling and Treatment
WAHO West African Health Organisation
WHO World Health Organization
WHR World Health Report
WIP Work in Progress
WISN Workload Indicators of staffing need
WTO World Trade Organisation
 MODULE 1
OVERVIEW AND CONTEXT OF A
HEALTH SYSTEM
LIST OF TABLES
Table 1.1: SDG Indicators for Country Assessment 4
Table 1.2: Stakeholder Groups At National and Local Levels 5
Table 4.1: Skills of systems thinking 22

LIST OF FIGURES
Figure 1.1: Decentralised organisation works and the actors involved in each step 10
Figure 1.2: Devolved health systems and its linkages to other structures 10
Figure 1.3: Components of health 12
Figure 2.1: Components of a Health System 16
Figure 4.1: The dynamic architecture and Interconnectedness of the health systems building blocks 21
Figure 4.2: Characteristics of a responsive health system 25
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MODULE 1: OVERVIEW AND CONTEXT OF A HEALTH SYSTEM

1.1 Module Introduction

Welcome to the first module on overview of health systems. This module will provide a broad overview of the health
systems in various African settings with emphasis on best practices. You will gain insight into the context of health
systems, components of a health system, holistic thinking approach and challenges faced by health systems.

1.2 Module Outcomes

By the end of this module you should be able to:
• Review the importance of sustainable goals in strengthening health systems
• Discuss the key concepts in health systems
• Apply the components of the health system to various country context
• Demonstrate understanding of a Holistic thinking approach in a health system
• Identify the Characteristics of a strong health system
• Analyse the various challenges that affect health systems in Africa
• Analyse best health systems practices in different African settings
• Apply eLearning methodology in the training of health system actors
• Apply Principles of Andragogy in the training of health systems actors

1.3 Module Content

This module is divided into the following nine (9) units:
Unit 1: Sustainable Development Goals
Unit 2: Context of a health system
Unit 3: Components of the health system
Unit 4: Holistic thinking in health system strengthening
Unit 5: Characteristics functioning health systems
Unit 6: Challenges faced by health system in Africa
Unit 7: Best practices from different settings
Unit 8: Introduction to concept of eLearning
Unit 9: Principles of andragogy
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UNIT 1: SUSTAINABLE DEVELOPMENT GOALS

1.1 Unit Introduction

Welcome to the Unit 1: The Sustainable Development Goals (SDGs). In this module, the possibility of sustainable
development is clarified a nd i nvestigated. S ome p owerful m eanings o f reasonable a dvancement v iewed a s the
fundamental standards of sustainable development are clarified. Additionally, a record of the rise and advancement
of the idea of sustainable development is given with a specific end goal to elucidate the chronicled setting of current
civil arguments. “Standard” thoughts of practical advancement are sketched out together with a portion of the key
systems that have been put forward to advance the reasonable improvement of the health system outcomes. By
and large, this module gives an outline of probably an essential discussion and debate on the link between SDGs
and health systems strengthening in the context of varied socio-economic developments.

Most importantly, the unit on Sustainable Development Goals introduces you to the concept of health
systems strengthening, so that you can identify and implement changes in policy and practice that help to
address the relevant SDGs that ultimately improve healthcare delivery at various levels.

1.2 Unit Outcomes

By the end of this unit you will be able to:

1. Apply relevant SDGs in health systems strengthening
2. Use appropriate indicators to measure progress in achieving SDGs in the context of
health system strengthening

1.3 The Sustainable Development Goals (SDGs)

The 17 Sustainable Development Goals form a cohesive and integrated package of global aspirations the world
commits to achieving by 2030. Building on the accomplishments of their predecessors the MDGs, the SDGs address
the most pressing global challenges of our time, calling upon collab­orative partnerships across and between
countries to balance the three dimensions of sustainable development - economic growth, environmental
sustainability, and social inclusion. (“Introduction to Sustainable Development Goals (SDG) Rationale ,” 2016).

1.3.1 Goals of SDG’s

• Goal 1: End poverty in all its forms everywhere.
• Goal 2: End hunger, achieve food secu­rity and improved nutrition and promote sustainable agriculture.
• Goal 3: Ensure healthy lives and promote well-being for all at all ages.
• Goal 4: Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all.
• Goal 5: Achieve gender equality and empower all women and girls.
• Goal 6: Ensure availability and sustain­able management of water and sanitation for all
• Goal 7: Ensure access to affordable, reliable, sustainable and modern energy for all
• Goal 8: Promote sustained, inclusive and sustainable economic growth, full and productive employment
and decent work for all
• Goal 9: Build resilient infrastructure, promote inclusive and sustainable indus­trialization and foster innovation
• Goal 10: Reduce inequality within and among countries
• Goal 11: Make cities and human settlements inclusive, safe, resilient and sustainable
• Goal 12: Ensure sustainable consump­tion and production patterns
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• Goal 13: Take urgent action to combat climate change and its impacts
• Goal 14: Conserve and sustainably use the oceans, seas and marine resources for sustainable development
• Goal 15: Protect, restore and promote sustainable use of terrestrial ecosystems, sustainably manage forests,
combat desertification, and halt and reverse land degradation and halt biodiversity loss
• Goal 16: Promote peaceful and inclusive societies for sustainable development, provide access to justice for
all and build effective, accountable and inclusive institutions at all levels
• Goal 17: Strengthen the means of implementation and revitalise the global partnership for sustainable
development. (Gostin & Friedman, 2015

The SDG agenda sets out the following five key opportunities relevant to health systems development and
management:
i. Inclusive Development
Participatory processes will allow stakeholders to give voice to the needs and interests of the people they
represent, enabling better-planned and better-informed initiatives.
ii. Universal Development
The SDGs are universal goals that apply to all countries and involve the entire world, developed and
developing countries alike, taking into account different national realities. Countries are asked to build on
current policy instruments and frameworks to meet the goals and targets, taking into account differences in
national contexts and development levels.
iii. Integrated Development
The SDG Agenda moves away from vertical approaches to development and promotes the integration of the
economy, environment, and society. The SDGs are integrated and indivisible and balance the three dimensions
of sustainable development. The success of one leads to the success of all.
iv. Locally-Focused Development
Local authorities and communities are responsible for the realisation of the goals at local scales, recognising
in particular interdependent relationships between urban, peri-urban, and rural areas.
v. Technology-driven Development
Rapid technological change, particularly in ICT and data, but also in material science, manufacturing (e.g.
3D printing), genomics, and other areas, is deepening the integration of the world economy and enabling
breakthroughs in productivity across the economy. There is a significant potential to speed the pace of global
development and economic convergence than before. E-government can offer new approaches to manage
the complex and dynamic relationships between institutions and stakeholders with diverse objectives and
competencies, assess and integrate initiatives at different governance levels, and support synergies to meet
different goals.

1.3.2 Principles for Indicator Selection

Effective SDGs and their targets serve as a management tool to help countries develop implementation strategies
and allocate resources accordingly. The targets also aid in focusing resources, measuring progress towards
sustainable development and ensure the accountability of all stakeholders for achieving the SDGs. Appropriate
indicators, which are the backbone of monitoring progress towards the SDGs at local, national, regional, and global
levels are therefore necessary. The monitoring framework and indicators for the SDGs should reflect the lessons
learned from the MDGs (Leadership Council of the Sustainable Development Solutions Network, 2015).
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1.3.3 Principles for Selecting Global Monitoring Indicators (Gostin & Friedman, 2015)
The following are the principles for selecting global monitoring indicators.
• Limited in number and globally harmonised
• Simple, single-variable indicators, with straightforward policy implications
• Allow for high-frequency monitoring
• Consensus-based, in line with international standards and system-based information
• Constructed from well-established data sources
• Disaggregated
• Universal
• Mainly outcome-focused
• Science-based and forward-looking
• A proxy for broader issues or conditions

1.3.4 Principles for Selecting Quick Stock-Taking Indicators

• Limited in number (2-3 per goal) but capturing core elements of each goal
• Applicable to broad range of country settings
• Recent high-quality data available for as many countries as possible
• Consensus-based, in line with international standards and system-based information
• Constructed from well-established and accessible data sources

Table 1.1 shows the indicators used for a quick assessment of a country or region’s starting position with
regards to sustainable development

Table 1.1: SDG Indicators for Country Assessment

Goal 1 Poverty headcount ratio at $1.90 a day (2011 PPP) (% of population)

Poverty headcount ratio at national poverty lines (% of population)

Goal 2 Prevalence of undernourishment (% of population)

Prevalence of obesity, BMI ≥ 30 (% of adult population)
Cereal yield per hectare

Goal 3 Mortality rate, under-5 (per 1,000 live births)

Life expectancy at birth, total (years)

Goal 4 Lower secondary completion rate (% of relevant age group)

PISA score

Goal 5 Proportion of seats held by women in national parliaments (%)

School enrolment, secondary (gross), gender parity index (GPI)

Goal 6 Improved water source (% of population with access)

Water Stress Score

Goal 7 Access to electricity (% of population)

Alternative and nuclear energy (% of total energy use)

Goal 8 Share of youth not in education, employment or training, total (% of youth population)
Average annual per capita GDP over the past five years

Goal 9 Mobile broadband subscriptions per 100 inhabitants

Research and development expenditure (% of GDP)
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Goal 10 Palma ratio

Gini index

Goal 11 Percentage of urban population living in slums or informal settlements

Mean annual concentration of PM2.5 in urban areas

Goal 12 Municipal solid waste generation (kg per capita)

Goal 13 CO2 emissions per capita

Losses from natural disasters (% GNI)

Goal 14 Share of marine areas that are protected

Fraction of fish stocks overexploited and collapsed (by exclusive economic zone)

Goal 15 Red List Index

Annual change in forest area

Goal 16 Homicides per 100,000 population

Corruption Perception Index

Goal 17 For high-income and upper-middle-income countries: International concessional public finance,
including official development assistance (% GNI)
For low- and lower-middle-income countries: Government revenues (% GNI)
Subjective Wellbeing (average ladder score)

1.3.5 Stakeholder Groups at National and Local Levels

Although stakeholders vary from country to country, Table 1.2 gives a general list of the main actors at the national
level. The list includes specific stakeholder groups that play an important role in urban and regional development.

Table 1.2: Stakeholder Groups At National And Local Levels (Gostin & Friedman, 2015)

Stakeholder Groups

Category Examples

National governments Professional staff within ministries; representatives from governments and
municipalities

Civil society Non-governmental organizations, volunteer organizations, indigenous peoples’

organizations organisations, faith-based organisations, social movements, and community-
based organisations

Businesses Business leaders, chambers of commerce and industry, cooperatives and unions,
economic development corporations, and manufacturers

Academic institutions National SDSNs, universities, technical institutions, research centres, National
Academies, and schools of urban planning, social sciences, and public policy

Development partners Bilateral and multilateral donors, UN agencies, regional development and central
banks, and international institutions such as the World Bank and IMF

Sub-national State/provincial governments or other forms of regional government are often

governments responsible for urban and local development

Local authorities Local councils and elected representatives, public utility and service providers,
planning bodies, parastatal agencies
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Activity 1
Describe how your country is contributing to the achievement of SDG’s, the
challenges it faces and how you can contribute to overcoming the challenges.

1.4 Unit Summary

In this unit, we have discussed SDGs and opportunities that are central to health
systems strengthening, i.e. inclusivity, universality,
Integration, Contextualisation and technology dexterity. We covered principles of
selecting for selecting global indicators that aid in measuring progress towards
achievement of relevant SDGs. Last but not least, you have acquainted yourself
with a list of possible development partners at your disposal, and you endeavour
to address Selected SDGs.

1.5 Unit References and Further Readings

1. Gostin, L. O., & Friedman, E. A. (2015). Scholarship @ GEORGETOWN LAW The

Sustainable Development Goals: One-Health in the World’ s Development Agenda.
Part of the International Public Health Commons JAMA, 314(2621). Retrieved from
[Link]
abstract=2706788%5Cn[Link]
2. Introduction to Sustainable Development Goals ( SDG ) Rationale: (2016).

Congratulations! You are now through with Unit 1 of Module 1. Now you are aware of the SDGs,
the opportunities for building a functioning health system and examples of potential partners. It is
time to tackle the Context of Health System in Unit 2. Enjoy your reading as you endeavour to discover
reality about the African Health Systems in general.
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UNIT 2: CONTEXT OF HEALTH SYSTEM

2.1 Unit Introduction

Welcome to the first unit on overview and context of a health system. In this Unit, you will be introduced to the
concepts of system, health system, health care system and health systems strengthening. You will also have an
opportunity to explore different contexts of health systems including the best practices in African countries and
other parts of the world. First, acquaint self with what is expected of you in unit 2 by looking at section 2.2 before
you explore the various definitions of relevant concepts in 2.3.

2.2 Unit Outcomes

By the end of this unit, you will be able to discuss the concept of health systems

2.3 Definition of Key Terms

Let us now look at the various concepts and their meaning as defined by various stakeholders or expert groups. It
is getting interesting as you confidently take steps into gaining a better understanding the context of the health
system. The discussion is in the form of question and answer format which we have no doubt; you will find unit two
(2) exciting as well as stimulating. Read on now!

What is a system?
A system is an organised, purposeful structure that consists of interrelated and interdependent elements
(components or parts, entities, factors, people, among others). These elements continually influence one another
(directly or indirectly) to maintain their activity and the existence of the system, to achieve the goal of the system.
[Link]

What is a health system?

Health system consists of all the activities whose primary purpose is to promote, restore and maintain health. It is
also defined as the people, institutions and resources, arranged together by established policies, to improve the
health of the population they serve, while responding to people’s legitimate expectations and protecting them
against the cost of ill-health through a variety of activities whose primary intent is to improve health. (WHO, 2017).
[Link]

What is 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 regarding the levels of healthcare and organisational
structure of the Ministry responsible for health in most countries.

A health care system is also defined as complex of facilities, organisations, and trained personnel engaged in
providing health care within a geographical area (Business Dictionary, 2016).
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A good health system delivers quality services to all people, when and where they need them. The exact configuration
of services varies from country to country, but in all cases requires a robust financing mechanism; a well-trained and
adequately paid workforce; reliable information on which to base decisions and policies; well-maintained facilities
and logistics to deliver quality medicines and technologies (WHO, 2017).

What is health 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

What is 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 in health services and health outcomes (WHO, 2007).

2.4 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

2.5 Context of the Health System in Africa

A health system can be organised based on the following categories:
• Organisational arrangements
• Economic Context
• Socio-cultural and political context
• Legislative context
• Main actors in the health system

2.5.1 Organisational arrangements

A health system can be organized into the following structure:
• Centralised health systems:
• Decentralised health systems: where the authority of and responsibility for public functions from the
central government to subordinate or quasi-independent government organisations and the private
sector is transferred —is a complex, multifaceted concept.
• Organisational levels of health systems

2.5.2 Characteristics of and Centralised health system:

• Top-down approach
• Authority concentrated at the top
• Bureaucratic
• Minimal community involvement
• Vertical programming
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Give examples of centralised health systems.

2.5.3 Characteristics of a decentralised health system:

• Bottom-up approach
- Active participation of community actors
- Ownership
- Sustainability
• Horizontal, primary health care programming
There are three types of decentralisation (political, administrative and fiscal) but for this unit, only the
administrative decentralisation will be discussed. The various types of Administrative decentralisation include:

De-concentration: the weakest form of decentralisation and is used most frequently in unitary states--
redistributes decision making authority and financial and management responsibilities among different levels
of the central government. It can merely shift responsibilities from central government officials in the capital city
to those working in regions, provinces or districts, or it can create strong field administration or local
administrative capacity under the supervision of the central government.

Delegation: a more extensive form of decentralisation. Through delegation, central governments

transfer responsibility for decision-making and administration of public functions to semi-autonomous
organisations not wholly controlled by the central government, but ultimately accountable to it (ibid).

Devolution: When governments devolve functions, they transfer authority for decision-making, finance,
and management to quasi-autonomous units of local government with corporate status Devolution usually
transfers responsibilities for services to municipalities that elect their mayors and councils, raise their revenues,
and have independent authority to make investment decisions. In a devolved system, local governments
have clear and legally recognised geographical boundaries over which they exercise authority and within
which they perform public functions. It is this type of administrative decentralisation that underlies most political
decentralisation (ibid).

Privatisation – outsourcing and contractual:

Privatization can include:

1. Allowing private enterprises to perform functions that had previously been monopolised by government;
2. Contracting out the provision or management of public services or facilities to commercial enterprises indeed,
there is a wide range of possible ways in which function can be organized and many examples of within
public sector and public-private institutional forms, particularly in infrastructure;
3. Financing public sector programs through the capital market (with adequate regulation or measures to
prevent situations where the central government bears the risk for this borrowing) and allowing private
organisations to participate; and
4. Transferring responsibility for providing services from the public to the private sector through the divestiture
of state-owned enterprises.
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The following figure 1.1 shows how a decentralised organisation works and the actors involved in each step.

Figure 1.1: Devolved health system and its linkages to other structures
The following figure demonstrates how a devolved health system coordinates the activities with other structures and
authors in health system strengthening.

Figure 1.2: Devolved health systems and its linkages to other structures
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2.6 Functions of a Health System

A well-functioning health system responds in a balanced way to a population’s needs and expectations by:
• improving the health status of individuals, families and communities
• defending the population against what threatens its health
• protecting people against the financial consequences of ill-health
• providing equitable access to people-centred care
• Making it possible for people to participate in decisions affecting their health and health system. (WHO,
2010)

The four vital functions of health systems have been defined as:
• Service provision: encompassing both formal and informal service providers, whether public or private
and also service organisation both at the level of service delivery and higher up the chain of management;
• Resource generation: encompassing key inputs such as human resources, physical capital, and drugs and
medical supplies;
• Financing: the volume and sources of financial resources available for the health system, together with the
mechanisms for pooling resources and transferring them to service providers;
• Stewardship: the role of oversight of the health system which falls to the government, and encompasses
defining the vision and direction of health policy, exerting influence through regulation, and collecting
and using key data. (WHO, 2010)

2.7 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

Activity 2: How is the health system in your country is organised

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The following diagram shows how a health system is organised and what are the key components that have to be
in mind for a well-coordinated health system to achieve the SDG.

Figure 1.3: Components of health (Source: IDRC, 2003)

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

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 conflicts
• Weak political will to implement policies and commitments
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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

Activity 3: What is the relationship between the economic, political and socio-cultural health
systems

Health systems: legislative context Laws, declarations and commitments on Health:

• Global
• Regional
• National

Health systems: legislative context declarations and commitments on health:

• Global
 SDGs 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

Activity 4: Briefly describe the purpose and content of one declaration and
commitment.

Health Systems: Main Actors in the Arena:

Core partners have the following primary roles:
• funders,
• providers,
• purchasers,
• implementers,
• watchdogs
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Which of these core partners exist in your health system?

Examples of core partners include the following:

• Government
• Private /NGOs
- Not for profit (e.g. faith-based)
- Private for profit
• Civil society organisations
• Development partners
- International
- Bilateral
- Foundations
• Media

2.8 Unit Summary

In this unit, we learned about the overview and context of healthcare systems.
You were also introduced to key aspects related to the context of healthcare
systems in different contexts including African countries and the role of each of
the actors.

2.9 Unit References

1. Gostin, L. O., & Friedman, E. A. (2015). Scholarship @ GEORGETOWN LAW

The Sustainable Development Goals: One-Health in the World’ s
Development Agenda. Part of the International Public Health Commons
JAMA, 314(2621). Retrieved from [Link]
facpub/1607%5Cn[Link]
[Link]/facpub
2. Introduction to Sustainable Development Goals ( SDG ) Rationale : (2016).
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UNIT 3: COMPONENTS OF THE HEALTH SYSTEM

3.1. Unit Introduction

Welcome to the third unit of this module. In the last unit, you learnt about the concept of health system
strengthening. In this unit, you will be introduced to the components of health systems as applied to the context
of various country settings.

A well-functioning health system responds in a balanced way to a population’s health needs and expectations.
The main objective of such response is by improving the health status of individuals, families and communities
protecting the population against what threatens its health. Protecting people against the financial consequences
of ill-health, providing equitable access to people-centred care and making it possible for people to participate
in decisions affecting their health and health system are among the key interventions (WHO 2013). Figure 2.1
illustrates the components of a health system and how each component provides various positive outputs. For
example, universal coverage or access to the services provided leads to improved equity of service provision and
health status of the population. With the above introduction, go to section 3.2 and familiarise yourself with the
expectations of the unit from you as you proceed to look at the section 3.3 on components of a health system.

3.2 Unit Outcome

By the end of this unit, you will be able to integrate the components of a health
system

3.3 Components in Health Systems

What are the components of a health system?

There are six (6) components of the health system as shown in Figure 2.1. These are:

• Service delivery
• Health workforce
• Information
• Medical products, vaccines and technologies
• Financing
• Leadership and governance
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Figure 2.1 Components of a Health System (Source: WHO, 2013)

Let us look at each component in turn.

3.3.1 Service delivery:

Includes delivery of effective, save, 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.

3.3.2 Health workforce:

Refers to the human resource that responsive, fair and efficient to achieve the best health outcomes possible,
given available resources and circumstances. Need norms/standards that govern the production of sufficient staffs
and ensure fair distribution (must be competent, responsive and productive); Human Resources for Health (HRH)
observatories are essential for facilitating HRH management.

3.3.3 Health Financing:

Is concerned with how financial resources are generated, allocated and used in health systems (WHO, 2012). The
health financing systems include:
 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, i.e. social protection for the vulnerable populations;
 Use of information, sound financial management/dialogue.

3.3.4 Health Information

The 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.
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3.3.5 Medical Products and Technologies:

This ensures equitable access to essential medical products and technologies that provide scientifically sound,
quality, safe, efficacious efficient and cost-effective. The medical products include medicine and reagents but a few
to mention.

The technologies include health infrastructure (e.g. X-ray, lab, vaccines). There is a need for norms/standards and
policy options on products and technologies; Procurement processes, monitoring, innovation and patenting of
new products are essential.

3.3.6 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?

Identify health system components that are present in your country and describe how they
function

That brings us to the end of this unit on the context of health systems. Let us now review what you have learnt.

3.4 Unit Summary

In this unit, we have learnt about in the six (6) components of health systems, namely:
Service delivery, Health workforce, Information
Medical products, vaccines and technologies, Financing, Leadership and governance.

3.5 Unit References

1. Gostin, L. O., & Friedman, E. A. (2015). Scholarship @ GEORGETOWN LAW The Sustainable Development
Goals: One-Health in the World’ s Development Agenda. Part of the International Public Health Commons
JAMA, 314(2621). Retrieved from [Link]
com/abstract=2706788%5Cn[Link]
2. Introduction to Sustainable Development Goals ( SDGs ) Rationale : (2016).
3. World Health Organization. (2010). Key components of a well-functioning health system. Geneva: WHO
Health System, 2
4. GONZE, G. G. A INTEGRALIDADE NA FORMAÇÃO DOS PROFISSIONAIS DE SAÚDE: tecendo saberes e
prática. Juiz de Fora.2009;
5. TEIXEIRA, E. Reflexões sobre o paradigma holístico e holismo e saú[Link], v.30, n.2, p. 286-90,
ago. 1996;
6. Jafar S. Tabrizi, Farid Gharibi, Andrew J. Wilson. Advantages and Disadvantages of Health Care
Accreditation Models. Faculty of Health, Queensland University of Technology, Brisbane-Australia July
2011.
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UNIT 4: HOLISTIC THINKING IN HEALTH SYSTEM STRENGTHENING

4.1 Unit introduction

In the preceding unit, you learnt about the composition of a health system. We hope you were able to identify the
components that exist in your country’s health system. In this unit, you will learn how you can think holistically for
effective health system strengthening. In particular, we shall look at the rationale for systems thinking, its merits and
demerits, as well as elements and principles.

4.2 Unit Outcome

By the end of this unit, you will be able to apply health systems thinking in health systems
strengthening

4.3 Rationale for Systems Thinking

Before we start our discussion on the rationale for systems thinking, complete the following activity.

Video: “Health systems create healthy futures: Meet Maya” (10 minutes)
After watching the video, write down the most important messages the video is trying to
address

• The system requires interaction with multiple players to organise and deliver health services
• Coordination of the stakeholders is essential to ensure that different stakeholders deliver on their mandate
• Collective responsibility and commitment among all players is a precursor to ensuring availability and access
to appropriate health care services.
• A health system requires stakeholders beyond the health sector hence the need to forge a close working
relationship with other sectors.

‘Are you a part of a family?’ Everybody is a part of a family. ‘Have you ever seen in a family, people producing
consequences in the family, how people act, how people feel, that is not what anybody intends?’ If yes, ‘How does
that happen?’ Well… then people tell their stories and think about it. However, that then grounds people in not the
jargon of ‘system’ or ‘systems thinking’ but the reality – which we live in webs of interdependence

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. It is diverse constantly
changing, with components that are tightly connected and highly sensitive to change elsewhere in the system.
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What Is The Fundamental Rationale Of Systems Thinking?

The fundamental rationale of systems thinking as earlier discussed is to understand how to address the problems
that we all deal with holistically. In systems thinking you can single out which issues or problems are the most
vexing, difficult and intransigent, how they arise and to gi ve us some perspective on those problems Th rough
system thinking one can identify areas of leverage and gain insight as to what we might do differently.”

4.4 Advantages and Disadvantages of Holistic System

The advantages of holistic health systems thinking are:

• Effectiveness,
• Quality assurance and cost rationalization of health service.
• Offers all kinds of assistance that the citizen needs, including disease prevention and health promotion
actions.

According to Gonze (2009), the principle of integrality guides health practices in the sense of offering all kinds
of assistance. The integrity is discussed in three senses, as a value of good medicine, as a way of reorganizing
practices; And as special policies. (Mattos, as cited in Gonze, 2009).

The disadvantages are that it demands finances to bring about the necessary reforms in the health systems
adopted in different African countries.

4.5. Elements of Systems Thinking

With a clear understanding of the rationale for system thinking, it is essential that you know the following four (4)
elements of systems thinking:

• Systems Organising
• Systems Networks
• Systems Dynamics
• Systems knowledge
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Let’s look at each in turn.

Systems Organising Managing and leading a system; the types of rules that govern the
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 Networks Understanding and managing system stakeholders; the web of all
stakeholders and actors, individual and institutional, in the system,
through understanding, including, and managing the networks
Systems Dynamics Conceptually modelling and understanding dynamic change; attempting
to conceptualize, model and understand dynamic change through
analysing organizational structure and how that influences behaviour of
the system
Systems knowledge Managing content and infrastructure for explicit and tacit knowledge; the
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)

4.6 Principles of Systems Thinking

The elements discussed in section 4.6 work in conjunction with the following Senge’s 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

Senge’s suggested principles are necessary for navigating the complex and dynamic health system to ensure
synergy in the implementation of the various building blocks (Figure 4. 1). The rationale for health systems thinking
is to make each building block functional and therefore achieve the agreed health system goal of providing quality
health services. Now let us look at the six health system building blocks by the World Health Organisation.
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Figure 4.1: The dynamic architecture and Interconnectedness of the health systems building blocks

The six building blocks of a health system

Good health service delivery refers to those services which deliver effective, safe, quality personal and non-personal
health interventions to those that need them, when and where needed, with minimum waste of resources.

A well-performing health workforce is one that works in ways that are responsive, fair and efficient to achieve
the best health outcomes possible, given available resources and circumstances (i.e. there is sufficient staff, fairly
distributed; they are competent, responsive and productive).

A well-functioning health information system is one that ensures the production, analysis, dissemination and use of
reliable and timely information on health determinants, health system performance and health status.
A well-functioning health system ensures equitable access to essential medical products, vaccines and technologies
of assured quality, safety, efficacy and cost-effectiveness, and their scientifically sound and cost-effective use.

A good health financing system raises 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.

Leadership and governance involve ensuring strategic policy frameworks exist and are combined with effective
oversight, coalition-building, regulation, attention to system-design and accountability.

Source: WHO, 2009, Systems thinking for health system strengthening, P.32 Fig 1.2
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Activity: Systems-level interventions (15 minutes)

• Identify and describe one example of a systems level interventions from your
country
• Demonstrate cases how systems thinking can improve organisation and
delivery of quality health services

4.7 Skills of Systems Thinking

Now you are well informed about the rationale, the principles and the various health systems building blocks. It is
time for you to familiarise yourself with the skills for enhancing systems thinking, given the complex relationships
and characteristics of the health systems. Applying conventional approaches commonly used to design and evaluate
intervention will not take us far enough. The conventional approaches are usually described in linear input-output-
outcome impact result chain, which drives the log-frames characteristically underpinning the monitoring and
evaluation of frameworks and investments.
The health systems require a radical shift in the intervention design, monitoring and evaluation approaches.
Along with an accompanying shift in mindset among designers implementers stewards and funders.
The type of skills needed for system thinking and the required shift in the way of thinking are illustrated in the table
below.

Table 4.1: Skills of systems thinking. (Source: WHO, 2009, Systems thinking for Health system
strengthening)

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 as Placing responsibility for a behaviour on internal actors who
driven by external forces 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 how a
with some result behaviour is generated
Straight-line thinking Loop thinking
Viewing causality as running in one Viewing causality as an on-going process, not a one-time
direction, ignoring (either deliberately or event, with effect feeding back to influence the causes and
not) the interdependence and interaction the causes affecting each other
between and among the causes
Source: WHO, 2009 Systems Thinking for health system strengthening, page 43-Table 2.1
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4.8 Unit Summary

In this unit, we learn the current thoughts regarding the strengthening of health
systems taking into account the local reality. We took into account the reality
lived in the country of study for better understanding.

4.9 Unit References

1. WHO, Key components of a well-functioning health system. May 2010;

2. GONZE, G. G. A INTEGRALIDADE NA FORMAÇÃO DOS PROFISSIONAIS DE
SAÚDE: tecendo saberes e prática. Juiz de Fora.2009;
3. TEIXEIRA, E. Reflexões sobre o paradigma holístico e holismo e saú[Link].
[Link], v.30, n.2, p. 286-90, ago. 1996;
4. Jafar S. Tabrizi, Farid Gharibi, Andrew J. Wilson. Advantages and
Disadvantages of Health Care Accreditation Models. Faculty of Health,
Queensland University of Technology, Brisbane – Australia.
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UNIT 5: CHARACTERISTICS OF FUNCTIONING HEALTH SYSTEMS

5.1 Unit Introduction

This unit introduces you to the characteristics of a strong health system to enable you to understand that a strong
functional health system will deliver quality and efficient services to the intended recipients.

5.2 Unit Outcome

By the end of this unit you should be able to discuss the characteristics of functioning
health system

5.3 Characteristics of a Functioning Health Systems

From your understanding, what is a functioning health system?

Several authors have defined functioning health systems. In this unit, we will use the definitions of World Health
Organisation and Mills to give you a clearer understanding of a functioning health system.

The World Health Organisation (2010) defines a functioning health system as a system that provides all the
necessary services by responding to the needs and expectations of the population. A functioning health system
delivers quality services when and where they are needed. The configuration of these services varies from one
country to another.

According to Mills, A (2014:552) “A functional health care system is fundamental to the achievement of universal
coverage for health care”

Take Note:
A functional health care system provides quality services and is universally accessible to
the entire population but varies in its functionality within different countries

Activity
List in your notebook the characteristics that help to create a responsive health care
system?
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Ideally, responsive health systems need to consider various characteristics which include amongst others:

• Timeliness in the delivery of services – this includes the provision of care and support on time. It
eliminates long waiting hours at a facility; one should not have to spend too much time at a facility
before they are attended to and eventually receive treatment.
• Health workers providing the services need to portray a positive attitude be courteous and helpful –
the image we display should bring out positive outcomes. Do on to others what we would like to be done
to us
• Service should be reliable and consistent - fit to be there and dependable not changing providing the
same type of service
• Management of data utilising the appropriate information systems
• Using friendly systems approach when providing the service.

Figure 4.1 illustrates the integration of these characteristics. As you can see in the figure, there is overlapping of
one characteristic to another. Each characteristic is interdependent on the other making the health system more
responsive to the needs of the population. For example, if your staff portray a positive and friendly attitude when
attending to the users of the service, this will make your health system more user-friendly, less bureaucratic and
more able to respond to the needs of users promptly.

Figure 4.2: Characteristics of a responsive health system World Health Organization. (2010)
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The World Health Organisation and other health systems literature have outlined some basic key characteristics
that a health system needs to exhibit for it to be continually responsive to the needs and expectations of its
populations thereby creating a functional health system. These include:

1. Access to services - Within reach of people that need the service; geographically, financially and functionally.
No barriers in relation to cost, language and or culture
2. Quality of care and service delivery - services that are of high quality; centred on the client’s needs, given in
a timely fashion and comprehensive.
3. Safety – services that do not cause any due harm or stress. Prevention of errors and adverse effects that may
be associated with healthcare
4. Continuity and Sustainability of services: Services organised to provide an individual with continuity of care
across the lifespan
5. Coverage - all people in a defined target population are covered
6. Equity - Service provision in relation to needs of the population should be available and accessible to all in the
community. Just and fair distribution of resources according to need, with more going to the needy.
7. Efficiency and Accountability - well managed with maximum productivity ensuring a minimum wastage of
efforts and resources. Service providers allocated with the necessary authority to achieve planned objectives
and held accountable for overall performance of those results.
8. Effectiveness of healthcare delivery - successful in producing the desired result which is positive health
outcomes
9. Ethics, and rights-based approach in the delivery of services – ensures that services are morally right
bringing about good outcomes while minimising the occurrence of bad outcomes.

Activity:
List the characteristics would consider when setting up a functional health system in
your country

5.4 Unit Summary

Well done, you have completed this Unit. In this unit, you learnt about the
characteristics of a responsive health system and the functional characteristics that
may be taken into consideration when creating responsive health systems. In the
next unit, you will be looking at challenges that healthcare systems face in Africa
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5.5 Unit Reference Materials

1. World Health Organisation (2012) Health Systems in Africa – Community

Perceptions and Perspectives. [Available from: [Link]
bitstream/10665/79711/2/[Link] ]

2. World Health Organisation. (2010). Health service delivery. Monitoring the Building
Blocks of Health Systems: A Handbook of Indicators and Their Measurement
Strategies, 46, 560–7. [Link]

3. World Health Organization. (2010). Key components of a well functioning health

system. Geneva: WHO Health System, 2. Retrieved from [Link]
4. World Health Organisation (2007) “Everybody’s business: strengthening Health
Systems to Improve Health Outcomes, WHO Framework for Action”
5. [Available from: [Link]
healthsystems/strategy/everybodys_business.pdf ]
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UNIT 6: CHALLENGES FACING HEALTH SYSTEMS IN AFRICA

6.1 Unit Introduction

Welcome to Unit 6. In this unit, you will look at the key challenges faced by most health systems in Africa. We will
also consider the possible interventions that you may employ to mitigate these challenges.

6.2 Unit Outcome

By the end of this unit, you should be able to analyse challenges and emerging
health system issues in Africa

6.3 Key Challenges and Emerging Health Issues

According to Literature, challenges and emerging health issues may create a risk to a problem or reduce the risks
or incidences to a problem in the population. There is a need for strong mechanisms to be put in place to mitigate
the above problems,

What are the key challenges and emerging health issues in your country?

Now, take a minute to think about them and then complete the following activity
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Activity 1:
Identify five key challenges and five key emerging issues that your country’s
health system is currently facing under the following components of a
health system; Leadership and governance (stewardship); Health
workforce; Health information; Service delivery; Medical products; vaccines and
technologies; Health financing.

Activity 2:
Once you have identified the challenges and emerging issues; Prioritise
what you consider to be the most significant challenges and emerging
issues then suggest context-specific interventions to address and mitigate the
effects of these challenges and emerging issues in health systems in Africa

Activity 3:
Then read the following two articles and summarise your responses to
activities 1 and 2.

1. Mills, A. (2014). Health care systems in low- and middle-income

countries. N Engl J Med, 370(6), 552–557
2. Tumusiime, P., Gonani, A., Walker, O., Asbu, E. Z., Awases, M., &
Kariyo, P. C. (2012). Health systems in sub-Saharan Africa: what is
their status and role in meeting the health Millennium Development
Goals? The African Health Monitor, (14), 14–24.

After you have reflected on the key challenges and emerging health issues in your country; compare your answers
with the main challenges and emerging health issues outlined in the following discussion. Some of the challenges
will also be discussed in great detail through in other modules of this course.

Challenges
The main Challenges facing our health systems include:

• Lack of political will or capacity to provide the basic services and or implement policies and commitments
• Weak strategic health policy frameworks (focus on few programme areas, with others ignored /missed)
• Lack of cooperative action and partnership
• Weak technical guidance, program management, and supervision
• Unsustainable and fluctuating donor support, inequalities in access, use and financing of services at all
levels
• Inappropriate application of technology
• Inadequate human resource; shortage and poorly distributed due to inadequate infrastructural capacity
• Low staff pay and poor motivation
• Emigration of doctors and nurses to high-income countries
• Limited communication and transport infrastructure
• Inadequate drugs and other medical supplies
• Lack of equipment and infrastructure, including poor accessibility of health services
• Lack of knowledge on use of technology
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Emerging Issues
The main emerging issues in our health systems include:
• Global ageing; changing the demands of the health care system to accommodate the older population
• New emerging health problems, and health threats like infectious diseases
• Changing behaviour, leading to new risks for various diseases, e.g. non- communicable diseases
(hypertension and other cardiovascular diseases, diabetes, cancer)
• Globalisation, that is, the integration and interchange from ever-expanding knowledge, technologies,
approaches, products and ideas. For example the use of digital technologies to train health workers

6.4 Unit Summary

Well done for completing this Unit. You have analysed some of the major challenges
and emerging issues affecting your country healthcare systems. You have also identified
possible solutions that can be used to mitigate the effects of these challenges and
emerging issues.
In the next unit you will be looking at Best Practices of Healthcare Systems in Africa

6.5 Core Reference Material

1. Assamala. (2014). African Regional Health Report 2014. World Health Organisation,
187. [Link]

2. Mills, A. (2014). Health care systems in low- and middle-income countries. N Engl J
Med, 370(6), 552–557. [Link]

3. Task Force on Global Action for Health System Strengthening. (2009). Global
action for health system strengthening Policy recommendations to the G8, 1–131.
Retrieved from [Link]

4. Tumusiime, P., Gonani, A., Walker, O., Asbu, E. Z., Awases, M., & Kariyo, P. C. (2012).
Health systems in sub-Saharan Africa: what is their status and role in meeting the
health Millennium Development Goals? The African Health Monitor, (14), 14–24.
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UNIT 7: BEST PRACTICES OF HEALTHCARE SYSTEMS IN AFRICA

7.1 Unit Introduction

In this unit, you will be expected to assess the best practices of health systems in various countries and identify
the best practice in Africa. Please follow the link below and then read the following papers as examples of good
practices in Africa:

- [Link]
- Guide for Documenting and Sharing “Best Practices” in Health Programmes. (WHO, 2008)

7.2 Unit Outcomes

In this Unit, you will be presented with the best practices regarding health systems and how African
countries overcome challenges with success.

1. What are the best practices of health systems in your country?

2. Prioritise what you consider to be the most significant challenges and emerging
issues
3. Present context-specific interventions that were implemented to overcome the
challenges.

7.4 Unit Summary

In this unit, we have learned how to assess the best practices in health systems and
how to overcome challenges in African countries.

7.5 Unit References

[Link]
studies/en/
Guide for Documenting and Sharing “Best Practices” in Health Programmes.(WHO,

MODULE SUMMARY
You have come to the end of this module on overview and context of a health system. We hope you have found it
interesting and informative. In the next module, you will learn about governance in health systems strengthening.
But before you move on, find out how much remember by doing the following self-test.
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Module References and Recommended Readings

1. Africa Union, Africa Health Strategy: 2007–2015 (URL: [Link]

root/UA/Conferences/2007/avril/SA/9-3%20avr/doc/en/Health_Strategy_Min_Draft
.pdf ). Accessed 17 Dec 2011
2. The African Union, Abuja Declaration and Plan of Action April 2000 Heads of State
Summit
3. The African Union, Maputo Declaration on Reproductive Health 2003, Heads of State
Summit, Maputo Mozambique
4. JICA, “Global Action for Health System Strengthening: Policy Recommendations to the
G8.” G8 Hokkaido Toyako Summit Follow-up, 2009
5. Savigny Don de, Harun Kasale, Conrad Mbuya, and Graham Reid 2008. “In focus:
FIXING HEALTH SYSTEMS” (2nd edition) IDRC 2008
6. Senge Peter, 1990, The Fifth Discipline: The art and practice of the learning
organisation, Doubleday, New York, 1990. new edition 2006
7. UNDP, “Who’s Got the Power? Transforming Health Systems to Improve the Lives of
Women and Children.” Task Force on Child Health and Maternal Health. UN Millennium
Project, United Nations Development Programme. January 2005.
8. WHO, 37th Conference on Primary Health Care Bamako 1987
9. WHO, “Everybody’s business: Strengthening Health Systems to Improve Health
Outcomes, WHO Framework for Action”, World Health Organisation 2007.
10. WHO, Ouagadougou declaration on Primary Health Care and Health Systems in Africa:
Achieving Better health for Africa in the New Millennium, Brazzaville 2008, Regional
Office for Africa
11. WHO, “Framework for the Implementation of the Ouagadougou Declaration on
Primary Health Care and Health Systems in Africa: Achieving Better health for Africa in
the New Millennium”, Brazzaville 2008, WHO Regional Office for Africa
12. WHO, “Systems thinking for health systems strengthening” edited by Don de Savigny
and Taghreed Adam, published by the Alliance for Health Policy and Systems Research,
World Health Organisation 2009
13. WHO, “Abuja Declaration ten years on 2010”, World Health Report (WHR) 2011
14. Joseph Jaworski, Synchronicity: The Inner Path of Leadership, Berrett-Koehler
Publisher, New York, 1996
15. Peter Senge, Presence: Human Purpose and the Field of Future, Crown Business, New
York.
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LIST OF TABLES
Table 2.2.1: Framework to ethical decision making process 56
Table 2.3.2: Worldwide Governance Indicators 64

LIST OF FIGURES
Figure 2.1.2: WHO Six Pillars Framework for Action 40
Figure 2.1.3: Relationships between the role of Good Governance and Ethics in the public sector 43
Figure 2.1.4: Linking governance to organizational results 45
Figure 2.3.1: Overall framework on governance principles 62
Figure 2.3.2: Components of Good Governance 62
Figure 2.3.3: Relationship between corruption indices and health outcomes 66
Figure 2.3.4: Indicators of Corruption 67
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MODULE 2: GOVERNANCE AND ETHICS IN HEALTH

Module Introduction
Welcome to module two on Governance and Ethics in Health. In this module, you will learn about governance and
ethics in health, a topic which involves the oversight, implementation and accountability of policies, the role of
health laws, agreements, and set up of governance structures in the health care sector. The module also covers
ethical, moral and professional rules and standards in health care delivery.

Module Outcomes

By the end of this module you should be able to:

• Describe the concept of governance and ethics in health care
• Apply the principles of good governance and ethics in decision making and
practice
• Formulate functioning governance structures at different levels of the health
system
• Apply health laws and regulations in governance
• Apply moral and ethical standards in health care delivery;

Module Content
This module is divided into the following 5 units:
• Unit 1: Overview of governance and ethics
• Unit 2: Professional ethics, morals, rules and standards in health
• Unit 3: Principles, characteristics and practice of good governance
• Unit 4: Governance structures and functions in health
• Unit 5: Health laws, agreements, and regulations in governance
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UNIT 1: OVERVIEW OF GOVERNANCE AND ETHICS

1.1 Unit Introduction

In this unit you will learn about the concepts of governance and ethics, and corporate governance. You will learn
why and how governance is a core function in health and what are the functions of good governance.

1.2 Unit Outcome

By the end of this unit you should be able to describe the concept of governance and ethics in
health

1.3 What is Governance?

Before we continue with our definition of governance, complete the following activity.

Write down the definition of the term ‘governance in your notebook

Now compare your definition with the ones we discuss in the following section.

The complexity of governance is difficult to capture in a simple definition. It is neither homogenous nor a one-
dimensional concept. There are as many definitions of governance as there are contexts! However, the need for
governance exists anytime a group of people come together to accomplish an end.

Examples of the various definitions of governance include the following:

“It 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)
• Governance determines who has power, who makes decisions, how other players make their voice heard
and how account is rendered. (Institute on Governance)
• Oversee management and organizational performance to ensure that the organization is working in the
best interests of the public, and more specifically the stakeholders who are served by the organization’s
mission ([Link])
• This action or manner of governing a state, organization, etc.: (English Oxford living dictionaries)
• The activity of governing a country or controlling a company or an organization; the way in which a
country is governed or a company or institution is controlled (Oxford Advanced Learner’s Dictionary)
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Although there are several definitions of governance, three dimensions are visibly consistent. These are: authority,
decision-making and accountability (Institute on Governance, 2017). This is demonstrated in the following examples:

Authority and decision making: Where a group is too large to efficiently make all necessary decisions, it creates an
entity like a board of directors, a committee or a team with the authority and responsibility to facilitate the decision
making process.

Accountable: The decision makers will acknowledge that there are multiple stakeholders with interests that need
to be absorbed in the decision making process. Decision makers are then accountable to these stakeholders for the
organizations outputs and outcomes.

Ultimately therefore, the application of good governance serves to realize organizational and societal goals.

“Governance”, has over the years evolved to focus on checking institutions that accumulate and use power, rather
than on power deploying institutions i.e., democracy and transitional justice and human rights. Governance not
only encompasses but also transcends the collective meaning of related concepts like the state, government,
regime and good government.

The definition of governance refers to structures and processes that are designed to ensure accountability,
transparency, responsiveness, rule of law, stability, equity and inclusiveness, empowerment, and broad-based
participation.

“Good governance is epitomized by predictable, open and enlightened policy-making, a bureaucracy imbued with
a professional ethos acting in furtherance of the public good, the rule of law, transparent processes, and a strong
civil society participating in public affairs (World Bank 1994).

You will learn about the principles of governance in the second Unit. Let us look at the conceptual framework of
governance.
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Conceptual Framework of Governance

Figure 2.1.1 below, depicts the concept of Governance. There are 6 components of Governance.

Can you relate the concepts you identified in Unit 1 with the below conceptual framework?

Let us look at each component in detail.

Figure2.1.1: Conceptual Framework of Governance and Ethics (source: revised from (WHO, 2007)

1. Policy and regulation: Formulating and implementing sector strategies, policies, charters, treaties
and declarations and legislative frameworks which fit with broader national development policies and
resource frameworks, and are underpinned by commitments to human rights, equity and gender equality;
Regulation : Designing regulations and incentives and ensuring they are fairly enforced
2. Oversight structures of implementation and effects of policies and reforms; on the political environment
and opportunities for action; and on policy options. 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
3. Stakeholder management or participation : Citizens’ engagement and empowerment in decision making
processes; This calls for collaboration and coalition building across sectors in government and with outside
government, including civil society, community, international agencies and development partners, to
influence action on key determinants of health and generate support for public policies.
4. Accountability: monitoring and reporting on health system performance and attainment of outcomes and
ensuring all health system actors are held publicly accountable including tackling corruption. Transparency
is required to achieve real accountability. Transparency: Openness to public scrutiny, clarity and visibility in
decision making process
5. 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
6. Budgeting: the aspect of financial planning to ensure that financial allocations have been properly
delegated to ensure that the intended outcomes are achieved. Transparency and accountability in financial
budgeting is key process in governance to mitigate collusion, theft, fraud and corruption.
7. Service delivery: this concept refers to the delivery of the intended outcomes and involves service to the
stakeholders. Service delivery is linked to service charters which define what the recipient of the service
can expect from the organization. Clarity in these expectations is a governance aspect which mitigates
ambiguity and removes the opportunity for corruption vices; for example, a situation whereby a customer
is paying for a service which is free or paying a fee to receive a service which the organization is obligated
to offer.
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Other related concepts of governance include:

1. Stewardship: refers to managing properties, finances or other affairs for others. It requires careful and
responsible management for the wellbeing of the population
2. The stewardship, function reflects the fact that people entrust both their lives and their resources to the
health system. The government in particular is called upon to play the role of a steward, because it spends
revenues that people pay through taxes and social insurance, and because government makes many of
the regulations that govern the operation of health services in other private and voluntary transactions
(WHO 2000).
3. Strategy alignment: Ensuring a fit between strategy and structure and reducing duplication and
fragmentation
4. Integrity :Adherence to moral and ethical principles; soundness of moral character and honesty
5. 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)
6. 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

You must be itching to continue discussing ethics. Hold on for a while. We shall learn about Ethics later in this
module.

1.5 Governance in Health

What do we mean when we say 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)

Governance in health is about the role of the government in health and its relation to other actors whose activities
impact on health (WHO, 2007).It is the effective oversight of the health system to protect the public interest. It
refers to policy agenda setting processes, implementation and accountability within the health sector. It includes
the management and administration of policies and resources in health, including processes for health systems
strengthening.

Why do we talk about Governance in Health?

Present a scenario which will illustrate why governance in health matters.

Governance in health is increasingly seen as the foundation for good practice, successful organizations and ethical
behaviour.

International consensus reflects that without urgent improvements in the performance of health systems, the
world will fail to meet the health-related goals (WHO, 2007). Health systems that function well have certain shared
characteristics; the WHO framework identifies six pillars to strengthen health systems, of which one of them is
Leadership and Governance.
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Figure 2.1.2 below depicts the six pillars identified by WHO to strengthen health systems.

Figure 2.1.2: WHO Six Pillars Framework for Action

The leadership and governance of health systems, also called stewardship, is arguably the most complex but
critical building block of any health system; it is for this reason that governance in health is a topic of learning.

The function of good governance in the public sector such as health is to ensure that entities act in the
public interest at all times. Acting in the public interest requires strong commitment to integrity, ethical values,
and the rule of law, openness and comprehensive stakeholder engagement. Ethics is the fabric of governance. It is
all about making choices, and about providing reasons why we should make these choices.(Bonde & Firenze,
2011)

The function of good governance in ensuring that entities act in the public interest raises the question of the role of
ethics in governance. Let us look at ethics as a concept in health.
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1.6 Ethics as a Concept in Governance

How do you define the term ethics?

Ethics can be defined as the “rules of conduct”, values and norms and acceptable practices for a given profession or
organization. Ethics provides a set of standards for behaviour that helps us decide how we ought to act in a range
of situations. Ethics is all about making choices, and about providing reasons why we should make these choices.
(Bonde & Firenze, 2011)

Most people do not see ethics as a domain unto itself, or as a set of concepts and principles that guide us in
determining what behaviour helps or harms humans. Ethical concepts and principles are universally defined,
through such documents as the UN Declaration of Human Rights which transcend cultural and religious beliefs and
create shared ethical concepts and principles as guides in reasoning through common ethical issues (Paul & Elder,
2005).

Ethics is sometimes confused with other ways of making choices, including religion, law or morality. Ethics provides
a rational basis for morality, it is the code that enables morality, while a good system of law should be ethical (Bonde
& Firenze, 2011). However, Ethics is more than just common sense. Ethics requires a critical-thinking approach that
examines important considerations such as fairness for all consumers, the impact of the decision on society, and the
future implications of the decision.

What is the link between Ethics, morality and law?

Ethics, Morality and Law

Morality is the distinction between right and wrong and living according to that understanding. Morality is
defined as having and living according to a moral code, or principles of right and wrong. It is a code of conduct,
a determination of what should be done and what should not be done. Morals deal with behaviours as well as
motives. Morality evolves with the evolution of society, differing noticeably in different cultures and time.

The philosophy of morality is Ethics. “Ethics” explores the idea of morality and its place in society and addresses
questions about morality. Ethics is sometimes taken to refer to a guide to behaviour wider in scope than morality,
and that an individual adopts as his or her own guide to life (Gert & Gert, 2016). Ethics is the philosophy of how that
morality guides individual and group behaviour. The two are closely related, with morality being the foundation of
ethics. Both Kant and Aristotle were famous for their approach to ethics. Kant believed ethics was based on duty
and obligation, while Aristotle based his ideas on virtue.
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Law
Law is distinguished from morality and ethic by having explicit written rules, penalties, and officials who interpret
the laws and apply the penalties. Laws are enacted to regulate human behaviour for the benefit of society. Laws are
designed to prevent harm to others while protecting the rights of individuals. Both law and ethics deal with questions
of how we should live together with others, but ethics is sometimes also thought to apply to how individuals act
even when others are not involved (Bonde & Firenze, 2011). Laws are often evaluated—and changed—on moral
grounds (Gert & Gert, 2016).

Put simply, law and ethics govern two different realms; Law prevails in public life, whereas ethics is a private matter.
Now that you have understood the concepts of governance and ethics, let us examine the role of governance and
ethics in health.

1.7 Role of Governance and Ethics in Health

Having a code of conduct (ethics) to govern members and staff is a key element of good Governance. On the other
hand, the rule of law is a means by which public sector entities and individuals within them can be held to account
through compliance.

1. Role of Governance in health

• Ensures that entities act in the public interest at all times
• Ensures that intended outcomes are defined in terms of sustainable economic, social and environmental
benefits. The achievement of those intended outcomes are assured through necessary interventions.
• Ensures that risk and performance management are properly monitored through robust internal control
and financial management frameworks
• Ensures that accountability exists through transparency and reporting mechanisms.
• Defines roles and responsibilities and decision making
• Establishes mechanisms to achieve accountability and transparency in the organisation
• Offers oversight of the organization’s operations, planning and strengthens the organisation in achieving
its mission
• Promotes efficient management of resources
• Enhances efficient and impartial practice of rule of law
• Augments equitable distribution and use of resources
• Encourages effective participation and partnerships among internal and external actors

2. Role of Ethics in health

The practice of medicine and ethics are inseparable. Every clinical decision invokes an ethical decision. Patients are
entitled to good standards of practice and care from healthcare providers at all times. Medical ethics is a practical
application of moral standard that are meant to benefit the patient. Healthcare workers make choices that need to
take into consideration, the common good of patients. It is therefore necessary to understand and adhere to ethical
standards and professional code of conduct (NMSUA Allied Health Program).

Ethical theory about what is right and wrong in human conduct lies behind the issues practitioners face and the
ethical codes they reference for guidance. It also provides guidance for actions, practices, and policies. Ethical
theories and principles are the viewpoints from which guidance can be obtained along the pathway to a decision.
Ethical principles guide ethical theories and in turn, ethical theories are based on ethical principles.

The relationship between roles and tenets of governance and ethics in health is depicted in figure 1.3 below. At the
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core of this relationship is ethics, the rule of law, transparency and stakeholder participation. The combination of these
principals lead to the definition of intended outcomes in terms of sustainable economic, social and environmental
benefits. Any necessary interventions and capacity building to assure achievement of these benefits is part of the
cycle. The existence of robust internal control and public financial management, supported by transparency and
reporting mechanisms ensures that risks are mitigated, and the intended performance levels are achieved.

Figure 2.1.3: Relationships between the role of Good Governance and Ethics in the public sector. Source:
(IFAC & CIPFA, 2013).
In health, good governance requires defining outcomes, determining interventions necessary to optimize
achievement of intended outcomes, capacity development and risk and performance management.(IFAC & CIPFA,
2013).
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1.8 Organizational Governance

What is organizational governance

There are many definitions of corporate governance. But it essentially refers to how a corporation is
governed. Who has the authority to make decisions for a corporation and within what guidelines? The following
are different categories of corporate governance (McRitchie, 2017)

Academic definition
Corporate governance system is the combination of mechanisms which ensure that the management (the
agent) runs the firm for the benefit of one or several stakeholders (principals). Such stakeholders may cover
shareholders, creditors, suppliers, clients, employees and other parties with whom the firm conducts its business.
(Goergen and Renneboog, 2006)

Practitioner definition
Is the relationship among various participants [chief executive officer, management, shareholders, employees]
in determining the direction and performance of corporations” – Monks and Minow, Corporate Governance,
from 1995 version.

Legal definition
“The most fundamental principles of corporate governance are a function of the allocation of power within
a corporation between its stockholders and its board of directors.” (J. Robert Brown, Jr. and Lisa L. Casey,
Corporate Governance: Cases and Materials, 2012)

Institutional definition
“Corporate Governance is concerned with holding the balance between economic and social goals and
between individual and communal goals. The corporate governance framework is there to encourage the
efficient use of resources and equally to require accountability for the stewardship of those resources. The
aim is to align as nearly as possible the interests of individuals, corporations and society” (Sir Adrian Cadbury in
‘Global Corporate Governance Forum’, World Bank, 2000)

… is the system by which companies are directed and managed. It influences how the objectives of the
company are set and achieved, how risk is monitored and assessed, and how performance is optimised. Good
corporate governance structures encourage companies to create value (through entrepreneurism, innovation,
development and exploration) and provide accountability and control systems commensurate with the risks
involved. (ASX Principles of Good Corporate Governance and Best Practices Recommendations, 2003)

Definition in health
Organizational governance in a medical practice consists of developing long-term strategies and the
strategic direction of an organization. Organizational governance involves the ability to facilitate the
corporate legal structure, define policy and define the organization’s culture.
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Importance of Organizational Corporate Governance

The importance of organizational corporate governance is that it facilitates the following:

• It’s the processes and structures used to guide and direct an organisation’s operations and activities in
order to serve the interests of the customers
• It 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 and leadership which is transparent and accountable

Figure 2.1.4 below depicts the link between Governance and Organizational Results. As a result of the corporate
governance structure, seen in the board, the executive management communicates, implements and reports on
the performance of the organization, to the satisfaction of the stakeholders.

Figure 2.1.4: linking governance to organizational results

That brings us to the end of this introductory unit on governance and ethics in health. Let us now review what
you have learnt.
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1.9 Unit Summary

Figure 3 above well summarizes the key lessons from this unit.
You have learned the definitions of governance and the key concepts and dimensions of
governance and ethics. You have learned the relationship between ethics, morality and
law whereby ethics is the fabric of governance and the philosophy of morality is ethics.
Laws on the other hand are enacted to regulate human behaviour for the benefit of
society and are often evaluated, and changed on moral grounds. You have also learned
the role of Ethics and governance in health which primarily is to ensure public interest is
upheld.
Unit 2 will delve more comprehensively into ethics and morality. It addresses the
principles and theories of professional ethics, morality and ethical management which is
a framework for ethical decision making.
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UNIT 2: PROFESSIONAL ETHICS, MORALS, RULES AND STANDARDS IN HEALTH CARE SERVICE DELIVERY

2.1 Unit Introduction

In this module, you will learn about the principles and theories of ethics, and ethical reasoning. These are the
foundations upon which we make ethical decisions. You will also learn the differentiation between Ethical
Management versus management of ethics. In this unit, you will learn the foundations that affect decision making
and the framework for ethical decision making. Lastly, this unit will cover the components and importance of a
corporate ethics program.

2.2 Unit Outcome

By the end of this unit you should be able to apply the principles of good governance and
ethics to practice

2.3 Principles and Theories of ethics

The Ethical principles of obligation offer general answers to the question, “Which acts/practices are morally right?”
(Schultz, 1993).

How do you gauge whether what you are about to do is morally right?

Ethical Principles

1. Principle of Beneficence: ‘do good’

This principle guides the ethical theory to do what is good. This principle is associated with the principle of utility,
and utilitarian ethical theory which states that we should attempt to generate the largest ratio of good over evil
possible in the world because people benefit from the most good. In health, beneficence is demonstrated whereby
an individual is bettered by treatment from a physician.

2. Principle of least harm (non-maleficence): ‘do no harm’

This principle guides situations in which neither choices available are beneficial and harm cannot be avoided. In
this case, a person should choose to do the least harm possible and to do harm to the fewest people. For both
beneficence and non-maleficence, each action must produce more good than harm. In health, this is demonstrated
by a doctor providing helpful treatment rather than to inflict more suffering to the patient.

3. Principle of respect for autonomy: ‘self-rule’

Based on the principle that we have an obligation to respect the autonomy of other persons. This concept is to
respect the decisions made by other people concerning their own lives because they are the only ones who have
experienced and completely understand their emotions, motivations and chosen type of lifestyle. This is also called
the principle of human dignity. This principle is an extension of the ethical principle of beneficence because a
person who is independent usually prefers to have control over his life experiences for good.
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There are two views of looking at respect for autonomy:

• Paternalistic view point: an authority prioritizes a dependent person’s best interests over the dependent
person’s wishes e.g., parental or physician; they are paternalistic figures who can manipulate the
dependent person to choose the path that benefits them best; because the paternalistic figure may not
share the same ideals, this may deny autonomy to the dependent person and ability to control their own
decisions. This leads to decreased amount of beneficence.
• Libertarian view: is more mindful of the patients’ desires and prioritizes patients’ wishes over their best
interests. This means autonomy and beneficence whereby the patient has control over their life and has
made decisions best suited for them.

4. Principle of Justice: ‘fairness’

This principle states that ethical theories should prescribe actions that are fair to those involved. We have an
obligation to provide others with whatever they are owed or deserve. This suggests that ethical decisions should
be consistent with the ethical theory otherwise an inconsistent decision should be well justified by extenuating
circumstances. An ethical decision that contains justice within it has a consistent logical basis that supports the
decision. This is demonstrated in a case where an ambulance may break speed and road rules (driving fast and on
the wrong side of the road) to save a life.

Ethical Theories
To make ethical decisions, an understanding of the fundamental of ethics is helpful. Ethical theories are based on
ethical principles.

Do you know of any ethical theories? Give at least one

Ethical theories emphasize different aspects of an ethical dilemma and lead to the most ethically correct resolution
according to the guidelines within the ethical theory. Ethical theories and principles bring significant characteristics
to the decision-making process. Due to the shortfalls in each ethical theory a combination of theories can be used
to obtain the most ethically correct answer possible for each scenario.

Ethical theories are broadly divided into three types:

i. Consequentialist theories
ii. Non-consequentialist theories
iii. Agent Centred theories

i. Consequentialist Theories:
These are concerned with ethical consequences of actions;
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Utilitarianism approach

Utilitarianism can be traced back to the school of the Ancient Greek philosopher Epicurus of Samos (341-270 BCE),
who argued that the best life is one that produces the least pain and distress

Utilitarianism is one of the most common approaches to making ethical decisions; it instructs us to weigh the
different amounts of good and bad that will be produced by our action and that the best action will be that which
provides the most good or does the least harm,

The utilitarian ethical theory is founded on the ability to predict the consequences of an action. To a utilitarian, the
choice that yields the greatest benefit to the most people is the choice that is ethically correct.

The benefit of this theory is that Utilitarian can compare projected solutions and determine which is the most
beneficial for more people. This provides a logical and rationale argument for each decision, applicable on a case
by case context.

Type of utilitarianism:

• Act utilitarianism: a person performs the acts that benefit the most people, regardless of personal
feelings or the societal constraints such as laws;
• Rule utilitarianism: takes into account the law and is concerned with fairness and seeks to benefit the
most people but through fairest and most just means available. Rule utilitarianism values justice and
includes beneficence at the same time.
Flaws of act and rule utilitarianism
• Both are associated with predicting the future; not possible to predict with certainty that predictions will
come true; can lead to unexpected results making the utilitarian look unethical as time passes because
his choice did not benefit the most people as he predicted
• The utilitarian must compare the various types of consequences against each other on a similar scale; this
may not always be possible; e.g., comparing material gain – vehicle to intangible gains - happiness.
• It does not allow for the existence of supererogation or heroes. In other words, people are obligated
to constantly behave so that the most people benefit regardless of the danger associated with an act
therefore such acts are not considered heroic.
• Act utilitarianism is not always concerned with justice, beneficence or autonomy for an individual if
oppressing the individual leads to the solution that benefits a majority of people.
• An act utilitarian could be nice to you one moment and then dislike you the next moment because the
variables have changed, and you are no longer beneficial to the most people

The Egoistic Approach

Traced to ancient Greek Sophists like Thrasymacus (c. 459-400 BCE), who famously claimed that might makes right
One variation of the utilitarian approach is known as ethical egoism, or the ethics of self-interest. In this approach,
an individual often uses utilitarian calculation to produce the greatest amount of good for him or herself.

The Common Good Approach

Traced to the ancient Greek philosophers Plato (427-347 BCE) and Aristotle (384-322 BCE) promoted the perspective
that our actions should contribute to ethical communal life. Jean-Jacques Rousseau (1712-1778), who argued that
the best society should be guided by the “general will” of the people which would then produce what is best for the
people as a whole. This approach to ethics underscores the networked aspects of society and emphasizes respect
and compassion for others, especially those who are more vulnerable.
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ii. Non-consequentialist Theories:

• Duty based approach or Deontology ethics
• Associated with the philosopher Immanuel Kant (1724-1804) who argued that doing what is right is
about having the proper intention in performing the action. The ethical action is one taken from duty,
that is, it is done precisely because it is our obligation to perform the action. “Act only according to that
maxim by which you can at the same time will that it should become a universal law.” Choosing to obey
the universal moral law is the very nature of acting ethically.
• The deontological theory states that people should adhere to their obligations and duties when
analysing an ethical dilemma. This suggests that a person will follow his or her obligations because
upholding one’s duty is what is considered ethically correct. A deontologist will always keep his promises
and will follow the law; this produces very consistent decisions. This theory also praises deontologists
who exceed their duties and obligations, which is called “supererogation”; e.g., during the 911 attack the
passengers of United Airways performed an act of supererogation by choosing to die rather than let the
hijackers determine their fate.
• The Rights Approach
• Traced to British empiricist philosopher John Locke (1632-1704). This approach stipulates that the
best ethical action is that which protects the ethical rights of those who are affected by the action.
It emphasizes the belief that all humans have a right to dignity. The rights set forth by a society are
protected and given the highest priority. Rights are considered to be ethically correct; “Act in such a way
that you treat humanity, whether in your own person or in the person of another, always at the same time
as an end and never simply as a means to an end.” (Kant)
• The Fairness or Justice Approach
• Associated with American philosopher John Rawls (1921-2002), who argued, along Kantian lines, that
just ethical principles are those that would be chosen by free and rational people in an initial situation of
equality.
• The Divine Command Approach
• Traced to The Medieval Christian philosopher William of Ockham (1285-1349). This approach sees what is
right as the same as what God commands, and ethical standards are the creation of God’s will.

iii Agent-Centered Theories

The Virtue Approach

The approach argues that ethical actions should be consistent with ideal human virtues. Because virtue ethics is
concerned with the entirety of a person’s life, it takes the process of education and training seriously, and emphasizes
the importance of role models to our understanding of how to engage in ethical deliberation. The virtue ethical
theory judges a person by his character rather than by an action that may deviate from his normal behaviour. It
takes the person’s morals, reputation and motivation into account when rating an unusual and irregular behaviour
that is considered unethical. E.g., a person known for good character and following the rules may be judged more
leniently. This theory overlooks a person’s change in moral character- a person previously of good moral standing
might have changed to immoral character.

Differentiate with examples, the key differences between the three theories of ethics
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2.4 Ethical Management and Management Ethics

Our twenty first century has exposed mammoth corporate scandals that have harmed businesses, and produced
regulatory backlash. Managers and researchers have turned their attention to questions of ethics management to
see how to prevent similar transgressions in the future. Ethical conduct should be managed proactively via explicit
ethical leadership and conscious management of the organization’s ethical culture.(Trevino & Brown, 2004)

Review the case study of a scandal scenario and identify the ethical failures

Ethical Management

Ethical Management is defined as acting ethically as a manager by doing the right thing or ‘walking the talk’. Ethical
management also refers to corporate management that not only fulfils economic, legal and ethical responsibilities,
but also strives to achieve sustainability through the company acting as a responsible member of society.

When engaging in business management and activities the standards for businesses are based on ‘Ethical Standards’
for transparent, fair, logical operations. Keeping the ethical standards means that the organizations decision making
is not only based on economical principals, but also on the premise of ethical judgments, transparency, fairness,
equity, and law.

Although Managers may be guided by their personal morals and beliefs, it is important to look at each decision
making situation objectively and make the most ethical decisions by following the four main principles of ethical
management.(Management Training Specialists, 2009)

• Respect for each employee: be mindful of the diverse nature of your team’s religious and cultural beliefs
and treat them respectfully
• Mutual respect: ensure that individual employees show respect for each other’s ideas and opinions.
• Procedural fairness: ensure the procedures you implement are fair to all the employees without favouring
or neglecting anyone
• Decision making transparency: be transparent about why certain decisions have been made, to
avoid perception that arbitrary choices are being made based on personal beliefs. This will gain more
acceptance of decisions and team work.

Management Ethics
It is a standard of behaviour that guides individual managers in their works”.(Tanuja, 2016)‘Management Ethics’ is
related to social responsiveness of a firm. It is “the discipline dealing with what is good and bad, or right and wrong,
or with moral duty and obligation.
“It is the set of moral principles that governs the actions of an individual or a group.”
Is defined as acting effectively in situation that have an ethical aspect, for example, firing unethical employees
(AMREF current manual).
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Types of Management Ethics:

There are three types of management ethics or standards of conduct are identified by Archie B. Carroll (Tanuja,
2016)

1. Immoral management:
It implies lack of ethical practices followed by managers. Managers want to maximise profits even if it is at the cost
of legal standards or concern for employees.

2. Moral management:
According to moral management ethics, managers aim to maximise profits within the confines of ethical values and
principles. They conform to professional and legal standards of conduct. The guiding principle in moral management
ethics is “Is this action, decision, or behaviour fair to us and all parties involved?”

3. Amoral management:
This type of management ethics lies between moral and immoral management ethics. Managers respond to personal
and legal ethics only if they are required to do so; otherwise there is lack of ethical perception and awareness.

There are two types of amoral management:

(a) Intentional:
Managers deliberately avoid ethical practices in business decisions because they think ethics should be followed in
non-business activities.

(b) Unintentional:
Managers do not deliberately avoid ethical practices but unintentionally they make decisions whose moral
implications are not taken into consideration.

Give examples of practices of management ethics in your organization

Approaches to Management Ethics

There are three approaches to management ethics:

1. Utilitarian approach:
In this approach, managers analyse the effects of decisions on people affected by these decisions. The action rather
than the motive behind the action is the focus of this approach. Positive and negative results are weighed and
managerial actions are justified if positive effects outweigh the negative effects. Pollution standards and analysing
the impact of pollution on society is management ethics code under utilitarian approach.

2. Moral rights approach:

In this approach, managers follow ethical code which takes care of fundamental and moral rights of human beings;
the right to speech, right to life and safety, right to express feelings etc. In the context of business organisations,
managers disclose information in the annual reports necessary for welfare of the people concerned. The nature,
timing and validity of information is taken into account while reporting information in the annual reports.
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3. Social justice approach:

According to this approach, managers’ actions are fair, impartial and equitable to all individuals and groups.
Employees are not distinguished on the basis of caste, religion, race or gender though distinction on the basis of
abilities or production is justified. For example, all employees, males or females with same skills should be treated
at par but it is justified to treat employees who produce more differently from those who produce less.

Barriers to Management Ethics (Tanuja, 2016):

James A. Waters describe three “organisational blocks” of management ethics:

1. Chain of command:
If employees know that superiors are not following ethical behaviour, they hesitate in reporting the matter up the
hierarchy for the fear of being misunderstood and penalized. The chain of command is, thus, a barrier to reporting
unethical activities of superiors.

2. Group membership:
Informal groups lead to group code of ethics. Group members are strongly bonded by their loyalty and respect for
each other and unethical behaviour of any member of the group is generally ignored by the rest.

3. Ambiguous priorities:
When policies are unclear and ambiguous, employees’ behaviour cannot be guided in a unified direction. It is
difficult to understand what is ethical and what is unethical.

Solutions to Barriers:
The following measures can improve the climate for ethical behaviour:
• Organisational objectives and policies should be clear so that every member works towards these goals
ethically.
• The behaviour of top managers is followed by others in the organisation. Ethical actions of top managers
promote ethical behaviour throughout the organisation.
• Imposing penalties and threats for not conforming to ethical behaviour can reduce unethical activities in
the organisation. Formal procedures of lodging complaints help subordinates report unethical behaviour
of superiors to the concerned committees.
• Educational institutions also offer courses and training in business ethics to develop conscientious
managers who observe ethical behaviour.

Ethical reasoning

What is ethical reasoning?

Ethical reasoning entails doing what is right even in the face of powerful selfish desires. Discuss and give examples

The proper role of ethical reasoning is to highlight acts of two kinds: those which enhance the well-being of
others—that warrant our praise—and those that harm or diminish the well-being of others—and thus warrant our
criticism (Paul & Elder, 2005).
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Let us look at the philosophical and psychological definition of ethical reasoning.

• Philosophical definition: ethical reasoning means taking the moral point of view; it involves willingness
to seek out and act on reasons and requires us to be impartial that is, we must regard the interests of
everyone including ourselves as equally worth of consideration and give all interests equal weight in
deciding what to do.
• Psychological definition: proposed by psychologist Lawrence Kohlberg- that people develop the
cognitive ability to engage in moral reasoning through a series of stages from infancy to adulthood.

Our ethical reasoning is influenced by religious thinking, conventional thinking (social folkways and taboos), political
thinking (ideology and vested interest) and legal thinking (based on political processes and social pressures).

How is our ethical reasoning influenced by religion, culture and political and legal thinking?
Give examples

2.5 Individual decision making

Wrong doing is often attributed to ‘bad people’- but how about the individual who knows that the action is wrong
but does it anyway? Individuals are prone to rationalizations and can often effectively persuade themselves that a
course of action is morally right or, at least is not wrong under the circumstances, or work under strong pressure to
follow orders.

Give examples of situations where you have experienced moral and ethical struggles with individual
decision making and describe the basis you have used to justify that action.

Four dangerous rationalizations: ‘why good managers make bad ethical choices’
• The action is within reasonable ethical and legal limits
• The activity is within the individual’s or corporation’s best interest.
• The activity is “safe” because it will never be found out or publicized.
• Because the activity helps the company, the company will condone and even protect the person who
engages in it.

Psychological biases we employ in decision making

Biases and heuristics serve us well but can lead to mistakes and cause us to fail to consider important consequences,
or prevent us from foreseeing disasters that we should have seen and leads us to overlook unethical conduct of
others.
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Psychologists have identified a number of features of human decision making that produce errors of judgement.
The individuals do not necessarily engage in ethics vs. profits or callous disregard for other people’s interest or
welfare but rather psychological tendencies that foster poor decision making both from an ethical and rational
perspective.
• Loss Aversion bias: People tend to weigh losses more heavily than gains and thus take greater risks to
avoid losing something they have than to gain something that they do not have.
• Framing effect: peoples decisions depend on how the choices are presented or framed. Loss aversion bias
leads people to choose alternatives that are framed in terms of gains.
• Confirmation bias: The tendency of people to seek and process information that confirms existing
attitudes and beliefs instead of seeking and processing information that poses challenges to their
attitudes and beliefs
• Cognitive dissonance: related to confirmation bias, it’s the tendency of people to dismiss information that
would disrupt their existing attitudes and beliefs
• Commitment and sunk costs bias: once commitments are made and resources expended, people tend to
persist in a course of action even in the face of negative information
• Hindsight bias: tending to believe that events are more predictable than they are and consequently
blaming themselves for not anticipating events that occur
• Causation bias and illusion of control: people often find causal patterns in random events, leading them
to the belief that they have greater ability to control events than warranted.
• Self Interest bias: people tend to make judgements, especially about fairness, that favour themselves
• Over optimism and overconfidence bias: people are unduly confident of their own knowledge and
abilities and thus overestimate the likelihood of success
• Risk Perception Bias: People make poor judgements about risk, overestimating some risk and
discounting others, often ignoring low- probability events and favouring risk

Heuristic (rule of thumb) methods we employ in decision making

• Anchoring and adjustment heuristic: form an initial choice, anchor then adjust the choice in response to
additional information. However, the final decision is heavily influenced by the initial choice.
• Representativeness heuristic: utilize recent and vivid examples rather than objective statistical data – e.g.,
relying on a friends experience rather than data to buy a car/house
• Availability heuristic: based on available information at hand – rather than seek out new sources of
information.

Frameworks for Ethical decision making

Ethical and legal aspects of a situation need to be considered in decision making.

Making good ethical decisions requires a trained sensitivity to ethical issues and a practiced method for exploring
the ethical aspects of a decision and weighing the considerations that should impact our choice of a course of
action. Having a method for ethical decision making is essential (Bonde & Firenze, 2011).
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There are three broad frameworks that exist to guide ethical decision making:
• The Consequentialist Framework; ‘the end justifies the means’: The person using the Consequences
framework desires to produce the most good that is, ethical conduct is whatever will achieve the best
consequences. They consider focus on the future effects of the possible courses of action, considering
the people who will be directly or indirectly affected. Its pragmatic, but it’s not always possible to predict
consequences and sometimes heinous actions may result in good outcome for some. Is this ethical?
• The Duty Framework; ‘do the right thing’: Ethical conduct is defined by doing one’s duties and doing the
right thing, and the goal is performing the correct action regardless of outcome. Therefore if an action is
ethically correct it is your duty to do it and applies to everyone in the situation. Encourages treating
everyone with equal dignity, respect. However, it can appear cold, impersonal, require actions which are
known to produce harm, does notion of duty apply to everyone?
• The Virtue Framework; model a virtuous person: Defines ethical behavior as whatever a virtuous person
would do in the situation, and we seek to develop similar virtues. For example, what would Jesus do?
Agreeing on the virtuous person, relying on character, role models

Share examples of decision making in each framework

Applying the framework to ethical decision making process (Bonde & Firenze, 2011).

Table 2.2.1 Framework to ethical decision making process (Source: Bonde & Firenze, 2011)

Consequentialist Duty Virtue

Deliberative Process What Kind of outcomes What are my obligations in this What kind of person
should i produce (or try to situation, and what are the should I be (or try to be),
and what will my actions
produce)? things I should never do? show about my character?
Focus Direct attention to the Direct attention to the duties Attempts to discern
future effect of an action, that exist prior to the situation character traits (virtues
and vices) that are, or
for all people who will and determines obligations. could be , motivating the
be directly or indirectly people involved in the
situation.
affected by the action
Definition of Ethical Ethical conduct is the Ethical conduct involves Ethical conduct is
Conduct action that will achieve always doing the right thing whatever a fully virtuous
person would do in the
the best consequences : never failing to do ones’s duty. circumstances.

Motivation Aim is to produce the Aim is to perform the right Aim is to develop one’s
most good. action character
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Seven step process to ethical decision making

Making ethical decisions requires sensitivity to the ethical implications of problems and situations and
practice. The following 7 guidelines are a helpful guide to making ethical decisions.

1. Recognizing an Ethical Issue

• At the beginning of ethical deliberation, locate the specifically ethical aspects of the issue at hand.

2. Consider the Parties Involved

• Reflect upon the various individuals and groups who may be affected by your decision. Consider who
might be harmed or who might benefit.

3. Gather all of the Relevant Information

• Before taking action gather all the pertinent information, and determine whether the potential sources of
information have been consulted.

4. Formulate Actions and Consider Alternatives

Evaluate your decision-making options by asking the following questions:
• Which action will produce the most good and do the least harm? (The Utilitarian Approach)
• Which action respects the rights of all who have a stake in the decision? (The Rights Approach)
• Which action treats people equally or proportionately? (The Justice Approach) Which action serves the
community as a whole, not just some members? (The Common Good Approach)
• Which action leads me to act as the sort of person I should be? (The Virtue Approach).

5. Make a Decision and Consider It

After examining all of the potential actions, which best addresses the situation? How do I feel about my
choice?

6. Act
Many ethical situations are uncomfortable because we can never have all of the information. Even so, we
must often take action.

7. Reflect on the Outcome

What were the results of my decision? What were the intended and unintended consequences? Would I
change anything now that I have seen the consequences?

Case study: application of the to make ethical decision making framework

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2.6 Corporate Ethics

Corporate ethics is a systematic approach to raising ethical awareness of employees, providing guides and education
on ethics and having resources available to assist in identifying and resolving ethical issues. Ethics programs are
essentially organizational policies put in place to promote law abiding and ethical conduct. To be effective, they
must be supported by procedures, communications efforts. Some ethics programs address compliance strategy
which tries to prevent criminal conduct, violation of government regulations, and self-interested behaviour by
employees (e.g., conflicts of interest). Such programs impose standards of conduct and tries to compel acceptable
behaviour. They rely more on compliance officers or corporation lawyers.

Corporate ethics vary widely falling into 3 main types:

1. Codes of Conduct or statement of business standards or practices
2. A statement of core values or vision of an organization, sometimes called a credo or mission statement
3. Corporate philosophies that describe beliefs guiding a particular company

Components of a corporate ethics program

Below are the components of a corporate ethics program:

1. Code of ethics: codes of conduct; statement of core values; and corporate philosophies.
2. Ethics training for employees
3. Means of communicating with employees about matters of ethics
4. A reporting mechanism for enabling employees to report alleged wrongdoing
5. An audit system for detecting wrong doing
6. A system for conducting investigations and taking corrective action.

Ethics in practice, strong vs. weak ethical values and practices

The main benefits or importance of an ethics program is to prevent ethical misconduct by employees, which is
costly to companies not only in direct losses but also in those sustained from a tarnished reputation.

Scenario
Using the scenario examples below, identify the weak and strong ethical conduct by
employees
1. A bond trading scandal at Salomon Brothers in 1991 cost the firm almost $1 billion
2. a Japanese copper trader hid losses estimated at $2.6 billion from his employer
3. Nicholas Leeson a 29 year old, Singapore based trader for Barings Bank destroyed the
British firm losing more than $1 billion in unauthorized trading
4. In 2008 a rogue trader at Societe Generale lost more than $7 billion for the French
Bank.
5. Add scenarios illustrating strong positive ethical conduct by employees

That brings us to the end of this unit on principles of governance. Let’s now review what you have learnt
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2.7 Unit Summary

We have covered a lot of material on the principles and theories of professional ethics and
decision making. You have learned how ethical decision making is affected by psychological
biases and heuristic methods. Ethical management which is defined as acting ethically links us
to corporate governance and ethics program; these are mechanisms and strategies employed
by organizations to raise ethical awareness of employees, providing guides and education on
ethics and availing resources to assist in identifying and resolving ethical issues.

2.8 Unit References and Further Reading

1. Bonde, S., & Firenze, P. (2011). Making Choices; a framework for making ethical decisions.
Making choices: Ethical Decisions at the frontier of Global Science. Brown University.
2. Gert, B., & Gert, J. (2016). The definition of morality. Stanford Encylopedia of Philosophy.
3. IFAC & CIPFA. (2013). Good Governance in the Public Sector; Consultation Draft for an
International Framework. IFAC & CIPFA.
4. Institute on Governance. (2017). Definition of Governance.
5. Management Training Specialists. (2009, June 22). The Four Principles of Ethical
Management. London, UK.
6. McRitchie, J. (2017). Corporate governance defined: not so easily. Retrieved from
Corporate governance: [Link]
7. NMSUA Allied Health Program. (n.d.). Legal and Ethical issues in Health Care.
8. Paul, D. R., & Elder, D. L. (2005). The thinkers guide to Ethical Reasoning. Critical Thinking.
9. Rainbow, C. (2002). Descriptions in Ethical Theories and Principles. North Carolina, NC,
USA.
10. Schultz, R. C. (1993). Ethical principals and theories. PubMed.
11. Tanuja, A. (2016). Management Ethics: Meaning, Need and Importance. Retrieved from
Business Management Ideas: [Link]
management-notes/corporate-social-responsibility/management-ethics-meaning-need-
and-importance/5319
12. Trevino, L. K., & Brown, M. B. (2004). Managing to be ethical: debunking five business
ethics myths. Academy of Management Perspective, Vol 18.
13. WHO. (2007). Strengthening health systems to improve health outcomes, WHO framework
for Action. Geneva: World Health Organization.
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UNIT 3: PRINCIPLES, CHARACTERISTICS AND PRACTICE OF GOOD GOVERNANCE

3.1 Unit Introduction

In this unit we discuss the principles, characteristics and practice of good governance. Governance as a system has
players that must not be ignored. Among them are the political actors, civil society, the media, formal oversight
institutions, the private sector participation, citizenry and the public sector managers. Each of these institutions has
a role to play in governance.

3.2 Unit Outcome

By the end of this unit you should be able to apply the principles of good governance
and ethics in decision making and practice

3. 3 General Principles of Governance in Health

Before we start our discussion on principles of governance, complete the following activity.

Activity 3.1 (20 minutes)

List in your notebook at least 2 principles of governance in health

Well done! We hope your answers included the following three principles of good governance. These are:
• Transparency,
• Accountability and
• Participation.

Transparency:
• Refers to openness to public scrutiny, clearness and visibility in decision making processes in Government
or when conducting public affairs. It also allows other stakeholders’ (representatives) participation in
decision making.
• Refers to various measures of public information disclosure and access (freedom of access to information,
acts, administrative procedure acts, “Government in the sunshine” acts, etc.)

Accountability:
• At all levels of the health system: National, regional, health facility, individual health provider.
• Government answerability and responsibility to explain its actions and responsiveness to peoples’ needs
and expectations/values.
• External in terms of responsiveness to clients and internally – proper use of resources
• Probity, efficiency and effectiveness in resource management, public goods and service delivery.
• For accountability to be effective, it should be accompanied with sanctions and, or incentives otherwise it
becomes weak and non- consequential.
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Participation:
• Citizen’s engagement, participation and empowerment in decision making process
• All are considered to improve efficiency, effectiveness and sustainability of public service delivery and in
implementation of development projects.
• Everyone has fundamental rights to be recognized and be heard in policy making, implementation and
Evaluation process.
• The country or organization manages its resources according to guidelines for development (wide use of
client and patient charters,)
• Good governance is associated with faster growth and more pro poor development outcomes
• Poor governance on the other hand, has the opposite effects and provides greater opportunities for
corruption to thrive at the expense of the citizenry (corruption is an outcome, consequence of poor
governance) the country/organization will stagnate, decline in GDP, high child and maternal mortality,
and increased incidence of infectious diseases will be the early indicators (SEARCH FOR VISUAL AID).
• Both poor governance and corruption reduce development effectiveness.

Stewardship:
• Stewardship refers to the “careful and responsible management of something entrusted to one’s care”.
Those who exercise the authority to make policy – the minister of health and others who work to reform
public health laws – must exercise stewardship, putting aside personal desires and working to maximize
the health interests of the people they serve.
• Unless law reformers approach the task of law reform with the public’s benefit in mind, public health
laws cannot maximize their potential to assist countries to progressively realize the right to health for all
members of the population.

Fairness:
• The principle of fairness makes a significant contribution to good governance because it encompasses
the related human rights of equality and non-discrimination. Article 26 of the International Covenant on
Civil and Political Rights states: All persons are equal before the law and are entitled without any
discrimination to the equal protection of the law. In this respect, the law shall prohibit any discrimination
and guarantee to all persons equal and effective protection against discrimination on any ground such as
race, color, sex, language, religion, political or other opinion, national or social origin, property, birth or
other status.
• Discrimination entrenches health inequalities and undermines the capacity of governments to pursue
the right to health for all members of the population. Governments have an obligation to take immediate
action to eliminate discrimination; doing so will help to ensure equality of access to health services and to
the resources needed to lead a healthy life.
• This does not necessarily mean that the State must provide health services and other social services to
everyone free of charge. On the other hand, the State does have an obligation to ensure that individuals
and vulnerable groups do not miss out on health care and health services because of their inability to
pay. Law is a powerful tool for establishing the principle of “equality of opportunity for people to enjoy
the highest attainable level of health”.

The rule of law:

• Good governance is based on the rule of law. The principle of the rule of law means that all persons,
officials and institutions, including the State itself, are accountable under laws that are publicly
disseminated, equally enforced, independently adjudicated, and consistent with international human
rights standards.
• The rule of law ensures that the law reform process itself is clear, fair and that it remains focused on the
public interest.
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Figure 2.3.1: Overall framework on governance principles (Source: institute of policy development at
the civil service college, Singapore 2006)

3.4 Characteristics of Good Governance As Compared To Weak Governance

Figure 2.3.2 depicts 8 components which should be present for Good Governance to exist

Figure 2.3.2: Components of Good Governance

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The 8 components which should be present for Good Governance to exist are as follows:
• Strategic vision - Good governance requires that government or an institution has a clear picture of the
future and that this s well-articulated in a national or organization strategic plan.
• Participation and consensus orientation – Participation by both men and women is key cornerstone of
good governance. Participation could be either direct or indirect through legitimate intermediate
institutions or representatives. Participation needs to be organized. Since there are several actors and
many viewpoints in a given society, good governance requires mediation of different interest to reach
a broad consensus in the best interest of the whole community. It also requires broad and long term
perspectives on what is needed to achieve sustainable human development and how to achieve such
goals.
• Rule of law - Good governance requires full protection of human rights particularly those of minorities.
This requires fair and impartial legal frameworks. Impartial enforcement of laws requires an independent
judiciary and an impartial and incorruptible police force.
• Transparency - Transparency means that information is freely available and directly accessible to those
who are affected by decisions and their enforcement. It also means that decisions taken and their
enforcement are done in a manner that follows rules and regulations.
• Responsiveness - Time is o essence. Good governance requires that institutions and processes try to
serve all stakeholders within reasonable timeframes.
• Equity and inclusiveness - A society’s well-being depends on ensuring that all its members including the
most vulnerable, feel that they have a stake in at and do not feel excluded from the mainstream of
society. This requires that all groups have opportunity to improve or maintain their well-being.
• Effectiveness and efficiency - The concept of effectiveness and efficiency in good governance means
that processes and institutions produce results that meet the needs of society while making the best use
of resources at their disposal. Efficiency also requires sustainable use of natural resources and the
protection of the environment.
• Accountability – Government institutions, the private sector and civil society organizations must be
accountable to the public and to their institutional stakeholders. Generally and organization or institution
is accountable to those who will be affected by its decisions or actions. Accountability cannot be enforced
without transparency and the rule of law as covered above.
• Intelligence and information – This concept will be covered in more detail later in the chapter.
• Ethics - This concept will be covered in more detail later in the chapter.

Activity 3.2 (20 minutes)

Describe the application of at least one principle at the selected level in your own
country. Specify the level.
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3.5 Weak Governance

What are the indicators or definition of weak governance?
The Health Systems Database includes both a point estimate and a percentile rank from the World Bank’s Governance
Indicators. Indicator Definition and Interpretation are covered in table 3.1 below.
The Worldwide Governance Indicators database “reflects the statistical compilation of responses on the quality of
governance given by a large number of enterprise, citizen, and expert survey respondents in industrialized and
developing countries” (World Bank 2006). The score for each indicator for a country ranges from –2.5 to 2.5, with
higher scores reflecting better outcomes. Countries that score in the negative range on all indicators are unlikely to
exhibit high-quality linkages among the actors in the health system.
Source for information on Indicators 1–6: World Bank Governance Indicators, [Link]
governance/govdata/

Table 2.3.2 – Worldwide Governance Indicators

No. Indicator Indicator Description
1 Voice and accountability Voice and accountability measures the extent to which a country’s
citizens are able to participate in selecting their government, as well as
freedom of expression, freedom
of association, and a free media. Thus, it is a measure of political, civil,
and human rights. The topics included in this indicator are civil
liberties, political rights and representation, and fairness of elections.
For more information see Topical Area C: Voice: Preference
aggregation.
2 Political stability Political stability and absence of violence measures the perceptions
of the likelihood that the government will be destabilized or
overthrown by unconstitutional or violent means, including
domestic violence and terrorism. Another indicator of political
stability is the smooth transition between governments after an
election. The political stability of a country has a direct impact on its
ability to provide, manage, and fund health services.
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3 Government effectiveness Government effectiveness measures the quality of public and privately
provided services, the quality of the civil service and the degree of its
independence from political pressures, the quality of policy
formulation and implementation, and the credibility of the
government’s commitment to such policies. Topics included in this
indicator are administrative and technical skills of the civil service,
transparency and openness, government stability, trust in
government,
and policy consistency. The effectiveness and quality of linkages
between state, citizens, and providers, influences the ability of the
health system to meet the performance criteria elaborated in Section
1: equity, efficiency, access, quality, and sustainability. See Indicator 8
(for example): The national government is transparent with regards to
health sector goals, planning, budgeting, expenditures, and data. It
regularly communicates with stakeholders in the health sector.

4 Rule of law Rule of law measures the extent to which agents have confidence in
and abide by the rules of society, in particular the quality of contract
enforcement, the police, and the courts, as well as the likelihood of
crime and violence.
The existence of the rule of law creates an environment in which
basic public health provisions can be enforced and regulated. This
includes things like public safety, protection against hazardous waste
disposal, safety regulations for workers, and traffic laws. See also
Indicator 22: Health sector regulations are known and enforced in
both public and private training institutions and health facilities.

5 Regulatory quality Regulatory quality measures the ability of the government to

formulate and implement sound policies and regulations that permit
and promote private sector development. Topics included in this
indicator are, for example, business regulations, taxation, trade and
competition policy, and government market intervention.
Regulatory quality
can influence the frequency of malpractice occurring in
a country as well as the licensing and accreditation of public and
private practitioners. See also Indicator 20: The government provides
overall direction to the health system through clear legislation,
policies, and regulations.

6 Control of corruption Control of corruption measures the extent to which public power is
exercised for private gain, including petty and grand forms of
corruption, as well as “capture” of the state by elites and private
interests. See Indicator 23: Procedures exist for reporting,
investigating, and adjudicating misallocation or misuse of resources.
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There is a relationship between good governance and health outcomes. For example increased coverage of
immunization is correlated with decreased child mortality. This is illustrated below in Figure 2.3.3.

Figure 2.3.3: Relationship between corruption indices and health outcomes

Activity 3.3 (20 minutes)

Drawing on your personalized experience in your country, highlight areas of poor

governance and consequent outcomes.

3.6 Corruption and Bribery

What is corruption?

Corruption is the abuse of public office for private gain. It is a key indicator of poor governance.

Generally, corruption can be understood as “the abuse of entrusted public power for private benefit”. The principles
of good governance help to strengthen the law reform process against corruption and other failures by governments
or government officials to faithfully serve the public interest. Whereas the attributes of good governance are
stewardship, transparency, participation, fairness, accountability, and adherence to the rule of law, “corrupt
governance fails to offer citizens’ adequate and accurate information about government and policies, curtails the
public’s opportunities for participation, violates the public’s right to be informed about government activities and
procedures, and compromises the right to political participation. Thus, corruption weakens the accountability
of State officials, reduces transparency in the work of State institutions and allows human rights violations to go
unpunished”. Corruption can be problematic in the health sector, especially in low-income countries. Prominent
examples of corruption in the health sector include poor health facility construction, absenteeism of health
professionals, improper spending and diversion of funds, theft of drugs, soliciting of informal payments to improve
levels of service, and accreditation and licensing bribery
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Preventive measures of Corruption

Emanuel Kant’s categorical imperatives:

According to Emanuel Kant, he says that there are some things we ought to do and others we ought not to do by
virtue of being rational. Kant’s main thrust can be formulated in two intuitive principles. The principle of:
• universality and
• Respect of persons

Principle of Universalizability: if an act is right or wrong for one person then, it is right/wrong for all other relevantly
similar persons in similar circumstances. As a matter of logic, we must be consistent in the judgments we make. Act
only on rules (or maxims) that you would be willing to have everyone follow, for example, a loan which the borrower
knows he will not pay back. This becomes an immoral conduct is somehow irrational. Kantian Ethics has immense
implications for moral reasoning. It counters the natural temptation to make exceptions for ourselves or to apply
a double standard (lying on a curriculum vitae and a company lying to you later) “What if everyone did that?” The
results will be disastrous hence wrong. Also cheating on taxes….

Respect for Persons: “Act so that you treat humanity, whether in your own person or that of another, always as an
end and never as a means only” That is, respect other people (and ourselves as human beings). For example, how
do we treat our lower cadre health workers in our work places? How do wives treat the step children the man has
brought into the marriage?

Figure 2.3.4: Indicators of corruption

Activity 3.1 (20 minutes)

List in your notebook at least 2 indicators of corruption and then compare your answer with
what you read in the following section.
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These include: lack of transparency, weak accountability, and monopoly of decision making, inefficiency of public
officials and lack of citizens’ participation in the conduct of public affairs.

This result into: haemorrhage/leakage of public resources (drugs, money, and equipment) to private hands, there
is theft or misuse of vast amounts of public resources by state officials-usually members of public sector, or people
associated with the political or administrative elite

Levels of Corruption:

a) State capture
Influence of powerful economic interests in the public and private sectors in the formation of laws, regulations, and
policies through illegal provision of private benefits for public officials.

b) Grand corruption
“The theft or misuse of vast amounts of public resources by state officials – usually members of, or people associated
with the political or administrative elites…”

c) Nepotism and patronage

Favouritism shown to narrowly targeted interests by those in power such as granting favours, giving contracts or
making appointments to office in return for political support.

d) Petty administrative corruption

Private payments and other benefits to public officials in connection with the implementation of government
policy and regulations. (Adapted from Shaw, 2007; and Campos, 2008)

Definition of Bribery
A bribe is a payment made with a:
• Intention to corrupt/ compromise the decision maker in your favour
• Accepted in a way that is corrupting/that would otherwise not be acceptable
• It is a sub set in the corruption module

A bribe occurs once an offered payment has been accepted, regardless whether the bribee acts as the briber
intends. Like all other kinds of misconduct, the incidence of bribery is a function of:

• the opportunity presented

• the amount to be gained
• the likelihood of success
• Hence it is done in secret

How are bribes given?

• Direct cash payment in under the table transaction
• Indirectly through deposit in a bank account
• Funnelled indirectly through locally hired consultants
• Joint venture partners and funds for the bribes may be disguised as consulting fees
• Joint venture through expenses
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Effects of Bribery
1. It reduces the resources available in an economy when elites transfer money out of the country into secret
foreign bank accounts
2. Money from bribes come from overcharging or delivering substandard products or services (fake drugs). Hence
the citizens lose.
3. The spending priorities of a country may be distorted
4. The sheer amount of time people in a corrupt country must spend dealing with government officials and
complying with needless regulation detracts from productive activity (how big is your rock?)
5. The potential for demanding bribes leads to government officials to create even more efficiency-impeding
laws and regulations that confer ever more discretion on them (drivers’ license; car registration, incorporating
a company, drug approval process)
6. Bribery has many adverse economic consequences: it enriches elites in the country which leads to greater
inequality (POLITICAL INSTABILITY ETC)everybody gets on the bandwagon…”a goat eats where it is tethered”

Types of Bribery
Although originating in the interference of justice by influencing judges, bribery has expanded beyond influence
over all types of government officials into commercial and even private transactions in all spheres.
Examples of bribery in everyday life are:

Business
Employees, managers, or salespeople of a business may offer money or gifts to a potential client in exchange for
business.
Government
A grey area may exist when payments to smooth transactions are made. Politicians receive campaign contributions
and other payoffs from powerful corporations or individuals when making choices in the interests of those parties,
or in anticipation of favorable policy
Law
In legal situations, lawyers, judges, and others with power may be subject to bribery or payoff for making a decision
that benefits the individual making the payment.

Medicine
Pharmaceutical corporations may seek to reward doctors through gifts for frequent prescription of their drugs.

Music
“Payola” is the commonplace practice where record companies buy air time from radio and television stations for
songs they are promoting. The term “payola” derives from a contraction of the words “pay” and “Victrola” (LP record
player). It can take a number of forms including vacations or electronics for radio show hosts, giveaways for the
stations listeners, or payments to cover station operating costs.

Sport
Referees and scoring judges may be offered money, gifts, or other compensation to guarantee a specific outcome
in an athletic competition. A well-known example of this manner of bribery in sport is the 2002 Olympic Winter
Games figure skating scandal, where the French judge in the pairs competition voted for the Russian skaters in
order to secure an advantage for the French skaters in the ice dancing competition.
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Virtue Ethics (Aristotle)

According to Aristotle, virtue is a character trait that manifests itself in habitual actions. For example, honesty
cannot consist in telling the truth once, but it is rather the trait of a person who tells the truth consistently as a
general practice. It is only after observing people over a period of time that we can determine whether they are
honest. Mere feelings, like hunger, are not virtues because virtues are acquired traits. A virtue is also something
that we actually practice. Honesty is not simply a matter of knowing how to tell the truth but involves habitually
telling the truth.

Thus Aristotle classifies virtue as a “state” of character, which is different from a feeling or a skill. Finally, virtue is
something that we admire in a person; a virtue is an excellence of some kind that is worth having for its own sake.

Virtue ethics could be applied to business or service delivery directly by holding that, the virtues of a good
business or service provider are the same as those of a good person. Thus virtue ethics defines a moral action
a wise person would do. But can that be applied in business? Not really always, because the business person
sometimes wants to earn an extra cash from unsuspecting client…! Can they be applied in patient care? Yes they
can…! For example, caring for a woman in labour who has no other support otherwise a woman can lose her life
and baby or, caring for a convulsing child whose mother cannot pay for the service.

When there is ethical failure (on the part of an individual/organization) how should the client of the
organization be compensated? Aristotle therefore distinguished three kinds of justice:

• Distributive- the distribution of benefits and burdens (correcting wrongs) should be spread over a
group/organization.
• Compensatory-compensating persons for wrongs done to them (accidents, failure to fulfil contracts)
• Retributive -punishment of wrongdoers (assault, theft etc.)

Strengthening Corporate Governance

1. “An effective board will provide good governance and leadership by:”
• Understanding their role;
• Ensuring delivery on the organizational purpose;
• Being effective as individuals and a team;
• Exercising control;
• Behaving with integrity; and
• Being open and accountable (representing the interests of the clientele)
• 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

2. Alter the role of government in the economy.

• Limit the government involvement, by promoting the private sector growth
• Increasing the prominence of free markets
• Strengthen institutions (both government, private and civil society) allowing them to operate
according to their mandate without interference from the political actors.
• Improve supply – side (state institutions) and demand – side (non -state institutions/actors) of
government in health sector.
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• The three arms of government should reclaim and exercise their independence in execution of their
duties
• The formal oversight institutions (independent judiciary, legislative oversight)
• Public sector management players: transparent budgeting and procurement, accountability for
performance in service delivery

3. Reform in civil service:

• More selective recruitment and better training
• Building a more professional civil service (passports in USA….”they don’t want to know you”)

4. Increase pay:
• Reduce the temptation among low-paid officials to demand or accept bribes
• More careful selection of government projects
• Eliminate projects that are most vulnerable to bribery:
• Closely monitoring the projects that go forward

CASE STUDY FROM GHANA

In Ghana they have a new approach to fighting corruption. They believe that the Christian
God takes long to take action, so the nationals there agreed to be taking oaths of office
against their cultural gods hence termed the final/African solution as said below:

Robert P (ADB) and a friend for more than 30 years recommended an African solution to
corruption. Bob says “Let us go the traditional ways that our great grandfathers have used”.
Welcome to the deities!!!!!!!! Christianity has not worked to stop corruption!!!!!

Let us go the Deity ways.

Ghanaian gods: Nogokpo, Antoa, Krachie Dente, Akonedi, 77gods of Anomabu Jaagbo,
Nawuni, Kurigbaya
Nigerian gods: Sango, Obatala, Oya, Amadioha, Okija, Obasejum, Cameroonian gods:
Nkwifor, kwefor, Lamcado of old Buba”.

Discuss the above proposal of using the African gods and its applicability or otherwise in
the management of modern challenges of corruption.
What solution would you recommend to this menace especially in your organisation?

Record your action points in your Jamii project

3.7Unit Summary

In this unit we learnt about the principles and practices of good governance
characteristics and indicators of good governance and weak governance, aspects of
corruption and bribery, ethical governance, leadership and ways of strengthening
corporate governance.
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UNIT 4: GOVERNANCE STRUCTURES AND FUNCTIONS IN HEALTH

4.1 Unit Introduction

In this Unit we will discuss Governance structures and functions in health. These are structures that are necessary
for execution of authority at various levels and include international levels, central/national levels; regional/
provincial levels other sub regional levels all the way down to community level.

4.2 Unit Outcome

By the end of this unit you should be able to formulate functioning governance structures at
different levels of the health system

4.3 Governance Structures at Various Levels

Outline the governance structures for health at various levels in your country

This refers to structures both formal and informal (government, non -government including CSOs, and community)
for execution of mandate at various levels. These governance structures should be responsive, resilient and proactive
in nature to meet the needs of the voiceless for which they exist. The governance structures in common that impact
on daily life are:

• International level, includes WHO, 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: District health teams (DHT)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 functions for
health matters.
• 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
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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
Write the answers in your notebook and then compare them with what you read in the
following section.

4.4 Governance in Healthcare

The words ‘good governance’ have been tossed around in health care circles over the last decade as if it were a
panacea to mean that everything is fine. However, the crucial aspects of governance and how to implement an
integrated governance system that operates effectively between corporate and clinical governance are poorly
understood in many systems around the world.

Problems in governance of healthcare emerge when:

• one of the elements (corporate or clinical governance) is weak or underperforming;

• the linkages between corporate and clinical governance are not understood and respected inside the
organization;
• the boundaries between corporate and clinical governance are not effectively managed.

4.5 Effective corporate governance in health care

Corporate governance is a multifaceted set of processes, policies, regulations, laws, organizational
structures, people, and customs. These should all work in concert to assure the quality, accountability and
effective management of an organization as a whole. The highest level of corporate governance in a healthcare
organization (often a Board of Directors or Trustees) should ensure that:

• results are delivered, and

• resources are prudently managed.
The board of a healthcare entity discharges these responsibilities in the same way as any corporate board does
through activities such as:

• appointment and evaluation of the CEO;

• engagement with the CEO and senior management in setting the strategy of the organization;
• identification and management of any real or perceived conflicts of interest among directors and/or
officers;
• assessment of the contributions of each individual board member as well as the collective performance
of the board;
• enabling the chairman to effectively discharge the special responsibilities as a “first among equals”;
• ensuring that new board members are thoroughly oriented to the organization and the operations of the
board;
• underscoring that the interests of the stakeholders are paramount (in the case of a healthcare entity, this
is the community the institution serves);
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In the case of healthcare organizations that have a board that sits under a corporate parent or government
controlled health system, there are additional responsibilities for the board to ensure that:

• the delegations, expectations and accountabilities from the parent organization are clearly understood
by the board and management, and that
• potential points of discord with the parent are respectfully and clearly transmitted upwards.

Much more can be written about corporate governance in general at another time. However, two key practical
elements deserve special mention:

• Accountability – well functioning boards define clear lines of accountability for the CEO and his/her
team (e.g. most operations) and reserve certain accountabilities squarely for the board per se (e.g. audit).
Accountability involves formal delegation of responsibility and intermittent review of such delegations.
• Transparency – effective boards operate openly and transparently. This is especially important where
society places the trusteeship for its health care in such an entity.

A final word on corporate governance in health care – all of the above is rather straightforward, so where is the
problem in ensuring that healthcare institutions around the world are well governed at the corporate level? The
confounders are people and customs. These variables often complicate the effect conduct of board functioning.
Common people problems in healthcare corporate governance include:

• Failure of elected /appointed representatives of interest groups to realize and accept that they do not
carry the interests of their appointing / electing group into the boardroom. Their role on the board is to
solely act for the good of the entity on whose board they sit.
• Inexperience or inability of senior management to actually implement the strategies of the board
within professional sectors of the organization, which are accustomed to idiosyncratic and autonomous
behavior.
Many boards and leaders also fail to understand that customs are powerful influences within organizations.
The difficulty of changing the customs of action and behavior for large parts of institutions often presents an
insurmountable problem for a board to see its mandates carried out. This raises the issue of how to manage
institutional cultural set points, which is a subject for another discussion.

4.6 Effective clinical governance in healthcare

The name clinical governance emerged in the United Kingdom where the National Health Service defined clinical
governance as a framework through which organizations are accountable for continually improving the quality of
services and safe guarding the high standards of patient care by creating an environment in which excellence in
clinical care will prevail.
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The basic elements of clinical governance/quality-safety include:

• emphasis on education and training for professionals;

• clinical audit systems – cyclic review of clinical performance against measurable standards with changes
in clinical practice upon such review;
• assessment of clinical effectiveness – whether a particular action works and whether it represents value
for expenditure etc.;
• research and development – to generate evidence to inform decisions about policy and implementation
changes;
• openness – to enable frank discussions about safety and quality matters while respecting confidentiality
of patients and providers;
• committees and processes to ensure that these elements occur;
• risk management components – in some jurisdictions, these are included in clinical governance whereas,
in others, formal risk management is handled separately.

In the realm of clinical governance, people and customs are the same confounders. Implementation requires that
long-standing rivalries between professional groups and personalities be managed. Deeply entrenched cultural
systems and customs of practice have to be broken down and rebuilt.

4.7 Functions of Governance at Various Levels

The following are some of the functions of governance at various levels:
• Setting standards, collecting basic information on performance and creating incentives for good
performance- (Lewis and Pettersson, 2009)
• Improving supply side (state institutions) and demand side (non-state institutions/actors) in delivery of
services.
• 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
• Hospital Boards provide the oversight role for effective functioning of the facility in order to deliver 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
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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)

Propose governance structures at various levels in your country

4.8 Unit Summary

In this unit you have learnt about governance in health care, governance structures
at various levels Effective corporate governance in health care, Effective clinical
governance in healthcare, how governance structures in common impact on daily life
of the health systems and the functions of governance in health.
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UNIT 5: HEALTH LAWS, AGREEMENTS, AND REGULATIONS IN GOVERNANCE

5.1 Unit Introduction

Welcome to the 5thand last unit in our module on governance and ethics in health. In the last unit you learnt
about governance structures at various levels and the functions of governance. In this unit we shall discuss the
role of health laws in governance as well as international health laws and declarations.

5.2 Unit Outcome

By the end of this unit you should be able to apply health laws and
regulations in governance

5.3 Role of Health Laws in Governance

Forms the legal basis for technical cooperation in promoting good governance and regulation of registration of
medical products
• 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

5.4 Health Laws and Related Regulations

5.4.1 Health laws

This encompass Health laws International and national healthcarelaws; 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

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
• Environmental Health (food safety)
• Occupational Health (work rule safety laws)
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Activity
1. Discuss any two health laws from your country
2. 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)
• Enforcement lapses until disaster strikes (flood cases in Ghana)

5.4.2 International Public Health Laws/Declarations

• International Health Regulation (vaccinations?)
• 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, known as the Abuja Declaration made a 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 mobilization,
• 2005 -Paris Declaration on aid effectiveness

International PH laws and Trade Related aspects of Intellectual Properties (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
• 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 licenses
• 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
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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

Were the above goals achieved in Africa or to what extent do you think these were
achieved in your country?

Sustainable Development Goals (SDGs)

The Sustainable Development Goals (SDGs) are 17 Goals to Transform Our World by 2030.

What are the Sustainable Development Goals?

The Sustainable Development Goals (SDGs), otherwise known as the Global Goals, are a universal call to action to end
poverty, protect the planet and ensure that all people enjoy peace and prosperity. The SDGs came into effect in January
2016, and they will continue guide UNDP policy and funding for the next 15 years. As the lead UN development agency,
UNDP is uniquely placed to help implement the Goals through its work in some 170 countries and territories.
Adopted by world leaders in September 2015 and implemented at the start of 2016, more than 150 countries have pledged to
mobilizeeffortstoendallformsofpoverty,fightinequalities,andtackleclimatechange,whileensuringthatnooneisleftbehind.

The SDGs build on the work of the Millennium Development Goals (MDGs) that were emphasized from 2000 to 2015. The
new SDGs are unique in that they’re broader in their scope of eradicating all forms of poverty by calling for action by all
countries, rich and poor, to promote prosperity while protecting the planet.

As of August 2015, there were 169 proposed targets for these goals and 304 proposed indicators to show compliance.

These 17 Goals build on the successes of the Millennium Development Goals, while including new areas such as climate
change, economic inequality, innovation, sustainable consumption, peace and justice, among other priorities. The
goals are interconnected – often the key to success on one will involve tackling issues more commonly associated with
another. The following are the SDGs:

1. No Poverty - End poverty in all its forms everywhere[20]

2. Zero Hunger - End hunger, achieve food security and improved nutrition and promote sustainable
agriculture
3. Good Health and Well-being - Ensure healthy lives and promote well-being for all at all ages
4. Quality Education
5. Gender Equality - Achieve gender equality and empower all women and girls. Providing women and girls
with equal access to education, health care, decent work, and representation in political and economic
decision-making processes will fuel sustainable economies and benefit societies and humanity at large
6. Clean Water and Sanitation - Ensure availability and sustainable management of water and sanitation
for all
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7. Affordable and Clean Energy - Ensure access to affordable, reliable, sustainable and modern energy for all
8. Decent Work and Economic Growth - Promote sustained, inclusive and sustainable economic growth, full
and productive employment and decent work for all
9. Industry, Innovation and Infrastructure - Build resilient infrastructure, promote inclusive and sustainable
industrialization and foster innovation
10. Reduced Inequalities - Reduce income inequality within and among countries
11. Sustainable Cities and Communities - Make cities and human settlements inclusive, safe, resilient and
sustainable
12. Responsible Consumption and Production - Ensure sustainable consumption and production patterns
13. Climate Action - Take urgent action to combat climate change and its impacts by regulating emissions
and promoting developments in renewable energy
14. Life Below Water - Conserve and sustainably use the oceans, seas and marine resources for sustainable
development
15. Life on Land - Protect, restore and promote sustainable use of terrestrial ecosystems, sustainably manage
forests, combat desertification, and halt and reverse land degradation and halt biodiversity loss
16. Peace, Justice and Strong Institutions - Promote peaceful and inclusive societies for sustainable
development, provide access to justice for all and build effective, accountable and inclusive institutions
at all levels
17. Partnerships for the Goals - Strengthen the means of implementation and revitalize the global partnership
for sustainable development

The following 6 of the 17 goals relate to health:

• Goal 1: No poverty
• Goal 2: Zero hunger
• Goal 3: Good Health and Well-being - Ensure healthy lives and promote well-being for all at all ages
• Goal 6: Gender Equality
• Goal 7: Clean Water and Sanitation - Ensure availability and sustainable management of water and
sanitation for all
• Goal 11: Sustainable Cities and Communities - Make cities and human settlements inclusive, safe,
resilient and sustainable

5.5.3 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
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5.5.4 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 result

5.5 Expired and Fake Drugs and Uncontrolled Substances

A Developing Problem: Counterfeit

In the developing world, where few countries have the regulatory and policing power of the United States, the
problem of counterfeit drugs is even more widespread and tragic. For example, according to the World Health
Organization, 200,000 people a year die because ineffective, fake, and substandard malaria drugs don’t clear their
systems of the parasite. And because these pills often contain small amounts of active ingredient—enough to
abate some symptoms but not cure disease—they contribute to drug-resistant strains. The WHO also estimates
that between 1% and 10% of drugs sold around the world are counterfeits, up to as many as 50% in some countries.

In North America, the problem has been mostly—though not entirely—restricted to “lifestyle” rather than life-saving
drugs. Among these, the most famous is Pfizer’s Viagra, widely described as one of the most counterfeited drugs in
the world. While it’s tempting to smirk at consumers duped by fake diet pills, baldness cures, and counterfeit Viagra,
these drugs are stepping stones for counterfeiters. Criminals who find success here, experts say, will likely expand
their business.

Case Study 1: Cracking Down on Counterfeit Drugs

By Barbara Moran on Tue, 20 Aug 2013

[Link]

People who saw Rick Hitsman in court say he looks like any other middle-aged man with grey hair and blue
eyes. For years, until he was indicted in 2012, Hitsman travelled back and forth between Arizona and California,
selling counterfeit Viagra out of the trunk of his gold Toyota Camry. He’d meet buyers at parking lots around the
San Fernando Valley and sell them boxes of fake Viagra, each containing four tablets, for $10 per box. Real Viagra
costs around $22 per pill, so for buyers it was quite a bargain. Hitsman also sold fake Viagra online, advertising on
Craigslist. Unfortunately for him, one of his customers was a man named “Mike,” a private investigator working for
Pfizer.
For two years, “Mike” bought counterfeit Viagra from Hitsman and sent samples to Amy Callanan, a senior scientist
at Pfizer. Callanan, who works at Pfizer’s R&D campus in Groton, Connecticut, is now sitting with me at a large
conference table scattered with baggies, blister packs, and bottles of pills. Callanan spends most of her time
analysing fake pharmaceuticals, looking for chemical clues that may lead investigators to culprits. She picks up
two small cardboard boxes. One box contains legitimate Viagra, the other is full of fakes. To me, they look almost
identical: same size, same wide blue stripes down the left-hand side, legitimate-looking Pfizer logos and holograms.
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Lipitor, a statin used to control

cholesterol, is among Pfizer’s drugs
that is counterfeited. Above,
counterfeit pills (left) sit next to
genuine examples (right).

But to Callanan, the fake is obvious. “I see this one all the time,” she says, handing me one of the boxes. It’s
the same type Hitsman sold. “This is the most common counterfeit Viagra we see—it’s manufactured for the
Malaysian market.” She points out the tell-tale signs of the fake: the blue stripe is too dark, the word
“contains” is spelled incorrectly (“contains”), and the box sports a hologram that Pfizer no longer uses. But
the giveaway is the lot number: 314833021, which Callanan rattles off from memory. Once a lot has been
distributed to patients, Pfizer permanently retires its number. But thanks to counterfeiters, this lot number still
lives on in knockoffs. It’s proven so popular among criminals that Callanan now sees knockoffs of the knockoffs.
“It’s interesting how these same mistakes get perpetuated,” she says.

An estimated 80% of counterfeit drugs come from overseas.

Fuelled by easy internet sales, global supply routes, and minimal punishments, counterfeit prescription drugs
have become an exploding industry, with an estimated market worth $75 billion a year worldwide. Long the
scourge of developing countries, fake drugs are now popping up in the United States. In 2012, a counterfeit
version of the cancer drug Avastin was widely distributed in the U.S., and a fake version of the ADHD drug
Adderall, in high demand because of a shortage, arrived in the U.S. through internet pharmacies. In early 2013,
the U.S. Food and Drug Administration (FDA) warned doctors that a fake version of another cancer drug, Altuzan,
containing no active ingredient, was being distributed in the United States. An estimated 80% of counterfeit drugs
come from overseas, and most of them are manufactured in India and China. In this era of globalization, the
supply chain for genuine pharmaceuticals has grown longer, and every link offers an opportunity for
counterfeiters.
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This counterfeit drug manufacturing site in

China produced fake Viagra and other drugs that
were sold to customers in the European Union
and the U.S.

“The ultimate way of making money, if you’re a counterfeiter, is to get into the legal supply chain,” said Roger
Bate, a resident scholar at the American Enterprise Institute and an expert on counterfeit prescription drugs.
“Even in the rich countries, the legitimate supply chain has been breached by counterfeiters. You could go into
a CVS or a Walgreens to fill your prescription for whatever it may be—it could be for a heart medication, a
cancer drug, an antibiotic—and you could be killed by that medicine.”

Pfizer won’t say how much money they lose on fake Viagra, but the drug is one of the company’s
blockbusters, pulling in more than $2 billion in 2012. Viagra isn’t Pfizer’s only counterfeit headache: in 2008,
according to John Clark, vice president of global security for the company, about 20 different Pfizer medicines
and products were being counterfeited around the world. Today, that number is up to 60—everything from
Lipitor and Centrum Vitamins to, bizarrely, Chap Stick.

Counterfeit cough syrup being dispensed from

a water cooler in Pakistan.

Like Pfizer, many large companies police their brands; after all, criminals fake everything from perfume to
tires. But according to Bate, pharmaceutical companies take their policing a step further. The prescription drug
market is vast and lucrative—$800 or $900 billion worldwide—and counterfeiting drugs is relatively simple. “It’s
probably easier to make fake pills than it is to make fake jeans, yet the mark-ups are far greater,” Bate says. “If you
are a smaller criminal getting into the fake drug business, it’s good and easy money.” It’s good money for big-
time criminals as well. According to a report from the Stimson Centre, a non-profit global security institute,
the Russian mafia, Colombian drug cartels, Mexican drug gangs, Hezbollah, and al Qaeda are all producing and
trafficking counterfeit drugs.
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Pfizer’s investigative powers are surprisingly broad. The U.S. government, naturally, has laws against counterfeiting
drugs, but the responsibility for enforcement is scattered across many agencies, including the FBI, the FDA, the
Drug Enforcement Administration (DEA), Immigration and Customs Enforcement (ICE), and state and local police.
“The FBI can look at it as a healthcare fraud case, a straight-up fraud case, or an importations case. They have the
broadest reach,” says Brian Donnelly, who was an FBI agent for 21 years before becoming director of investigations
for Pfizer North America. “But since 9/11—I can speak from personal experience—they’ve been sort of side tracked
onto terrorism.”

Donnelly describes his role at Pfizer as providing law enforcement with “grounders,” or cases that Pfizer has already
investigated and prepped for prosecution. Pfizer’s investigative powers are surprisingly broad. After their computer
experts sweep the internet for possible counterfeits, the company hires private investigators to purchase drugs from
stores or online pharmacies and record conversations with sellers in jurisdictions where it’s legal. Then scientists
analyze the fake drugs in one of Pfizer’s three testing facilities: Groton, Connecticut; Sandwich, England; or Dalian,
China. Donnelly says his team gives U.S. and Canadian law enforcement two or three cases each week, and Pfizer’s
work leads to about 50 or 60 convictions each year.

Case Study 2: Fingerprinting the Fakes

The case involving Rick Hitsman, the man who sold fake Viagra out of the trunk of his Camry, was fairly typical. After
Pfizer organized the case against him, they turned it over to ICE, who continued the investigation. Hitsman assured
undercover ICE agents that the Viagra was high quality. In fact, he said, he used the counterfeit Viagra himself. He
had a 28-year-old girlfriend, and the stuff would last a week. Both Callanan and Donnelly testified at Hitsman’s trial,
and he was convicted of trafficking in counterfeit goods in June 2013. “It wasn’t that hard to convince the jury,”
Donnelly says.
The prosecution, of course, had science on their side. In the lab at Pfizer, Callanan picks up a yellow envelope and
removes an evidence bag from the Hitsman case. She opens it and pulls out a box of the infamous Malaysian
counterfeit Viagra. To test the drug, Callanan scratches off a patch of blue coating, then scrapes out some of the
white interior. She places the white dust into an infrared spectrometer, which shines infrared light on the sample to
analyze its chemical bonds. What results is a graph of peaks and valleys—reflected and absorbed wavelengths—
unique to that drug. Callanan taps the keyboard and the IR spectra from four samples from the Hitsman case appear
on the screen. She zooms into the “fingerprint” region, an area of peaks and valleys that reveal secrets about the
pills’ chemical makeup.

Counterfeit Viagra pills (left), such as these

from Pakistan, may look indistinguishable
from the real thing (right), but chemical
analysis can reveal the fake.
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“They’re all pretty similar,” she says, peering at the four red squiggles. “It looks like the same maker, but maybe
different batches.” She taps on the keyboard again, and the chemical signature of authentic Viagra, outlined in black,
pops onto the screen. Moving the mouse, she superimposes the real Viagra fingerprint over the fakes. “Here’s the
tell-tale difference,” she says, pointing to a low red peak juxtaposed with a high black peak at 1700 cm -1. “This is the
active ingredient—sildenafil citrate—you can see where it’s supposed to be, and how low it is in the counterfeit.”
Callanan grinds a bit more of the counterfeit pill with a mortar and pestle, and tests it with X-ray diffraction to
confirm the first set of results. Here, Callanan further refines the fake’s formula by comparing it to Pfizer’s library of
excipients—the inert ingredients that give a drug its form and consistency. “You see these other red mystery peaks,”
she says, pointing at the screen. “Those are calcium sulphate diehydrate and calcium sulfate hemihydrate, the two
most common ingredients we see in counterfeits.” Noticing my blank expression, she adds, “its gypsum, the same
stuff as sheetrock.”

These used vials, seized during a raid in Colombia,

were being washed for reuse to hold counterfeit
medications.

According to Callanan, counterfeiters often add gypsum because it’s cheap, easily available, and will compress
and hold the shape of a tablet. But extra ingredients like caffeine baffle her. Counterfeiters, it seems, have no
limit to their imaginations. “What I really like is counterfeit Xanax spiked with melatonin,” she says with a laugh.
“It’s like, why?”

“We can’t always figure out why,” adds Brian Donnelly, who is standing nearby. “But I can guarantee it has
something to do with making money.”

Finding Fakes for Less

Pfizer doesn’t police the market beyond their own brands, but the company has given developing
countries sophisticated handheld scanners that can detect a variety of counterfeits, including some non-Pfizer
medications. But still, the largest percentage of counterfeit drugs—the generic antibiotics, tuberculosis
drugs, and malaria medicines so prevalent in the developing world—often go unmonitored, since many
countries don’t even have their equivalent of the FDA. For these reasons, a handful scientists and engineers are
trying to create cheap, nearly indestructible devices to test for counterfeits. They want to do what Pfizer does for
pennies.

One of these scientists is Marya Lieberman, a chemist at the University of Notre Dame. “In a developing country,
if you go to one of the little shops that sell medications, you cannot look inside the pill and see if it’s good or not,”
Lieberman says. “The technological tools that you need for that are very rare and expensive.”
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To address that problem, Lieberman has developed a simple paper card that tests whether a drug contains the
correct active ingredients. The user scrapes a tablet across the test card, then dips the card into water. Water travels
up the card, mixing chemicals with the drug, and a coloured bar code shows whether the correct ingredients
are present. Lieberman’s cards currently sense 12 substances, including different types of antibiotics and anti-
tuberculosis medications, as well as fillers like chalk, flour, and acetaminophen, a common additive since it lowers
fevers, making patients believe the medicine is authentic. She’s currently testing the card with pharmacists in Kenya.
Right now, Lieberman’s cards only detect if an ingredient is present or absent. Her next step is to design cards that
detect if the drug contains some, but not enough, active ingredient. She also wants to make the cards cheaper—
they now cost about 45 cents—and easier to read.

Lieberman knows that her cards alone can’t fix the problem. Developing countries need trustworthy agencies to
regulate and distribute drugs. Governments need stiffer penalties for counterfeiters and better enforcement, doctors
and patients need to recognize the issue, and the technology that detects fake and substandard drugs needs to be
cheaper and more robust. But Lieberman is optimistic that her cards will help, at least a little. “Sometimes you can’t
solve the whole problem,” she says, “but you can start nibbling away at it.”

The Fake Drug Industry Is Exploding, and We Can’t Do anything about it ... - Newsweek
[Link]
In the mid-2000s, Myanmar saw between 500,000 and 600,000 cases of malaria every year. So it wasn’t surprising
when, in February 2005, a 23-year-old man in Myanmar came down with a fever, nausea, chills and a headache so
severe he had to be taken to the local hospital. His doctors quickly determined he was, in fact, stricken with malaria.
They prescribed him artesunate, an inexpensive anti-malarial regularly used by Myanmar’s health care professionals
to treat the infectious disease.

Typically, a patient’s symptoms will subside after a few days on the drug, but this young man grew much worse. He
slipped into a coma, his kidneys showed signs of failing, and the concentration of malarial parasites in his blood grew
higher. His doctors tried to give him fluids and a more powerful dose of artesunate injected into his bloodstream,
but they were too late. The infection spread to his brain and killed him.
Because artesunate is safe, generally well-tolerated and highly effective, hospital investigators decided to probe the
case to try to understand what might have gone wrong. They were shocked to discover that the artesunate given
to the patient had only 20 percent of the active ingredient required to kill the parasites. The drug, in other words,
was a fake.

In the small village, word spread quickly of the tragedy, and community leaders were distraught. No one in their
small town had ever died from a fake drug before—at least, not that they knew of. Fearing the threat of other
preventable deaths, they collected all the artesunate from the hospital’s supply, went out to local pharmacies and
pulled any other suspicious artesunate from the shelves, and then publicly burned it all.

Globally counterfeit medication is a major issue for public health and international trade. BSIP SA/Alamy
Tragic incidents like this happen all over the world and with almost every type of drug. In Pakistan, a poor-quality
tuberculosis drug killed 100 patients at a Lahore hospital in 2012 by triggering severe adverse reactions. In 2013,
officials in India discovered that 8,000 patients died over a five-year period in a remote Himalayan hospital because
an antibiotic used to prevent infection after surgery had no active ingredient. And in May this year, the World Health
Organization (WHO) issued a warning about expired meningitis vaccines being sold in West Africa—a devastating
blow to those trying to slow a viral outbreak in the region.
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Advertisement

Every type of drug is susceptible, from anti-malarials to vaccines, antibiotics, HIV treatments and even Viagra. At
their best, falsified drugs have none or too little of the active ingredient; at their worst, sellers are providing hospitals
and patients with “drugs” that are life-threatening poisons.
“These falsifiers are in fact murderers—they are causing death,” says Jim Herrington, executive director of the
Gillings Global Gateway at the University of North Carolina’s Gillings School of Public Health. “And you’re more likely
to get prosecuted for counterfeiting a Gucci purse than a drug.”

Internet Roulette
Task forces are finding more fake drugs every year. Interpol’s flagship pharmaceutical investigation, Operation
Pangea, for example, says it seized 2.4 million fake and illicit pills in 2011; in 2015, the total number of pills and other
medications that officials seized jumped to 20.7 million.
That’s either good news or a terrible harbinger of what’s to come. It might be the case that officials finally know
where to look for fakes and are just now catching up to the crooks. Though public health officials have known
about falsified pharmaceuticals for decades, they didn’t understand the extent of the catastrophe until they started
collecting data in the early 2000. Interpol’s pharmaceutical crime unit wasn’t even founded until 2005.

On the other hand, many experts believe that the problem is on the rise and that more criminals are turning to
pharmaceuticals for a simple reason: low risk and high reward. “The penalties are relatively weak for trading in
falsified pharmaceuticals compared to those for trade in narcotics and human trafficking,” says Paul Newton, a
professor of tropical medicine at the University of Oxford medical school who has spent decades tracking poor-
quality medicines. And criminals can make a lot of money by falsifying drugs that are in high demand, in short
supply or are exorbitantly expensive for consumers.

Advertisement
“We’ve seen it happen regularly—if a shortage occurs, hospitals and clinics will step outside the normal supply
chain, and the [criminals] exploit the situation,” says Michael Deats, a group lead for the WHO’s Department of
Essential Medicines and Health Products. Meanwhile, different organizations over the past few years have estimated
that anywhere from 100,000 to a million people die every year due to falsified drugs. This number has likely risen
over time, echoing what experts assume to be a rise in the number of fake drugs in circulation. But it’s impossible
to know for sure, in large part because it’s so difficult to know that it was, in fact, a fake drug that killed someone.
Maybe the diagnosis was wrong. Maybe a quality drug was administered too late.

The global pharma industry has complex networks that crisscross the globe. A single pill might pass through a
dozen countries during its manufacturing process, which offers many opportunities for criminals to put fake drugs
into the supply chain. For example, chemicals synthesized in China can be combined with fillers in India and then
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packaged in Mexico before arriving at a pharmacy in Canada. Often, fake-drug-trafficking criminals have extensive
international networks. In 2013, a Puerto Rican man was sentenced to two years in prison for selling hundreds
of thousands of fake pharmaceuticals online. He was the American contact for a counterfeit drug ring allegedly
headed by Bo Jiang, a Chinese national who was last seen in New Zealand before he went on the run from officials.
The international nature of the fake-drug trade is what makes it such a difficult problem to manage. “Very few of the
196 countries in the world have a specific dedicated service to deal with pharmaceuticals,” says Aline Plançon, the
assistant director of Interpol’s program fighting counterfeit medical products and pharmaceutical crime. “Others
can’t enforce their laws because they don’t have the capacity or budget.”

When pharmaceutical components arrive at each new country, in most cases enforcement agents check a drug’s
paper trail to ensure legitimacy and spot-check the packaging, as well as its chemistry and appearance. But
criminals often use falsified papers to sneak their fake drugs through checks, and the WHO estimates that about 30
percent of countries worldwide don’t have a functional drug regulation agency equivalent to the Food and Drug
Administration (FDA) in the U.S.
Not surprisingly, these countries are more likely to be relatively poor, with underfunded and understaffed
governments. With limited government oversight, officials in these countries sometimes accept bribes. A 2014
report published by the Independent Joint Anti-Corruption Monitoring and Evaluation Committee found, for
example, that in Afghanistan, Ministry of Public Health officials “solicit bribes for activities outside their departmental
mandates with little chance of being detected.” In China, an official was executed in 2007 for accepting bribes to
approve untested medicines.

Even in wealthier countries like the U.S. and the United Kingdom, where drugs are tested frequently, fakes can slip
through, often when patients or clinicians buy them over the Internet. Studies show that about 90 percent of drugs
purchased online come from a different country than what the website claims, and Internet pharmacies often buy
drugs from countries with lax regulatory systems.
The majority of drugs purchased online are sent through the mail. Most of these shipments are subjected to standard
border control mechanism, including X-rays and drug-sniffing dogs. If there’s a reason to believe a specific shipment
is likely to have fakes—for example, if officials have received reports that certain drugs have been falsified recently,
or if the paperwork seems suspicious—customs agents are more likely to open the packages and inspect their
contents, according to a spokesman from the National Intellectual Property Rights Coordination Center (NIPRCC),
one of the government agencies involved in U.S. customs protection.

Brigadier General Long Sreng, right, a deputy chief of

the anti-economic crimes department of the
Cambodian interior ministry, looks through
confiscated fake medicines in Phnom Penh,
Cambodia, November 28, 2014. About five tons of
counterfeit medicines were seized. Phearum/Xinhua/
eyevine/Redux
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But neither the FDA nor U.S. Immigration and Customs Enforcement could tell Newsweek what percentage of
these drugs are actually checked or confiscated every year. Even if they find something amiss, there’s no guarantee
they’ll seize the product—seizures involve a 25-step process of testing and investigations, the NIPRCC
spokesman says, and they are costly in time, manpower and resources. So officials seize drugs only if they are
both suspicious and likely to affect a large number of people. “Seizures happen if there’s a lot of a product, often
thousands of dollars’ worth,” the NIPRCC spokesman adds.

If there’s not enough of a product to conduct a formal seizure, officials set the package aside and send a letter
to its intended recipient saying that officials suspect that this product contains fakes and that, if he wants the
shipment anyway, he assumes the risk of its contents. If the recipient contacts officials in response to the letter,
they will ask questions about where the drugs were purchased so that customs agents can more effectively
monitor future shipments. The FDA says that screening and evaluation programs like these have led its Office of
Criminal Investigations to arrest more than 400 people over the past two decades.

The system is far from fool proof. In 2011, for example, the FDA received reports that customers who had
ordered drugs like Ambien, Xanax and Lexapro online instead received pills of Haldol, a potent antipsychotic.
According to the FDA, “These customers needed emergency medical treatment for symptoms such as difficulty in
breathing, muscle spasms and muscle stiffness.”

Big, Dirty Pharma

Stopping this scourge would at a minimum require a great deal of cooperation among more than a handful
of nations. Amir Attaran, a professor of law and medicine at the University of Ottawa, suggests an international
treaty whereby countries would all agree on a set of laws. Attaran compares it to the aviation industry: “There are
dozens of treaties on civil aviation, and every single country is following those. If not, they don’t fly.” To raise the
standards for pharmaceuticals worldwide, Attaran says, we need a similar system that penalizes countries that
don’t enforce medicinal quality controls.

The closest protocol now is the Medicrime convention: Since 2011, countries can sign the informal treaty
to criminalize pharmaceutical fraud within their borders. But countries aren’t under much pressure to pass
more formal legislation or to enforce the statutes of the convention. And in fact, they often have incentives not
to. Some countries, like India and Brazil, are dragging their feet on international enforcement regulations
because poor-quality pharmaceuticals make up such a large part of their economy, Attaran says.

Others are trapped by policies that conflate fake and counterfeit drugs. Counterfeit drugs are those that infringe
on a patent registered by the pharmaceutical company. Counterfeit Viagra, for example, might contain the
same ingredients as the legitimate drug, but Pfizer didn’t authorize the pill’s production and doesn’t get a cut
of the profits. Counterfeit drugs don’t necessarily endanger people’s lives—they’re more a threat to Big Pharma’s
bottom line than anything else. From a public health perspective, falsified drugs are the real menace, as they
kill many thousands of unsuspecting people around the world each year. But in countries where policies do not
adequately distinguish between the two, enforcement agencies have to spend their limited resources
cracking down on minuscule infringements on intellectual property instead of tracking down the cartels
falsifying drugs.

The WHO is in a unique position to resolve the issue. The organization hosts and mediates the conferences in
which countries meet to discuss what they can do together to reduce the number of falsified pharmaceuticals
reaching patients. It also is the central clearinghouse for reports of fake drugs across the world. But, to date, the
organization
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has declined to push countries to sign fake-drug-related treaties and has not taken a strong stand on separating out
the public health issue of falsified drugs from the counterfeit concerns of manufacturers. The WHO has used and will
continue to use the term “substandard, spurious, falsely labelled, falsified and counterfeit”—SSFFC—to talk about
the larger public health issue, Deats says, “Until member states agree on a universal definition.” But Attaran and
others say that this is really because the WHO doesn’t want to alienate Big Pharma—a close partner and financial
supporter.

“The difference between falsified and counterfeit drugs seems trivial, but half the reason the world isn’t doing more
about pharmaceutical crime is precisely because of this language,” Attaran says. “Pharma companies, at least dirty
ones, have tried to expand the fight against falsified drugs to protect their intellectual properties, and that’s just
wrong.”

A year ago, Attaran was working as a consultant for a project on falsified pharmaceuticals with the United Nations
Office of Drugs and Crime. At one point, he says, he was ordered to make sure they would also go after intellectual
property cases by someone working at Sanofi, the French pharma giant. Sanofi had explicitly co-sponsored the
project through its non-profit subsidiary, the Institute of Research Against Counterfeit Medicine. (An IRACM
spokeswoman confirmed that the organization was founded in 2010 at “the instigation of Sanofi” and that it
continues to receive funding from the company.) Attaran withdrew from the project for ethical reasons, and it
continued on without him. In December 2014, several member countries sent letters of complaint to the UNODC
because its policies linked counterfeit and falsified medicines.

A Chinese policeman walks across a pile of

fake medicines seized in Beijing. The rapid
growth of Internet commerce has led to an
explosion of counterfeit drugs sold around
the world, with China believed to be the
biggest source of fake medicines in the
world. (AFP/Getty)

Big Pharma has a lot of sway with the international organizations working to keep drugs safe. The IRACM,
for example, partners with a number of global regulatory groups in addition to the U.N., like the World
Customs Organization and Interpol. And in recent years, the WHO has been accused by journalists and
nonprofits of falling under the influence of Big Pharma after accepting donations from organizations explicitly
funded by it; in 2007,
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The BMJpublished an article exposing the fact that a $10,000 donation to the WHO was made by pharma giant
GlaxoSmithKline, laundered through the non-profit European Parkinson’s Disease Association.

Asked about the WHO’s relationship with pharmaceutical companies, Deats says that in order to combat SSFFC
drugs, all kinds of stakeholders need to collaborate on every scale. “That means working with public sector, private
sector, health care professionals, civil society and law enforcement.” Ultimately, he says, the WHO should not be
responsible for a legal framework. He sees his organization as a facilitator, a means through which countries and
health care professionals can communicate when they find fake drugs. But the legal framework as well as the
enforcement of those laws, he says, are out of the WHO’s hands—and up to individual countries.

There is one group acting as an international regulator for fake drugs. In the past seven years, Interpol’s Operation
Pangea has led to the seizure of millions of packages of falsified drugs, many of which were sold online. This is
always touted as a great example of successful international collaboration—one Pangea bust in 2014 involved
authorities from 111 different countries, according to an FDA press release at the time.

But those numbers are deceiving, Attaran says. “What Interpol never tells you is that well over half the medicines
they seize in Pangea operations are from only a few countries, such as the United Kingdom, the U.S. and France”—
countries that already have strong regulatory and enforcement systems. “It’s really an isolated few national efforts
stitched together by Interpol to create the illusion of a grand global effort [against falsified pharmaceuticals], which
doesn’t exist.” That leaves poorer countries vulnerable, he says, and keeps those in wealthier ones just satisfied
enough that they don’t feel the need to clamour for more dramatic action.

Plançon says Interpol is doing the best it can to divide its limited manpower between wealthy and poorer countries,
while figuring out what unique approach each area will require. For example, on a recent visit to Guinea, Plançon
helped authorities decide that the best use of their resources was to beef up their FDA equivalent instead of
conducting a one-time bust of fake drugs.

Cell phone Salvation

The best way to catch a fake is to send samples to a lab where researchers can do tests. But even lab tests are not
100 percent accurate, and in low-income countries, sending thousands of samples to a lab is slow and prohibitively
expensive. There are handheld mass spectrometers (a tool used to analyze the chemical makeup of foods,
pharmaceuticals, etc.), but they are new, unproven and costly.

That’s why scientists and tech innovators are working on getting cheap and effective solutions that can make
a difference locally. The CD-3 is one promising example; it’s a handheld device invented by the FDA that emits
ultraviolet and infrared light onto pills and their packaging to determine if they are genuine. It’s intuitive to use,
relatively inexpensive at $1,000 per device and surprisingly effective.

In 2012, Patricia Tabernero, then a researcher at the Worldwide Antimalarial Resistance Network, a global project
tracking falsified anti-malarials, was in Laos looking for fake drugs. At the time, Laos was on the brink of a health
crisis because fake drugs were making diseases, especially malaria, more resistant; drugs with too little of the active
ingredient kill some of the bacteria but leave the hardiest in the body to multiply and then spread.
Tabernero and her colleagues decided to try out the CD-3, in what would become the first field test of the device, in
a developing country. First, they needed to collect sample drugs from as many pharmacies as possible in southern
Laos. But they didn’t want to tip off the pharmacists, who might skew their sample by giving the researchers more
or fewer suspicious drugs, or even alert local criminals involved in manufacturing the fakes. So Tabernero and her
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European colleagues enlisted local volunteers to enter the pharmacies and ask, “I would like to buy some drugs for
my friend who is sick. We are traveling and work in construction. May I see which ones you have?”

In just four weeks, Tabernero’s team collected anti-malarials from 144 private drug outlets. In the evenings, she
would test the samples in her hotel room using the CD-3. The results were encouraging: The local officials caught
on quickly, mastering the device in just two days of training. And it worked well. They shipped all the tested pills to
a U.S. Centres for Disease Control and Prevention lab for chemical analysis, to see how well the device did, and it was
nearly 100 percent accurate for all the samples it tested.

But the CD-3 could evaluate only 35 percent of the samples. To see if a drug is legitimate, the instrument needs
to compare it with a genuine example, which regulators may not have if the drug is rare or if the manufacturer
changes the formula without warning. This is especially true in a developing country like Laos. So far, officials don’t
have access to a universal registry of packaging; if the CD-3 is going to become more popular and used worldwide,
agencies like the FDA will need to form stronger partnerships with manufacturers to make this universal registry a
reality.

A sign for a Macau, China, and drugstore

assures customers there are no fake drugs
being sold in the shop. But retailers often
have no clue what’s real and what’s not.
NeilSetchfield/Alamy

In the meantime, other low-tech solutions are helping consumers in developing parts of the world
protect themselves. The widespread use of cell phones has helped: Legitimate drug manufacturers are starting
to design packaging with scratch-off codes that a consumer texts to a special phone number. They then receive an
automatic response confirming whether or not the drug is genuine. This has promising initial results—so far,
Herrington says, no falsifier has been able to hack this system. But in the long term, experts agree, this solution is
not ideal because it doesn’t strengthen the regulatory system, as the CD-3 does. And without a strong regulatory
system, falsifiers can’t be caught.
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That’s also why, ultimately, the problem will be fully solved only when large importing countries like the U.S. adopt
stronger legislation and insist that their trade partners do the same. “If they don’t want to play by the rules, within
five years their access to the U.S. market is gone,” Attaran says. Take India, for example. Indian manufacturers are
currently responsible for 40 percent of the generic drugs in the U.S., and recently they have come under increased
scrutiny due to lapses in quality and regulation. The FDA could place sanctions on the country or ban the import
of all drugs “until India cleans up its act,” Attaran says. The agency could provide a five-year grace period, he adds,
to allow American drug companies to find trustworthy facilities and continue manufacturing to prevent drug
shortages domestically.

The U.S. is not immune to fake drugs, of course. In 2012, hundreds of cancer patients took what they thought was
Avastin, a monoclonal antibody, only to learn that their drug lacked the active ingredients. This past April, the FDA
received reports of fake Botox in clinics all over the country. The FDA has a website warning consumers against
fakes known to be in the drug supply. The government regularly files lawsuits against online pharmacies and their
collaborators, charging them with drug trafficking, smuggling, counterfeiting and money laundering.
Nevertheless, one of the reasons the U.S. hasn’t taken stronger international action is that most citizens don’t know
the problem is so pervasive. Americans enjoy some of the strongest regulatory and enforcement systems in the
world. Despite the occasional problematic batch here and there, what consumers buy at their local pharmacy in the
States is probably genuine, which means Americans are less likely to push our leaders to make changes.

Citizen awareness could make all the difference. It’s happened before, most recently with dietary supplements
with false claims about their ingredients or effects. For the past few years, people ranging from health nuts to
journalists have decried the ineffective and largely unregulated supplements, which often contain ingredients
not listed on the packaging. But enforcement agencies like the FDA didn’t do anything about it. Earlier this year,
enforcement agencies finally gave in; the New York attorney general, along with the FDA, began to crack down on
supplement companies selling fake or dangerous products. In New York, authorities tested top-selling herbal
supplements at four retail giants—GNC, Target, Walgreen and Wal-Mart—and found that 80 percent did not contain
the medicinal herbs listed on the label. In response, attorneys for the state issues cease and desist letters to the
retailers.

It’s an elegant solution to a very complex problem: If citizens force the U.S. to play a larger role in the international
conversation about falsified drugs, the drug supply would be safer within U.S. borders but would also extend far
beyond. With the pressure on, countries would likely band together to share detection technologies, collaborate on
a universal database of legitimate pharmaceuticals and pass international standards with real consequences. And
that could quell rampant drug-resistant malaria in Laos, or save the lives of thousands of Sudanese citizens who
thought they were safe because they got the meningitis vaccine but really were injected with little more than saline.
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COUNTERFEIT AND EXPIRED DRUGS

[Link]

Did You Ever Wonder Why People Buy Counterfeit Drugs?

Last month, the Wall Street Journal featured an article that discussed the efforts currently underway to deter
people from buying counterfeit products. It pointed out that many anti-counterfeiting messages fail to address the
underlying motivation which leads people to buy counterfeit products. The authors surveyed people in the United
States, Brazil, China, India, and Russia. They asked consumers to consider and rank five factors that may influence
their decision to buy counterfeit drugs or a pirated movie – quality, cost, sentiment, ethics and ease of purchase.

Not surprisingly, the researchers received very different responses from the survey participants as to “why they
would buy a fake DVD” versus “why they would buy a counterfeit drug.” But overall, the authors found consumers
would buy a fake because:
• they thought it was just as good as a legitimate product;
• they could not afford the genuine product;
• they do not like the big businesses that make the authentic products;
• they do not think it is illegal or immoral to do so; and/or,
• the products were easy to obtain.

ACTIVITY
Addressing end-of-life issues?
Discuss how many would be willing to pay $50,000 US equivalent to have a life-saving surgery for their 85 year
old grandmother under the following conditions
i. Surgery and post-operative care costs $50,000 US and will be paid by government
ii. Surgery and post-operative care costs $50,000 US and will be paid by your family

SURROGACY

Surrogacy: A 21st Century Human Rights Challenge

The growing surrogacy phenomenon in which women agree to have their bodies used to undergo a pregnancy
and give birth to the resulting baby is becoming a major issue of the 21st century. Surrogacy is often referred
to as “womb renting” wherein a bodily service is provided for a fee. The practice is fraught with complexity and
controversy surrounding the implications for women’s health and human rights generally. Society is only beginning
to grapple with the issues that it raises. Increasingly, surrogates function as gestational carriers, carrying a pregnancy
to delivery after having been implanted with an embryo. Since the surrogate usually has no biological relationship
to the child, she has no legal claim and the surrogate’s name does not appear on the birth certificate. In the United
States there is no national regulation of surrogacy and its fifty states constitute a patchwork quilt of policies and
laws, ranging from outright bans to no regulation.

A few of the many issues raised by surrogacy include: the rights of the children produced; the ethical and practical
ramifications of the further commodification of women’s bodies; without regulation, fraud committed by surrogacy
companies cannot be prevented or prosecuted; the exploitation of poor and low income women desperate for
money; the moral and ethical consequences of transforming a normal biological function of a woman’s body into
a commercial transaction.
The lack of national laws or regulation of surrogacy in the United States is cast against a backdrop of rising usage.
The American Society for Reproductive Medicine reported a 30% increase in surrogate births between 2004 and
2006, for a total of 1,059 live births in 2006, the most recent year for which it could provide data. Industry experts
estimate that the actual number is much higher since many surrogate births go unreported.
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A fertility-industrial complex has been created to cater to the 8 million infertile women in the United States alone,
who are spending approximately $3 billion a year to try to help themselves conceive. Even though the cost to
the intended parent(s), including medical and legal bills, runs from $40,000 to $120,000, the demand for qualified
surrogates is well ahead of supply. The surrogate herself typically is paid $20,000 to $25,000 in the U.S., which
averages approximately $3.00 per hour for each hour she is pregnant, based on a pregnancy of 266 days or 6,384
hours.
In surrogacy, the rights of the child are almost never considered. Transferring the duties of parenthood from the
birthing mother to a contracting couple denies the child any claim to its “gestational carrier” and to its biological
parents if the egg and/or sperm is/are not that of the contracting parents. In addition, the child has no right to
information about any siblings he or she may have in the latter instance.

Surrogacy is another form of the commodification of women’s bodies. Surrogate services are advertised, surrogates
are recruited, and operating agencies make large profits. The commercialism of surrogacy raises fears of a black
market and baby selling, of breeding farms, turning impoverished women into baby producers and the possibility
of selective breeding at a price. Surrogacy degrades a pregnancy to a service and a baby to a product.

The Center for Bioethics and Culture (CBC) has been in the forefront of the movement demanding morally responsible
science for over a decade. We call for a cessation of this practice that exploits women’s bodies and endangers their
health, disregards the human rights of the children produced, and commodifies human life, turning the miracle of
birth into just another commercial transaction and business opportunity for endless profit generation.

What’s Wrong with Surrogacy?

Surrogacy Carries Health Risks that often go Untold. There have been confirmed deaths of surrogate mothers in
both the United States and abroad.

Due to the high costs involved in surrogacy and the strong desire to boost success rates, multiple embryos are often
transferred into the surrogate mother. In addition to the increased risk of caesarean sections and longer hospital
stays, the British Journal of Medicine warns

“Multiple pregnancies are associated with maternal and perinatal complications such as gestational diabetes, foetal
growth with restriction, and preeclampsia as well as premature birth.”

Multiple studies have found “increased in multiple births, NICU admission, and length of stay with hospital charges
several multiples beyond that of a term infant conceived naturally and provided care in our nursery” for surrogate
pregnancies.

Studies show that women pregnant with donor eggs, very common in surrogate pregnancies (the definition of
gestational surrogacy) have a more than threefold risk of developing pregnancy induced hypertension and
preeclampsia.

Lupron use in preparing a gestational surrogate to receive transferred embryos has been documented to put a
woman at risk for increased intracranial pressure. There are Health and Psychological Risks to the Children Born via
Surrogacy .Children born through surrogacy are much more likely to suffer from low and very low birth weights.
In addition, a 2014 study from the Journal of Perinatology found a 4-5 fold increase in stillbirths from pregnancies
through assisted reproductive technologies
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Surrogate pregnancies intentionally sever natural maternal bonding that takes place during pregnancy. A study
in the Journal of Child Psychology and Psychiatry found “surrogacy children showed higher levels of adjustment
difficulties at age 7” and “the absence of a gestational connection to the mother may be more problematic. The
study also reported that such difficulties “may have been under reported by reproductive donation mothers who
may have wished to present their children in a positive light.”

Young adult children born via anonymous gamete donation suffer serious genealogical bewilderment according to
both empirical studies and actual testimonies. A study in the journal Human Reproduction concluded, “Disclosure
to children conceived with donor gametes should not be optional.” Surrogacy is Expensive, Risky, and Eugenic, and
it Involves Coercion. The fertility industry is estimated to be a multi-billion dollar industry in the United States alone.
A review of most agency websites reveals a dehumanizing approach where patients are referred to as “clients,”
surrogate mothers are referred to as “carriers,” and surrogate pregnancy arrangements referred to as “sales.”

During a surrogate pregnancy, intended parents have borne the financial costs of IVF, egg donation, surrogacy etc.
but the health insurance industry picks up the long term costs associated with these high risks pregnancies, which
require longer hospitalization stays and intensive care for the surrogate mother and child (ren). When compared to
a natural pregnancy, surrogate pregnancies of a singleton or twin resulted in hospital charges 26 times higher and
173 times higher when triplets or more were born. Xiii Teresa Erickson, a reproductive attorney convicted of baby
selling, called herself “the tip of the iceberg.”

Rudy Rupak, founder of Planet Hospital, a global IVF provider, told the New York Times, “Here’s a little secret for all of
you. There is a lot of treachery and deception in I.V.F./fertility/surrogacy because there is gobs of money to be made.”

It has been suggested that marketing and advertising that states only the “benefits” of renting your womb should
also state the risks. In short, there are “significant ethical and policy problem[s] with the status quo.” And yet, brokers
and clinics who stand to profit most resist calls to do the necessary studies or warn women of potential risks.
Surrogacy often depends on the exploitation of low income and poor women by those with means to pay for
surrogacy

These unequal transactions result in “uninformed” consent, coercion, low payments, poor health care, and severe
risks to the short and long term health of women As the European parliament stated in a 2011 resolution, surrogacy
is “an exploitation of the female body and her reproductive organs.” The New York State Task Force on Life and
the Law stated that commercial surrogacy “could not be distinguished from the sale of children and that it placed
children at significant risk of harm.”

5.6 Unit Summary

In this unit we have looked at the Role of Health Laws in Governance, Health Laws and
Related Regulations and Expired and Fake Drugs and Uncontrolled Substances. Sevral
case stidies outlining the role of health laws in governance have also been outlined.
These include: cracking down on counterfeit drugs, fingerprinting the fakes and surrogacy.
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5.7 References and Further Readings

1. Riben, Mirah. The Huffington Post. “American Surrogate Death: Not the First.” October 25, 2015. [Link]
[Link]/mirahriben/American surrogate-death _b_8298930.html
2. Kamphuis, E., Bhattacharya, S., van der Veen, F., and Mol, B.W.J., (2014). British Journal of Medicine. “Are We
Overusing IVF?” [Link]
3. Yona Nicolau, Austin Purkeypile, T. Allen Merritt, Mitchell Goldstein, Bryan Oshiro (2015). World Journal of
Obstetrics and Gynecology. “Outcomes of surrogate pregnancies in California and hospital economics of
surrogate maternity and newborn care.” November 10; 4(4).
4. T.A. Merritt, M. Goldstein, R. Philips, R. Peverini, J. Iwakoshi, A. Rodriguez, B. Oshiro (2014) Journal of
Perinatology. “Impact of ART pregnancies on California: analysis of maternity outcomes and insights into the
added burden of neonatal intensive care.” February, 2014.
5. Science Daily. “Pregnancies following egg donation associated with more than 3-fold higher risk of
hypertension” July 1, 2014.
6. Alexander, J., and Levi, L. (2013). Journal of Neuro-Opthalmology. “Intracranial Hypertension in a Patient
Preparing for Gestational Surrogacy with Leuprolide Acetate and Estrogen,” 33:307-318.
7. Schieve, L., Meikle, S., Ferre, C., Petersen, H., Jeng, G., and Wilcox, L. (2002). New England Journal of Medicine.
“Low and Very Low Birth Weight in Infants Conceived with Use of Assisted Reproductive Technology,” 346:731-
737. [Link]
8. Merritt, T. “Impact of ART on Pregnancies in California: An Analysis of Maternity Outcomes and Insights into
the Added Burden of Neonatal Intensive Care,” Journal of Perinatology, February 2014, 1-6.
9. Golumbok, S., Blake, L., Casey, P., Roman, G., and Jadva, V. (2013). The Journal of Psychology and Psychiatry.
“Children born through reproductive donation: A longitudinal study of psychological studies,” 54:6, pp 653-
660.
10. See [Link], an online story collective for real life testimonials for voluntary and involuntary
participants of assisted reproduction, as well as our 2012 documentary Anonymous Father’s Day. [Link]
[Link]
11. McGee, G., Brakman, S.V., and Gurmankin, A.D. (2001). Human Reproduction. “Gamete donation and
anonymity: disclosure to children conceived with donor gametes should not be optional”. [Link]
[Link]/pubmed/11574486
12. Yona Nicolau, Austin Purkeypile, T Allen Merritt, Mitchell Goldstein, Bryan Oshiro (2015). World Journal of
Obstetrics and Gynecology. “Outcomes of surrogate pregnancies in California and hospital economics of
surrogate maternity and newborn care.” November 10; 4(4).
13. Rory Devine and R. Stickney, “Convicted Surrogacy Attorney: I’m Tip of Iceberg,” NBC San Diego February
29, 2012. [Link]
[Link]
14. Tamar Lewin, “A Surrogacy Agency that Delivered Heartache,” The New York Times, July 27, 2014. [Link]
[Link]/2014/07/28/us/[Link]
15. Alberta, H., Berry, R., and Levine, A. (2014). Journal of Law, Medicine and Ethics “Risk Disclosure and the
Recruitment of Oocyte Donors: Are Advertisers Telling the Full Story?”
16. European Parliament resolution of 5 April 2011 on priorities and outline of a new EU policy framework to
fight violence against women [Link]
ence=P7-TA-2011-0127
17. New York State Task Force on Life and the Law. Surrogate Parenting: Analysis and Recommendations for Public
Policy, 1988. [Link]
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LEADERSHIP IN HEALTH
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LIST OF TABLES
Table 3.1.1: Comparison between a leader and a manager 105
Table 3.1.2: Guidelines for becoming a Transformational leader 108
Table 3.1.3: Maturity levels 110
Table 3.2.1: Types of Emotions 117
Table 3.2.2: Skills in Emotional Intelligence 119
Table 3.2.3: Questions assessing state of Emotional Intelligence 120
Table 3.2.4: Interpretations of total scores 120
Table 3.2.5: The XYZ of Communication 122
Table 3.2.6: Application of the XYZ of Communication 122
Table 3.2.7: Characteristics of Vision Statements 124
Table 3.2.8: Principles for Building Strong and Lasting Relationships 126
Table 3.4.1: Differences between Organizational Culture and Organizational Climate 154
Table 3.4.2: Types of Work place Climate 155
Table 3.4.3: Assessment of Work Climates 157

LIST OF FIGURES
Figure 3.1.1: Leadership styles 109
Figure 3.1.2: Level 5 Hierarchy 111
Figure 3.2.1: The Ladder of Inference Source 121
Figure 3.2.2: This is the Challenge Model 128
Figure 3.2.3: The Ishikawa Diagram or Fish Bone Diagram 132
Figure 3.3.1: Leading Change Framework 137
Figure 3.3.2: Changing People 138
Figure 3.3.3: Means of changing people 139
Figure 3.3.4: Strategies for dealing with change resistance 141
Figure 3.3.5: Steps in Change Management 142
Figure 3.3.6: Forming Powerful Coalitions 142
Figure 3.4.1: Components of Attitude 150
Figure 3.4.2: The Betari Box 152
Figure 3.4.3: Factors influencing work climate and its effects 155
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MODULE 3: LEADERSHIP IN HEALTH

3.1 Module Introduction

Welcome to Module 3. In this module, we will discuss leadership. This module together with the previous one
on Governance are important building blocks of the health system. It is said that if you cannot see something,
you cannot have it. It has been well acclaimed that the health systems in many African Countries need to be
strengthened. Yes, but achieving this depends on who can see and lead the change. The change may start small,
but if it is genuine, sincere and result oriented, it can soon envelop the entire health systems of nations. This makes
leadership as a concept a very important tool in the achievement of strong health systems. Hence, the need for this
module. The purpose of this module is to build leadership skills in leaders for a strengthened health system.

At the end of this module, it is expected that you will be able to effectively communicate, inspire and effect shared
vision and change in your organisation.

3.2 Module Outcomes

At the end of this module you will be able to:

• Apply the concepts and styles of leadership to lead self, others and the organisation
• Display characteristics of an effective leader
• Lead organisational change
• Practice effective leadership in health

3.3 Module Content

This module is divided into the following 4 units:

• Unit 1: Concepts, styles and practice of leadership
• Unit 2: Characteristics of an effective leadership
• Unit 3: Change Management
• Unit 4: Leadership Practice in health
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Unit 1: Concepts, Styles and Practice of Leadership

1.1 Introduction
First, we shall be reminding ourselves of the concepts and styles of leadership.
This unit speaks to the evolutionary background of leadership. It shares with the participants the various styles
of leadership emphasising the Transformational leadership style comparing it with the Transactional leaders. It
rounds up the unit by challenging participants to become level 5 hierarchy leaders.

Leadership is the most studied aspect of business and administration because it is the one overarching topic
that makes the difference between success and failure.

1.2 Unit Outcome

At the end of this unit, you should be able to apply the concepts and styles of
leader-ship to lead yourself, others and the organization

1.3 Concepts of Leadership

Are good leaders made not born? If you have the desire and will power, you can become a good leader. You can do
this through a never ending process of self-study, education training and experience. In this section we will examine
some concepts of leadership.

Leadership and the study of it is ever evolving, even today. Various theories have been used to try and understand
leadership the most prominent being:

1. Great man theory

2. Trait theory
3. Behavioural theory
4. Participative theory
5. Situational theories
6. Contingency theory
7. Transactional theory
8. Transformational theory
9. Servant leadership
10. Level 5 leadership theory
11. Followership
12. Women and leadership

And the study continues.

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1.3.2 A Leader and Leadership

What do you understand by the terms ‘leader’ and ‘leadership’? Brainstorm about the
above leadership theories.
Write the answers in your note book.

Well done! You may have written down some of the definitions below which we are now going to look at in detail.

A leader is an individual who is able to influence and inspire a group or organizational members to help the group
or organization achieve its goals

Leadership is a process whereby an individual influences a group of individuals to achieve a common goal.
(Northouse, 2007)

Leadership is the ability of an individual to influence, motivate, and enable others to contribute toward the
effectiveness and success of the organization.

Leadership is a function of knowing yourself, having a vision that is well communicated, building trust among
colleagues and taking effective action to realize your own leadership potential

Leadership is a function of knowing yourself, having a vision that is well communicated, building trust among
colleagues and taking effective action to realize your own leadership potential.

Leadership is a function of a leader, the followers, and the situation in striving to achieve a common purpose or
goal.

1.3.2 Qualities of a Leader

Like an iceberg, a leader is approximately 20% of expertise and 80 % of know how (Kotter, 1996). We generally
consider that a leader is:
• a visionary and forward-looking;
• adaptable and able to change with changing circumstances;
• honest and sincere of purpose;

A leader is able to see things in perspective, admit mistakes and learn from others. He or she is:
• self-confident;
• has a sense of humor;
• has ability to listen to his/her subordinates;
• humble, diplomatic and understands problems of those under him/her.

What are other qualities of an effective leader?

Write down the answer in your notebook

Compare your answers with what you read in the following discussion.
Leadership is action and not position; a leader shows somebody how to do something, while a boss simply tells a
subordinate to get something done.

The leader has a vision and a plan and must inspire people around them to believe in and execute a plan. Although
there are different types of leaders, all successful leaders share common characteristics that contribute towards
their success.
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An effective leader knows his or her strengths and weaknesses, and is able to maximize all of them.

Leaders have a certain confidence about them, and are able to stay calm under pressure.

They are able to control their emotions so they can think clearly and make the best decisions that will achieve goals
and produce winning situations.

Leaders need to be flexible and know how and when to change to best meet each situation.

Leadership is action and not position; a leader shows somebody how to do something, while a boss simply tells a
subordinate to get something done.

The leader has a vision and a plan and must inspire people around them to believe in and execute a plan. Although
there are different types of leaders, all successful leaders share common characteristics that contribute towards
their success.

An effective leader knows his or her strengths and weaknesses, and is able to maximize all of them.

Leaders have a certain confidence about them, and are able to stay calm under pressure.

They are able to control their emotions so they can think clearly and make the best decisions that will achieve goals
and produce winning situations.

Leaders need to be flexible and know how and when to change to best meet each situation.

A leader has a vision and a plan and must inspire people around them to believe in
and execute a plan.

1.3.3 Leadership vs. Management

Let us now look at the relationship between leadership and management.

What is the difference between management and leadership?

The difference between management and leadership is a question that has been asked more than once and also
answered in different ways. The biggest difference between managers and leaders is the way they motivate the
people who work or follow them, and this sets the tone for most other aspects of what they do.

Many people, by the way, are both. They have management jobs, but they realize that they cannot buy hearts, to
follow them especially down a difficult path, and so they act as leaders too.

Managers have subordinates

By definition, managers have subordinates - unless their title is honorary and given as a mark of seniority, in which
case the title is a misnomer and their power over others is other than formal authority.

Authoritarian, transactional style

Managers have a position of authority vested in them by the company, and their subordinates work for them and
largely do as they are told. Management style is transactional, in that the manager tells the subordinate what to do,
and the subordinate does this not because they are a blind robot, but because they have been promised a reward
(at minimum their salary) for doing so.
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Work focus
Managers are paid to get things done (they are subordinates too), often within tight constraints of time and
money. They thus naturally pass on this work focus to their subordinates.

Seek comfort
An interesting research finding about managers is that they tend to come from stable home backgrounds and
led relatively normal and comfortable lives. This leads them to be relatively risk-averse and they will seek to avoid
conflict where possible. In terms of people, they generally like to run a ‘happy ship’.

Leaders have followers

Leaders do not have subordinates - at least not when they are leading. Many organizational leaders do have
subordinates, but only because they are also managers. But when they want to lead, they have to give up formal
authoritarian control, because to lead is to have followers, and following is always a voluntary activity.

Charismatic, transformational style

Telling people what to do does not inspire them to follow you. You have to appeal to them, showing how following
you will lead them to their hearts’ desire. They must want to follow you enough to stop what they are doing and
perhaps walk into danger and situations that they would not normally consider risking.

Leaders with a stronger charisma find it easier to attract people to their cause. As a part of their persuasion they
typically promise transformational benefits, such that their followers will not just receive extrinsic rewards but will
somehow become better people.

People focus
Although many leaders have a charismatic style to some extent, this does not require a loud personality:
• They are always good with people, this does not mean they are friendly with them.
• They take blame on themselves,
• They are very effective at creating the loyalty that great leaders engender.

In order to keep the mystique of leadership, they often retain a degree of separation and aloofness.

This does not mean that leaders do not pay attention to tasks - in fact they are often very achievement-focused.
What they do realize, however, is the importance of enthusing others to work towards their vision.

Seek risk
In the same study that showed managers as risk-averse, leaders appeared as risk-seeking, although they are not
blind thrill-seekers. When pursuing their vision, they consider it natural to encounter problems and hurdles that
must be overcome along the way. They are thus comfortable with risk and will see routes that others avoid as
potential opportunities for advantage and will happily break rules in order to get things done.

A surprising number of these leaders had some form of handicap in their lives which they had to overcome. Some
had traumatic childhoods, some had problems such as dyslexia, others were shorter than average. This perhaps
taught them the independence of mind that is needed to go out on a limb and not worry about what others are
thinking about you.
This table summarizes the above (and more) and gives a sense of the differences between being a leader and being
a manager.
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Table 3.1.1 Comparison between a leader and a manager.

SUBJECT LEADER MANAGER

Essence Change Stability
Focus Leading people Managing work
Have Followers Subordinates
Horizon Long-term Short-term
Seeks Vision Objectives
Approach Sets direction Plans detail
Decision Facilitates Makes
Power Personal charisma Formal authority
Appeal to Heart Head
Energy Passion Control
Culture Shapes Enacts
Dynamic Proactive Reactive
Persuasion Sell Tell
STYLE TRANSFORMATIONAL TRANSACTIONAL
Exchange Excitement for work Money for work
Likes Striving Action
Wants Achievement Results
Risk Takes Minimizes
Rules Breaks Makes
Conflict Uses Avoids
Direction New roads Existing roads
Truth Seeks Establishes
Concern What is right Being right
Credit Gives Takes
Blame Takes Blames

1.4 Styles of Leadership

Now that you know who a leader is, let us examine the different styles of leadership.

1.4.1 Leadership Styles

Leadership styles have been evolving over time. Some of these include:

• Laissez-faire style: this is a non-authoritarian leadership. Laissez faire leaders try to give the least possible
guidance to subordinates, and try to achieve control through less obvious means. They believe that people
excel when they are left alone to respond to their responsibilities and obligations in their own ways.
• Autocratic leadership: this is a leadership style wherein one person controls all the decisions and takes
very little inputs from other group members. Autocratic leaders make choices or decisions based on their
own beliefs and do not involve others for their suggestion or advice.
• Servant leadership: this is a philosophy and set of practices that enriches the lives of individuals, builds
better organizations and ultimately creates a more just and caring world. The leader is a servant of the
people.
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• Democratic Leadership: involves a team guided by a leader where all individuals are involved in the
decision-making process to determine what needs to be done and how it should be done. The group’s
leader has the authority to make the final decision of the group.
• Bureaucratic style: this is a style of leadership that emphasizes procedures and historical methods
regardless of their usefulness in changing environments. Bureaucratic leaders attempt to solve problems
by adding layers of control, and their power comes from controlling the flow of information.

Think about each of these leadership styles and identify leaders in your context who
portray their use.
Write down your answer in your notebook.

1.4.2 Transformational vs. Transactional Leadership

Let us now look at two other styles of leadership and identify their similarities and differences.

Transformational leadership: serves to change the status quo by appealing to followers’ values and their sense of
higher purpose.

Transactional leadership: occurs when leaders and followers are in an exchange

relationship in order to get needs met.

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

Transformational leadership:
• Is 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 organizational stature.

Transformational leadership is a process that changes and transforms individuals.

- It is concerned with:
V.E.S.E.L = Values, Ethics, Standards, Emotions, Long-term goals (Sano, 2017)
- It includes assessing followers’ motives, satisfying their needs, and treating them as full
human beings.

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 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 organizations.
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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 Karamchand Gandhi (1869-1948) 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 (Gardner, & Laskin, 2011)

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 organizations
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 organization

Transformational leaders also act as change agents who initiate and implement new directions within organizations

The transformational approach also requires that leaders become social architects
This means they make clear the emerging values and norms of the organization
They involve themselves in the culture of the organization and help shape its meaning

Transformational leader is
-Charismatic/Inspirational
-Focuses on vision
-Is not as concerned with day-to-day issues.

Kouzes-Posner leadership model (transformational leadership)

James Kouzes and Barry Posner identify five competencies as follows:
1. Challenging the process
2. Inspiring a shared vision
3. Enabling others to act
4. Modeling the way
5. Encouraging the heart

They emphasize that leadership behaviors can be learnt. This can be done through the coaching process. Please
take some time and read more on this in their book (Kouzes, & Posner, 2006).

Leadership truth:
We praise leaders too much when organizations succeed, and blame them too much
when organizations fail.

Guidelines for becoming a Transformational leader

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Think about it! How does one become a transformational leader?

Good! I know that you are eager to learn how to become a transformational leader. Let us look at some ways to do
this.

Table 3.1.2 Guidelines for becoming a Transformational leader

Suggestion Explanation

Develop a vision that is both clear and A clear vision will guide followers toward achieving organiza-
highly appealing to followers tional goals and make them feel good about doing so

Articulate a strategy for bringing that don’t present an elaborate plan; rather, state the best path
vision to life towards achieving the mission
State your vision clearly and promote Visions must not only be clear, but made compelling, such as by
It to others using anecdotes

Show confidence and optimism about If a leader lacks confidence about success, followers will not try
your vision very hard to achieve that vision
Express confidence in followers’ capacity Followers must believe that they are capable of implementing a
to carry out the strategy leader’s vision. Leaders
should build followers’ self-confidence
Build confidence by recognizing small if a group experiences early success, it will be motivated to
accomplishments toward the goal continue working hard
Celebrate successes and accomplishments Formal or informal ceremonies are useful for celebrating suc-
cess, thereby building optimism and commitment
Take dramatic action to symbolize key Visions are reinforced by things leaders do to symbolize them
organisational values 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 followers to make
words sacrifices, for example, they should do so themselves

a) Watch the following videos as examples of great leaders and leadership skills
Martin Luther King – Dream (1 Min)
Martin Luther King – Last Speech (2 Mins)

b) Reflection
- How do you assess your leadership style?
- Please include some action points in your JAMII.
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Situational Leadership
Different situations call for different styles of leadership.

Figure 3.1.1: Leadership styles

Hersey and Blanchard characterized leadership style in terms of the amount of Task Behavior and Relationship
Behavior that the leader provides to their followers (Hersey & Blanchard, 1969). They categorized all leadership
styles into four behavior types, which they named S1 to S4:

• S1: Telling – is characterized by one-way communication in which the leader defines the roles of the
individual or group and provides the what, how, why, when and where to do the task;
• S2: Selling – while the leader is still providing the direction, he or she is now using two-way communication
and providing the socio-emotional support that will allow the individual or group being influenced to buy
into the process;
• S3: Participating – this is how shared decision-making about aspects of how the task is accomplished and the
leader is providing fewer task behaviours while maintaining high relationship behavior;
• S4: Delegating – the leader is still involved in decisions; however, the process and responsibility has been
passed to the individual or group. The leader stays involved to monitor progress.

Of these, no one style is considered optimal for all leaders to use all the time. Effective leaders need to be flexible,
and must adapt themselves according to the situation.
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Table 3.1.3: Maturity levels

High Moderate M/L Low
M4 M3 M2 M1
Very capable and confident Capable but unwilling Unable but confident Unable and insecure

The right leadership style will depend on the person or group being led. The Hersey-Blanchard Situational Leadership
Theory identified four levels of maturity M1 through M4:

• M1 – They lack the specific skills required for the job in hand and are unable and unwilling to take responsibility
for this job or task.

• M2 – They are unable to take on responsibility for the task being done; however, they are willing to work at the
task. They are novice but enthusiastic.

• M3 – They are experienced and able to do the task but lack the confidence or the willingness to take on
responsibility.

• M4 – They are experienced at the task, and comfortable with their own ability to do it well. They are able and
willing to not only do the task, but to take responsibility for the task.

Maturity levels are also task-specific. A person might be generally skilled, confident and motivated in their job, but
would still have a maturity level M1 when asked to perform a task requiring skills they don’t possess.
Developing people and self-motivation
A good leader develops “the competence and commitment of their people so they’re self-motivated rather than
dependent on others for direction and guidance.” According to Hersey’s book, a leader’s high, realistic expectation
causes high performance of followers; a leader’s low expectations lead to low performance of followers. According
to Ken Blanchard, “Four combinations of competence and commitment make up what we call ‘development level.’”
• D1 - Low competence and high commitment
• D2 - Low competence and low commitment
• D3 - High competence and low/variable commitment
• D4 - High competence and high commitment

In order to make an effective cycle, a leader needs to motivate followers properly.

Think of 3 of your staff and identify which of the four quadrants they fall in. What
support do they need and what style do you need to use to give that support for
improved performance?

1.5 Level 5 Hierarchy Leadership

We will now look at a more recent style of leadership: Level 5 hierarchy leadership as discussed by Jim Collins in
his book: Good to Great” (Collins, 2001). A level 5 leader is an individual who blends extreme personal humility
with intense professional will hence, the equation: HUMILITY + WILL = LEVEL 5

• Level 5 leaders are the one who takes companies from good results to great results.
• Level 5 leaders 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.
• Leaders at the other four levels in the hierarchy can produce high levels of success but not enough to
elevate organizations from mediocrity to sustained excellence.
• Good-to-great transformations don’t happen without Level 5 leadership
• Sits on top of a hierarchy of capabilities
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• 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

Figure 3.1.2: Level 5 Hierarchy

The level 5 hierarchy

Figure 3.1.2 shows the five level hierarchy which we shall also explain below:

• 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 - Organizes people and resources toward the effective and
efficient pursuit of predetermined objectives
• Level 4 – Effective Leader - Catalyzes 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.
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People generally assume that transforming from good to great organizations 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 organization 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 organization beyond
unremarkable. These drivers are:

• First Who,
• Stockdale Paradox,
• The Flywheel,
• The Hedgehog Concept and
• A Culture of Discipline

Please take time to read more about this in the book “Good to Great” by Jim Collins.

A level 5 leader builds enduring greatness through a paradoxical combination of person-

al humility plus professional will.

Level 5 leadership is a study in duality:

• Modest and willful
• Shy and fearless, do not talk about themselves
• They would talk about the organization, about the contribution of others and instinctively deflect
discussion about their own role.

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 organizations
• They routinely select superb successors.
• They want to see their organizations 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 organization for enduring success – what better way to demonstrate
your personal greatness than that the place falls apart after you leave

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
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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”

1: Read the case study of Nelson Mandela, note down 8 lessons of quality leadership
so as to share the information in discussion at the end this module.
Nelson Mandela; [Link]

1.6 Unit Summary

Well done! You have just completed Unit 1 in this module. By now, you should be able to apply the qualities of a
Transactional and Transformational leader and aspire to become a level 5 leader. Let us now review what you have
learnt.

In this unit we have learnt that success of an institution depends a lot on the leader. In
our context, we agree with Paul R. in following:
“The success of open universities depends on leadership and vision - a value-driven
commitment to the ideas of open learning, honesty and integrity, without rigidity - a
flexible approach in a world of ambiguity, change and challenge. If every institutional
leader strives for open management, leadership which encompasses the values of open
learning, which we hold up for our students, the world’s open universities will be much
more effective institutions, and will increasingly be seen as models for the university of
tomorrow” (Paul, 1990).

Paul Ross H. (1990), Open learning and open management: leadership and integrity
In distance education, London, UK, Kogan Page Reardon Kathleen Kelley (1995), Is your
leadership style holding you back? “Executive Female”, V. 18, n. 6, pp. 72-73
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UNIT 2: CHARACTERISTICS OF EFFECTIVE LEADERSHIP

2.1 Unit Introduction

You are welcome to unit 2 of this module. In the previous unit, you learnt about the qualities of a good leader.
In this unit, we will discuss what it takes to be an effective leader. The success of an organization or health system is
largely dependent on what her leaders are made of. This unit unveils the key characteristics of what an
effective leader must be made of. It does not promise to exhaust them but to draw attention to a few critical ones.
A leader can only give what he has. And to be a 21st century leader, the characteristics discussed in this unit are
very important.

2.2 Unit Outcome

By the end of this unit, you will be able to display the characteristics of an effective leader.

2.3 Characteristics of Effective Leadership

How can you know an effective leader when you meet one? Is there a way to measure
and decide who is a leader or not?

Leadership as a concept is difficult to measure (MSH, 2008.) Galer et al., 2005 attempted to measure the outcomes
of Leadership and Management Programs using the Work Group Climate Assessment (WCA) tool and by
triangulating with several data. They recommended that a mixed method approach may be the sure way to
measuring leadership. They also attested to the fact that not all leadership results are quantifiable as it is not just
about the results of how effective has the leadership being but also the process of engaging in effective
leadership. The good news is that leadership competencies and behaviours can be learned by anyone regardless
of position or age.

What Is Effective Leadership?

Now, to answer this question, think of someone you know very closely as a leader. List the
things this leader does that makes you think he or she is an effective leader.

‘Effective leadership can be described as one that requires the establishment by the leader of a smartly
organized entity and in itself an efficient infrastructure to which he can delegate and at times even defer
to’ (Randol, 2011). (Randol, 2011). According to Kaitlyn, the difference between a leader and an effective leader
are their intentions. Leaders work for themselves, entangling their aims with their own advancement; while an
effective leader works purely for the aims they wish to promulgate. They are not the heart and soul of their vision.
Their vision is such that is able to continue on without them.

Effective leadership has also been said to be a function of individual competencies as well as organizational
culture (Sahu & Bharti, 2009). An effective leader must have a personal mastery of self, possess exemplary value
based skills, confident, have clarity of vision, be emotionally intelligent and have a slightly higher level of
intelligence than their contemporaries. They must understand their organizational environment such as its vision
and mission. They must also be courageous enough to take prudent risks so as to initiate change and be able
to effectively manage the change. This they do by showing empathy and building strong relations with their
followers.

The leader you identified in the last activity, do you still think he or she is an effective leader?
Give your reasons.
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Good. I believe you are now able to differentiate between a leader and an effective one. To help illustrate this
better, you will be having an assignment. When you click the link below, it will take you to the biographies of the
following selected leaders:
Fidel Castro; [Link]
Mahatma Gandhi; [Link]
Mother Theresa; [Link]
Martin Luther King, Jr.; [Link]
Al Capone; [Link]
Nelson Mandela; [Link]
I would like you to read through these biographies and then tease out what they lived for as well as their
positive and negative qualities or characteristics. You will then compare these positive and negative
characteristics of them all and answer the following questions.

a. Which of these positive and negative characteristics was common to them all.
b. Did they outlive what they lived for or what they lived for outlived them.
c. Which of them will you describe as effective leaders and why.

Well done, I believe you are learning fast on how to be an effective leader. From the reflection you have done
on these selected leaders, you would have identified the personal characteristics that contributed to their
effectiveness. Some of these characteristics will now be discussed in details.

2.3.1 Personal Mastery of Self

What does having a personal mastery of self-mean to you?

“Personal Mastery is the phrase used for the discipline of personal growth and learning” according to Peter Senge
(Senge, 1990). (Senge, 1990). People with high levels of self-mastery are learners. They are continually expanding
their ability to create the results in life that they truly seek. Personal Mastery is living life form a creative perspective
rather than being reactive. It is much more than having competencies and skill.

Personal mastery involves:

• clarifying what is important to us; and
• continually learning how to see the current reality more clearly.

Personal Mastery is:

• About our own development, our own quest for learning, and our ability to work with the forces around us.
• Personal mastery means having a vision of where we want to go, yet recognize the realities of where we
are right now, and then making a commitment to work toward that vision.
• If we coach others, we must first model our own personal vision of where we want to be, so others can see
us working toward our vision.
• Then we can help them define and clarify their vision, identify the obstacles, and find a way of working
through these to achieve their aim.

Leaders who bring change in organizations have a high level of mastering themselves. They know who they are,
decided early on what they want to achieve in life and in their organization and they work towards achieving that by
going all out to equip themselves with all the qualifications, skills, experience they need to be what they want to be.
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Basic Characteristics of people with high level of Personal Mastery:

1. A sense of purpose that lies behind their visions and goals. For them, vision as a calling, not just a good idea.
2. They see current reality as an ally not as an enemy
3. They work with forces of change not resist them
4. They are deeply inquisitive about seeing reality more accurately
5. They feel connected to others and to life itself
6. They feel part of a larger creative process
7. They live in continual learning mode.
8. They live more fulfilling lives with higher balance of work-life balance

Your Personal Mission & Vision and Value Statements

• In order to know yourself, you have to understand your “be,” “know,” and “do” attributes.
• Just like organizations have a mission statement, a vision statement and values, a leader needs to have the
same for him/herself.
• What is your mission?
• What is your vision – where do you see yourself in 5, 10, 15 years’ time?
• What values are important to you?

Another important thing a leader must have is ‘A high sense of Self - Awareness’
This means
• Knowing yourself and seeking self-improvement
• Helping employees understand the company’s overall business strategy
• This is made possible by continually strengthening your attributes by reading and self-study
• Being technically proficient

A leader must have a personal mastery of self and a high sense of self awareness.

Assignment
1. Reflect on your own life purpose and write out your personal mission and vision
statement
2. What is your current reality and what tension are you facing between it and your
vision. How are you responding to it?
3. Share this on the discussion forum and listen to others give you feedback.

2.3.2 Emotional Intelligence

From the start of this module, you have learnt about the various leadership styles and you have been challenged to
adopt the Transformational leadership style and also strive to become a level 5 hierarchy leader. You have also learnt
that to be an effective leader, you will yet need to adopt some specific characteristics, such as, Personal mastery of
yourself. We will now continue with our discussion and look at yet another key characteristics of effective leaders
which you must learn to have personal mastery of, namely emotional intelligence.

Before we start our discussion on emotional intelligence read through the following scenario.
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Has this happened to you before?

You woke up a bit late and got too late getting the children ready for school. Your spouse (husband)
feels your sloppiness was responsible for the children’s lateness and you didn’t take that in well at all
because you felt he could have done better to assist you rather than ‘insulting you’ in your words. You
decided to keep mute and not tell him a piece of your mind so that you do not cause a fight. However,
your mood changed, you started stamping / storming around the house, slamming the doors, shouted
at the house girl for keeping you waiting and not cleaning the car on time. You left the house barely say-
ing a goodbye to your spouse. Your lateness got you trapped in traffic on your way to work. You found
yourself shouting and cursing every other car driver that tried to get in your way. On getting to work,
you barely looked at your other colleagues and refused to smile when they cracked jokes with you about
your looks. You found that you were so upset and impatient with the patients that came your way that
day and did not greet them instead, you kept hissing in between the time they spent with you as you
recall how your day started and how it had been going. You eventually find yourself picking a fight with
one of your junior colleagues because you felt she was disrespectful and you gave her a piece of your
mind. Patients who also could not be patient enough, you sent out of your clinic. Your children were
not spared, you shouted at them during school runs for not getting into the car early enough, for not
greeting you on time and the lists goes on. You still could not bring yourself to talking freely with your
spouse when he got back from work. You barely could eat anything reasonable that day as you had no
appetite. And at last, when you went to sleep, both of you faced the other sides of the wall. Oh, what a
bad day it was for you.
Answer the following questions
What emotions did the lady display (if possible mention the emotions and moods in sequence of how
she experienced them, starting with the first)
Who spoilt her day? (Assuming she is a woman)
What could she have done better?

Emotions are complex psychological states that involve three distinct components: a subjective experience, a
physiological response, and a behavioural or expressive response.”(Hockenbury & Hockenbury, 2010).

List the various types of emotions that you know? Can you divide them into positive and negative emotions?

Compare your answers with the emotions listed in Table 3.2.1.

Table 3.2.1: Types of Emotions

Primary Secondary Emotions Tertiary Emotions

Emo-tions

Love Affection, Lust, Longing Adoration, Fondness, Liking, Attraction, Caring, Tender-
ness, Compassion, Sentimentality, Desire, Passion

Joy Cheerfulness, Pride, Content- Amusement, Bliss, Jolliness, Delight, Enjoyment, Gladness,
ment, Relief, Optimism Happiness, Jubilation, Ecstasy, Euphoria

Surprise Surprise Amazement, Astonishment

Anger Irritation, Disgust, Aggravation, Agitation, annoyance, Grumpiness, Frustra-

Exaspera-tion, Rage tion, Contempt

Sadness Suffering, Sadness, Disap- Agony, Hurt, Anguish, Depression, Despair, Gloom, Un-
pointment, Neglect, Sympathy happiness, Grief, Sorrow, Misery, Melancholy

Fear Horror, Nervousness Alarm, Shock, Fear, Panic, Hysteria, Anxiety, Tenseness,
Apprehension, Worry, Distress
(Parott, 2001) (Parrott, 2001)
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Emotions and moods come natural to us just like hunger and thirst. Emotions which include our moods play out
in every function of a leader or a manager. It influences how far they see a vision, decision is made, and how
actions are implemented. It influences communication and many more. How leaders manage their emotions is
critical to their effectiveness.

Leaders are often believed or expected to be super humans with no emotions. A response to this may explain
why leaders sometimes supress and deny certain emotions even when it is there gnawing at them and hurting
them. Emotional intelligence is not about denying emotions but being able to analyse the emotions critically
and how you got there as well as being in control of that emotion. Expressing the emotion in such a way that it
does not hurt anyone and yet the truth has been told.

So, what is Emotional Intelligence?

Emotional Intelligence can be defined as a set of competencies demonstrating the ability one has to recognize his
or her behaviours, moods and impulses and to manage them best according to the situation (Sahu & Bharti, 2009).
(Sahu & Bharti, 2009).

Emotional Intelligence is a way of recognizing, understanding, and choosing how we think, feel, and act”

Emotional Intelligence is the ability to manage ones’ own emotions and those of others. According to Daniel
Goleman a person can have the best training in the world, an incisive, analytical mind, and an endless supply of
smart ideas, but without being emotionally intelligent, he still won’t make a great leader (Goleman, 2006).
(Goleman, 2006) .

Emotional Intelligence and Leadership

Emotional intelligence is strongly related to leadership. Studies have shown that a positive relationship
exists between emotionally intelligent leadership and employee satisfaction, retention, and performance.
Organizations now always seek to recruit and promote from within people that are strongly emotionally
intelligent.

The five skills and competencies in emotional intelligence are outlined in Table 3.2.2.
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Table 3.2.2: Skills in Emotional Intelligence

Skills What they entail

Self-awareness Emotional self- awareness- (reading one’s own emotions)
Accurate self-assessment- (knowing one’s strengths and limits)
Self-confident- (a sound sense of worth)
Self-Management Emotional Self-control- (keep emotions under control)
/ Self- Regulation Transparency- (displaying honesty and Trustworthiness)
Adaptability- (Easily adapts to changing situations)
Conscientiousness- (takes responsibility for personal performance)
Innovation- (Open to new ideas and creates novel ideas)
Motivation Achievement – (Possesses a strong drive to improve performance)
Commitment- (Aligns with organizational goals)
Initiative- (Seizes opportunities readily)
Optimism – (Has a positive outlook to life)
Social awareness Empathy- (Takes active interest in others’ emotions)
Organizational awareness- (understands the strategic direction of his or her organiza-
tion and its players)
Service orientation- (passionate about meeting customers’ needs)
Relationship Inspirational leader- (Motivates towards a compelling vision)
management Influence- (effortlessly draws others towards his or her vision)
Develops others- (Mentors and coaches to build other leaders)
Change catalyst- (Seeks or charts new direction to lead others to)
Conflict management- (does not breed but resolves conflicts)
Builds Bonds- (cultivates and maintains lasting relationships)
Team work and collaboration- (always seeks new collaboration)

How emotionally intelligent are you?

To help you determine your emotional intelligence, answer the 15 questions in Table 3.2.3 as
they actually are, rather than as you think they should be. When finished, calculate the total
and guided by the explanations in Table 3.2.4, determine how emotionally intelligent you are.
Guide on the questions is provided below.

Guide
Competencies Test questions Colour codes
Self – Awareness Questions 1, 2, 3 Blue
Social – Awareness Questions 4, 5, 6 Yellow
Relationship Management Questions 7, 8, 9 Gary
Self – Management / Regulation Questions 10, 11, 12 Green
Motivation Questions 13, 14, 15 Pink
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Table 3.2.3: Questions assessing state of Emotional Intelligence

Assessments Not at All Sometimes Often Very
Often
1 3 4 5
1. I can recognize my emotions as I experience them.

2. I know my strengths and weaknesses.

3. I ask people for feedback on what I do well, and how I can improve.

4. I enjoy organizing groups.

5. I avoid conflict and negotiations

6. I find it easy to build rapport with others.

7. People have told me that I’m a good listener.

8. I use active listening skills when people speak to me.

9. I find it difficult to read other people’s emotions.

10. I lose my temper when I feel frustrated.

11. I find it difficult to move on when I feel frustrated or unhappy.

12. I don’t know how to calm myself down when I feel anxious or upset.

13. I find it hard to focus on something over the long term.

14. I hardly set long-term goals, nor review my progress regularly.

15. I feel that I don’t enjoy my work.

Table 3.2.4: Interpretations of total scores

Scores Comments
15 – 34 You need to work on your emotional intelligence. You may find that you feel overwhelmed
by your emotions, especially in stressful situations; or, you may avoid conflict because you
think that you’ll find it distressing.
35 – 55 Your emotional intelligence level is... OK.
You probably have good relationships with some of your colleagues, but others may be
more difficult to work with.
56 – 75 Great! You’re an emotionally intelligent person. You have great relationships, and you prob-
ably find that people approach you for advice.

However, when so many people admire your people skills, it’s easy to lose sight of your
own needs. Rather, focus and continue to build your EI.

The five competencies you must have to be emotionally competent are:

Self-Awareness; Social-Awareness; Self-Management; Relationship Management; Motivation
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2.3.4 Effective Communication

In 1938, Chester Bernard concluded that communication was the main task of managers and leaders (Kline, 2011).
(Kline, 2011). Effective communication skills are crucial to the success of any organization and as a result, many
organizations have worked at improving communication skills continually amongst their workers through capacity
building and addressing communication barriers.

According to Christine Noffz, the greatest communication problem in the world is that we do not listen to
understand, we listen to reply.

Have you ever wondered how someone had gone so far as to misunderstand an action of yours? Or Can
you remember how sorry you had been after making far reaching conclusions about an action of your
spouse or a close friend or relative until you eventually confronted the person in question and he or she
refuted all your claims and you then realised you had been wrong all along and had stressed yourself for
no justifiable reason. You had all been climbing the ladder of inference.

Have a look at this diagram in Figure 3.2.1, what does it look like?

Figure 3.2.1: The Ladder of Inference Source (Senge, 1990)

The ladder of inference takes us through what are the underpinnings of our communications. And it has been found
that we often climb this ladder unconsciously and it informs the content of our communications.

The ladder of inference can be used to correct misinformation and put effective communication in its right place. It
helps you to work back the ladder and ask yourself questions such as:

• What are the observable data, which means what exactly are the real facts that played out?
• What are my selected data? Which means, which of these real facts did I choose to hold unto?
• What are my added meanings or interpretations I gave to the selected data?
• On what assumption did I give the meanings or interpretations to the selected data?
• Are my meanings and assumptions verifiable? Do I have sufficient information to hold unto such meanings
and assumptions? Do I need to seek more information and data?
• So, what were my initial conclusions and the actions they informed? Can I guarantee that my actions are
justifiable?

By the time you are done reflecting on these, you will be able to separate your emotions from your actions and deal
with the facts.
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After identifying the real facts, Employ the XYZ of Communication (Kasting, 2015).

Table 3.2.5: The XYZ of Communication

X Analyse how it made you feel. Don’t ignore how it made you feel.
Then confront the person involved and state the exact facts, mainly the selected data.
Not the meanings nor assumptions nor conclusions.
Y Tell the person how it made you feel and give the person an opportunity to explain himself or herself.
Z Then, politely recommend how best you will like the person to handle such a situation at another time.

Now apply the XYZ of communication. Advice Jane in the following case study on what to do

Table 3.2.6: Application of the XYZ of Communication

X Jane’s selected data was that Jemimah was not picking her calls, nor responding to her messages.
She should conform Jemimah and tell her those exact words only

Y This inaction of Jemimah made her feel rejected

So, she should tell Jemimah how her not picking her calls made her feel rejected.
She will then wait for Jemimah to give an explanation.
(Some may have no excuse, if none after waiting, then go to Z)

Z Jane should then politely tell Jemimah that ‘Please I will appreciate it that you delegate others to
respond to me when you cannot respond to my calls or sms’
Or, I will appreciate it if you will make effort to scribble just a word like Busy, See later or similar ones
till you are able to respond.

 Been able to diffuse the emotions out of the facts and deal with the facts alone removes tension,
hurts, aggression, bitterness from our communication.
 It makes communication more open.
 The use of the Ladder of Inference and the XYZ of Communication both help to bring out the facts
and guide on how to address any issues in an organization.
 It is also applicable to whatever level of communication, be it vertical (from boss to subordinate)
or horizontal (among colleagues)
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Other Tips on Effective Communication

Below are other practical suggestions on how to communicate effectively as a leader.

a. Develop a culture of giving and receiving feedback in your organization

• Encourage your subordinates or followers to provide you with feedback, either positive or negative.
In fact, encourage more of the negative feedback. You may even be specific in the areas where you
need feedback. You may plant your followers to watch your back so as to give you immediate
feedback on any issue. Create an environment that no one is perfect and that everyone needs to look
out for one another. By doing so, you remove a major communication barrier which is fear.
• You may need to educate your team or followers on how to provide feedback such that it does not
eventually generate bad feelings or conflict. You first apply the praise then the negative feedback.
The person giving feedback and the person receiving it must know that the intentions are for the
good of both.

b. Learn to listen effectively as a leader

• A leader must be prepared to listen, not just for the facts but also for new ideas.
• While listening, you must be engaging. Such that you make eye contacts and not be distracted and
yet be saying, “I am all ears, don’t mind my actions” You may need to create time for it so you are in no
way distracted when listening to a report, a feedback, or suggestions from colleagues or followers.
• Sometimes, you may already have an understanding of what the speaker is driving at, yet try to be
patient and keep an open mind.
• To be an effective listener, try to understand what the speaker is saying. Put yourself in the speaker’s
shoes. Justify the reasons for the speaker’s comments before condemning. Even if there is nothing
beneficial in what he has to say today, your listening has created opportunities to get more
beneficial information from such a person at another day.

c. Use the ladder of inference to avoid misinterpretation of words.

• Try to clarify statements if they are not very clear, ask questions like ‘do you mean’’ so that you and the
speaker are both on the same page.
• For a communication to be deemed effective, what you meant to say, what you said and what is
received by the receiver must be the same. This you can achieve by asking questions like ‘what do you
understand by what I have just said’
• Be sure you have enough data to reach a conclusion about a verbal or non-verbal action or
communication from a colleague. To have more data or information, you may need to ask more
questions.

d. Promote consensus

• Do not be seen to be more tilted to only one person’s or one groups’ viewpoints. Be open to all
suggestions. In fact, ensure you hear every stakeholders’ point of view on issues as much as you can.
This gives room for an open door policy and makes communication in your organization a tool that
can guarantee the success of the organization.
• Finally, do not use communication as a tool to relegate, degrade or punish anyone. Some leaders
withhold information from their immediate subordinates and pass it on to people much lower on the
organogram. This they do to make some of their immediate subordinates (like their assistants)
irrelevant. These type of people are called ‘Toxic Managers or Leaders’. Avoid being one of such.
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I believe you have learnt a lot from this section on how to communicate effectively.

Personal examination
Can you recollect on the steps in the ladder of Inference?
If you do, now mention them?
What do you understand by XYZ of Communication?

Well done! Now you may take a well- deserved break before continuing to the next topic.

2.3.4. Navigating Organizations

In this section, we will look at an effective leader in relation to his or her organization.

A leader has an environment in which he operates from. He or she cannot bring about positive changes if he
or she does not have a firm grasp of what his or her organization stands for.

Before we continue with our discussion, we would like you to think about your organisation and reflect on
the following questions.

 What is a vision statement and why have one?

 What is the vision of your institution?
 What is your organization’s mission?
 Do you know it? Critique the mission and vision of your organisation.
 What challenges do you experience in actualising this vision?

The following table summarises what a vision statement is and why it is important.

Table 3.2.7: Characteristics of Vision Statements

A Vision Statement
Reflects desired impact of the organisation in Provides a clear picture of the future
the future
Describes future aspirations Helps keep mission on track
Defines the dream, long term, unconditional Helps organisational to focus
direction organisation is heading in
Is inspirational, motivational, hopeful Has a possible team building effect
Is achievable, even if far out in the future

What is an Organization’s Mission Statement?

The Organization’s Mission Statement …

 Expresses organisation’s identity and over-riding purpose.

 It is the reason for your organization’s existence.
 It outlines the contribution organisations will make and outcomes it seeks to deliver.
 Captures interest of key stakeholders and motivates them in a common direction
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 Can you draw a very simple organogram of your organization?

 Do you know the key decision makers of your organization?
 What are the set goals or targets of your organization for this year?
 Who are the clients your organization seeks to satisfy?
 Who are the stakeholders in the delivery of the service your organization offers?
 How best can you engage these stakeholders to continually sustain their interest in your
organization?

 You as a leader need to make your own personal plans on how to help achieve your orga-
nization’s mission, vision and goals.
 You will need to personally improve yourself and keep yourself relevant by having a per-
sonal Mastery of yourself.
 Remember to always set the example, not only when someone is watching. Be a good role
model for other employees. They will believe what they see – not what they hear.

I will like you to remind us of the various characteristics an effective leader should possess that
has been treated in this unit thus far. So, list them

We hope you remembered them all, namely: Personal Mastery of Self, Emotional Intelligence; Communicating
effectively; Understand and Navigate Organizations creatively

Good, Kudos to you if you got them all. And if not, put them to heart now, you will do better next time. Next we
shall look at the fourth characteristic of leadership, namely building and maintaining lasting relationships.

2.3.5 Build and Maintain Lasting Relationships

This section will look at another characteristics that is equally as important as others to a leader’s effectiveness. This
is because, you can never achieve it all alone as a leader, and you need to have the right people working with you.
So, let’s talk about relationships.

People are the most important resource at the disposal of a leader. The reason why a leader is called a leader is
because he has followers’. Hence, maintaining and sustaining lasting vertical (between leaders and followers) and
horizontal (among co- workers or co-management teams) relationships among the members of an organization or
a team is very essential.
The ability of a leader to build strong and lasting relationships is one of the key ingredients for becoming an effective
and successful leader. Building of relationships is not limited to the members of your team or organization alone, it
should also include your clients or customers. The relationship built earns you their loyalty and this is key.

According to Peter Farquharson, relationships of trust depend on our willingness to look not only to our own
interests, but also the interests of others.

Principles for Building and maintaining strong and lasting relationships

 I will like you to personally reflect on each of these principles in the table below.
 Then identify an ACTION WORD from the principles and use it to decode the word listed in the
second column.
 Tip: to guide you, the first letter of the ACTION WORD is given in the first column.
 To help you remember the ACTION WORDS from the Principles given below, you have the mne-
monics CLEARKIT.
 After attempting to identify the action words, check in the third column if you can unravel the
puzzle to get the action word. Does it correspond with yours?
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Table 3.2.8: Principles for Building Strong and Lasting Relationships

First letter Principles Action word
C Show concern for your teams’ career progression. Ensure their given tasks are
understood, supervised, and accomplished. ORNCECN
L Listen to others and seek first to understand them before being understood. TISLNE
E Have and show empathy when they are in difficult situations. Make effort to
show care and concern and associate with them when they have personal func- YTAMHEP
tions like sending birthday wishes and attending their functions when possible.
Be cognisant of their expressions, when they appear sad, distracted, anxious, de-
jected, show that you see it and care.
A Maintain a positive mental attitude and don’t be afraid to show your funny side TUDIATET
R Do not be afraid to let members of your team or organization know where you
falter. Be willing to take full responsibilities for your actions. Even where your OIBLITR-
team member is responsible for an action, try to share in the blame. It helps to SYPSNIE
make it lighter and makes them trust you more.
K Be friendly and seek to know your members better beyond the work. Know them
and look out for their wellbeing. Know about their children, their other interests OWNK
outside work. You may need to adopt the attitude of calling people one on one to
ask about their welfare, their work and their fears. And provide support not just
ask for the sake of it.
I Instil a sense of accountability, ownership and responsibility in yourself and in
your team members. Train your people as a team by developing and instilling a LNLTISI
team spirit. By this, you will be able to get the best from your team. These traits
will help them carry out their responsibilities with professionalism.
T Tell them as much about yourself as you would want to know about theirs. By
telling them about yourself, they will be able to trust you also with their personal LTEL
lives.

Were you able to identify them all? If yes, good. The action words were:
• Concern
• Listen
• Empathy
• Attitude
• Responsibilities
• Know
• Instil
• Tell

Mapping of Relationships

Some relationships are even more crucial to a leader than others. This is not limited to only the top cadre managers
alone. There is therefore the need for leaders to ask these questions and hence map the relationships.

This will determine how much effort you give into keeping such a relationship.

 Who are the key people I need to succeed with my deliverables or targets in a particular assignment/
project/ in the organization?
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Gradually, we are coming to the end of this unit. I guess you had fun trying to unravel the ACTION
WORDS in the last sub-unit. Can you quickly spell out what is meant by CLEARKIT?

The next section is a very critical and thought provoking one as well. I hope you enjoy it. By the time you are done,
your effectiveness as a leader would have improved.

2.3.6 Value Based Leadership

What does the term ‘VALUE’ mean?

Values
• Are the principles or commitments that organisational members stand for.
• They depict who we are and what we stand for.
• They are the qualities and behaviours most highly regarded by organisations as a whole.
• They define the ethical guidelines and standards that direct action in the organisation.
• They are the guiding rules, beliefs, principles or standards of behaviour we are never willing to compromise
that defines human behaviours.
• Values are typically limited to 3-5.
• They are expected to be deeply embedded in an organization and they can withstand the test of time.
• The strategies, tactics and approach of a leader may change given different situation, but his or her values
may never really change except he or she undergoes some supernatural transformation.

It is said that if a leader has nothing he or she stands for, he or she can fall for anything.

Very successful organizations have been found to be those who uphold a strong value system because their values
sustains them through the changes in time. People can afford to trust you only if you have good values.

People will readily follow a leader with a strong and positive value systems because he or she can be trusted to
remain unflinching on his values.
A leader with no strong values will have to compromise for his organization as he has no value to shape into the
organization.

The following are examples of Core Values an Effective Leader must possess:
• Courage- It takes courage to make some very difficult decisions in organizations, challenge and change
entrenched negative behaviours or cultures like corruption.
• Humility- Embracing humility as a leader facilities ability to learn from others which will lead to growth
and more success.
• Integrity
• Commitment
• Respect
• Trust
• Continuous learning

Now, which of these values can you boldly say you possess
Which would you work on to possess.
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2.3.7 Effect change using the Challenge Model and JAMII Project

Welcome to the last section in unit 2. Thus far we have been discussing the key characteristics a leader must
possess to be effective. The last of these characteristics to be discussed is the ability of a leader to effect change. I
guess there are many changes you will like to effect in your organization. How do you go about this? I hope the
following discussion will provide you with the answers to this question.

We face challenges daily as health managers and leaders of teams. Challenges such as inability to meet set
targets; drop in revenue to manage the health facility; a fall in utilization rate; uncooperative customers; over-
burdened human resources and so on. However, we should take note that these are not described as
PROBLEMS but as CHALLENGES. Why?

A problem is something perceived as insurmountable.

It suggests one may already be giving up on it.
It makes the issue sound daunting; difficult and this could be very discouraging.

Whereas, a challenge connotes something that may be difficult, but one that you are willing to face, to confront,
to attempt, to tackle and to overcome.

An effective leader is expected to train his or her followers in the habit of addressing issues as a Challenge and
NEVER a Problem.

Briefly describe the diagram below. What does it look like?

Figure 3.2.2: This is the Challenge Model.

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The Challenge Model (Galer et al., 2005) is a tool used by leaders to identify and analyse their challenges in the
course of their work.

How useful is this to the leader?

• It helps leaders to create a shared vision within the context of the organization’s mission.
• With it, the leader develops milestones or measurable results with which to measure the attainment of the
vision.
• The leader uses it to analyse his current situation in relation to the attainment of this measurable results.
• Guided by it, the leader identifies the obstacle and also do a root cause analysis of these obstacles.
• This helps the leader to identify the challenge that has inhibited the attainment of the measurable results
/ goals/ objectives.
• The challenge is captured in a single sentence and the priority action(s) needed to specifically address this
challenge and ensure change is then identified.

• It is always advisable to identify priority actions that addresses the root causes and one that is
within one’s circle of influence.
• That is, priority action(s) that the leader can influence within his capacity as the leader and not
one that is left for the government or any other third party to handle.
• This may sometimes require the leader to think out of the box

Steps in Using the Challenge Model

The steps in using the Challenge Model. Leaders will need to fill in the following:

• Mission
• Vision
• Measureable results
• Current situation
• Obstacles and root causes
• Challenge
• Select Priority Actions & Develop Action Plans
• Implement the Action Plans
• Evaluate the Action Plans

The Mission
This is what the organization is known for or why it exists. This should not just be to be pasted on the walls or
merely for the documents of the organization, such as in its constitution. Rather, this should be ingrained within
the members. Everyone should know what the organization stands for or why it exists. Hence, as a leader, you may
need to review your organization’s mission statement and together with your team have a common understanding
of your organization’s mission and priorities.

What is the vision of your organisation?

The Vision
This is the future of the organization or a team. It is where the leader hopes to get the organization to. However, the
vision is better as a Shared Vision.

A Shared Vision is such that is developed by the various stakeholders in the organization. Hence, it is not just from the
top managers alone and passed down to the others. Or one that was given to a consultant to do for an organization.
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It is easy for members of a team or an organization to own a Shared Vision.

As a leader, you may have a vision for the organization, get the necessary stakeholders together and let them also
put down their vision and you all bring them all together to form a Single Vision (A shared Vision)

How to Create a Shared Vision (You can do this among your colleagues at work)
• Each participant should write down a picture or vision in simple terms of where you want
the health systems in Africa too be in the next five years.
• Share this vision with the partner beside you and both of you harmonize it into one vision
• You and your partner should join another team and harmonize your visions together to
form one
• Each group of four now present at plenary stating the key elements of their harmonized
vision
• Prioritize these key elements and then use it to form one single vision statement for the
entire team.

The Measurable Results

These are the milestones to measure the Shared Vision. A leader identifies specific aspects of the Shared Vision, and
then develops measurable results which are objectives for them. These objectives must be SMART

(S-Specific, M- Measurable, A- Achievable, R- Realistic or Relevant, T-Time Bound). These help in evaluating the
achievement of the vision.

An example of a measurable result is ‘To increase use of voluntary counselling and testing (VCT) services in all the
districts by 50% (to an average of 80 clients per month) by the end of the year’

However, this is an iterative process. After addressing the other steps in the Challenge Model such as
the Current situation, the obstacles and the root cause analysis, you may need to go back and review
the measurable results and make them more realistic within the expected time frame.

Write down more examples of measurable results in relation to the Shared Vision they have created.

Current Situation
As a leader in a team, you will need to analyse your current situation that is, the current situation of your internal
and external environments in relation to your stated objectives or measurable results. To do this, you need to do a
SWOT analysis.

SWOT means (S-Strength, W-Weakness, O-Opportunities and T-Threats).

The Strength and Weaknesses are for the internal environments while the Opportunities and Threats are to analyse
the external environments.

Remember!
The internal environments for example will include the employee. The employee-employer relations, the unions
within the organization; the management team.

The external environments will include government regulations and policies, competitors of the organization; the
Clients, the Regulatory Agencies, Political environment, the socio-economic situation within which the organization
exists to mention a few.

Conducting a SWOT Analysis is covered in more detail in Module 4 Unit 4 that deals with Strategic Planning.
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Using the example of a measurable result which we gave above, List one example of a strength,
weakness, opportunity and threat in your internal and external environment.

Now compare your answer with examples we have given in the following discussion.

The Strength of your organization may be that majority of your health workers have been trained in conducting
VCTs.

Weaknesses may include ‘The organization is still faced with incessant industrial actions that may hinder the
availability of the service.

Opportunities may include new donor funding for the project, increase in the level of literacy in the community.

Threats may include new policies of the international governments providing Donor Funding; poor male
participation in the health of their women, Cultural practices, myths and beliefs.

Example:
‘An example of a current situation may be that VCT utilisation is at 20% in most of the districts. There are trained person-
nel on VCT who however, are faced with incessant industrial action. They hope to leverage on the new donor funding
and in order to address the myths and beliefs of the people towards achieving the stated results’.

Obstacles and Root Causes

Now it is time to learn about how to do a Root Cause Analysis!

The leader and the team will try to identify and list the possible obstacles they will need to overcome to reach the
stated results. And then analyse the root causes of these problems by asking, why?

For the example of a measurable result given earlier which is being used this far, one obstacle to overcome is
“Getting the people to utilize the Voluntary Counselling and Testing Services.

To identify the root causes, the team will need to answer the questions,
• ‘Why is the utilization rate low now or what is it currently”
• By using for example the five why technique or the Ishikawa diagram also known as the Fish Bone Diagram
(looks like the fish bone), or the Root tree diagram and so on.
• The first why may be- The people have refused to utilize the services despite all the promotional programs to
create demand for it in media.
• Why this? - The message in the promotional programs target only a specific category of people or connotes a
wrong message
• And Why that? - There were no adequate stakeholder engagement when the promotional programs were
developed
• And Why that? - There was no proper stakeholder analysis done and minimal consultation to evidence in
research was done.

• The Why’s may not necessarily have to be five, they may be more or less. What matters is to
identify the root causes for the obstacle.
• There may be other why’s too, such that many root causes are identified.
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Another technique that can be adopted in doing a root cause analysis is the Ishikawa Diagram also known as the
Fish Bone Diagram. See Figure 3.2.3 below.

Fig 3.2.3: The Ishikawa Diagram or Fish Bone Diagram

Using the Ishikawa Diagram

The Ishikawa diagram is categorised into specific groups in relation to the stated measurable results for example,
in the diagram X, they are categorised into People related, Process/ Policy Related, Equipment / Supplies and
Environmental related root causes.

Practice doing the root cause analysis using any of the techniques that you are most conver-
sant with.

Challenge Statement.

After doing the root causes, the team will then identify the key root cause(s) that may need to be addressed and
also craft their challenge statement. The Challenge statement is the realistic statement of the issue to be tackled. It
is best written as a question and started with- How?

Only one Challenge statement is crafted but it can be written such that all the major or key challenges to be
addressed are put together in one statement.

Example of a Challenge statement:

How do we increase the utilization of the voluntary counselling and testing (VCT0 services by 50% considering
the lack of a well-targeted adequately prepared health promotional message for it?

Participants should practice writing Challenge statement given examples of root causes and a measurable result.

Priority Action
From the Challenge statement, it becomes clear and easy to develop Priority Actions.
The Priority Actions are those specific actions that must be done to effect change truly.

For the above Challenge Statement, the Priority Action may be to:

‘Develop an evidence based well targeted promotional message to be aired on media using a detailed
stakeholder approach.’
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Developing Action Plans for Identified Priority Actions using the JAMII project.

This stated Priority Action will now have to be planned for. Several actions will need to take place, like gathering a
team, review of evidence on what target group to focus on, what type of promotional messages they would listen
to, and what type of media to promote it will be most acceptable to them. This may even require conducting a
research.

In planning for this action, you will need to state ‘Who to do what, By When, State the measurable outputs in
monitoring the plan, what indicators will be used to track results, what assumptions will guide the action and so
much more.

The African Health leadership and Management Network (AHLMN) developed a Model for achieving this. It is called
the JAMII Project.

JAMII in the Swahili language means family. This connotes that change in health will occur from the most basic unit
such as THE FAMILY.

The JAMII project details the step by step action leaders will need to employ to implement change in their
organization after identifying the priority actions that needs to be taken to bring about this change. The JAMII
project may be related to any aspect of the health system that must be strengthened.

Explanation on the JAMII Project.

In addition to the background on the organization already developed using the Challenge Model, the JAMII
projects also requires that information on the Core Values of the organization, the Leadership Challenges being
faced and the major organizational policy issues in the organization be provided.

The JAMII project template provides an avenue for doing a detailed stakeholder analysis, listing the Monitoring
and Evaluation Plans, doing a detailed budget and a Resource Mobilization Plan asides from the step by step
activities in the action Plan.

The Template of the JAMII project is provided in the Appendix I at the end of this Module. Also, a tool to follow
up on the execution of Priority Actions using the JAMII project is provided as an appendix at the end of this
Module.

As we gradually round up this unit, you can see that a lot is expected of the leader to make change in the
organization. The good news is

‘These characteristics can be learnt’

Let us now discuss in practical terms the Challenges that leaders face in bring about change in the African Health
System

Challenges of Leadership in Health in Africa.

What are the key leadership challenges in health in your country

Now reflect on the following questions and give concrete examples from your health system. Then share your
answers in the online discussion forum.
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To what extent is / are ……

• Health Care delivery comprehensive, integrated, continuous and effective?
• Access guaranteed and are people aware of what benefits they are entitled to?
• People protected against the economic consequences of ill-health?
• Authorities effective in ensuring protection for the populace against exclusion from care?
• Authorities are effective in ensuring protection against exploitation by commercial
providers?

You have come to the end of this unit on characteristics of effective leadership. Let us now review what you have
learnt.

2.4 Unit Summary

In this unit you have learnt the following:

1. There is a difference between being a leader and being an effective leader

2. A few of the characteristics needed to be an effective leader include: having a Person-
al Mastery of Self; Being Emotionally Intelligent; effective communicate; Understand-
ing and navigating your organization creatively; building strong and lasting human
relationships; practicing value based leadership, and initiating and effecting change
in the organization by identifying challenges using the Challenge Model and execut-
ing priority actions using the JAMII Project Template.
3. You must understand the Vision, Mission, Organizational structure, stakeholders and
clients in your organization well enough to effect change.
4. The Steps of the Challenge Model which is used to effect change include the follow-
ing: Defining or Reviewing your Mission,; Developing a Shared Vision; Writing out
your measurable results or objectives or goals; Defining your current situation; iden-
tifying the obstacles to your measurable results and find their root causes using the
Fish Bone Diagram; craft a Challenge statement that addresses the key root causes
of why you haven’t reached your measurable results; Identify the priority actions you
will need to do to create change. Finally, plan, implement and evaluate the change
using the JAMII project template.
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2.5 References and Further Reading

1. Galer, J. B., Vriesendorp, S., & Ellis, A. (2005). Managers who lead: A handbook for
improving health services.

2. Goleman, D. (2006). Emotional intelligence: Bantam.

3. Hockenbury, D. H., & Hockenbury, S. E. (2010). Discovering psychology: Macmillan.

4. Johnson, S., & Rodway, G. (2002). Management Strategies for Improving Health
Services. Creating a Work Climate That Motivates Staff and Improves Performance.
The Manager, 11(3).

5. Kline, J. A. (2011). Leaders communicating effectively: Article prepared for AU-24,

Concepts for Air Force Leadership.

6. Parrott, W. G. (2001). Emotions in social psychology: Essential readings: Psychology

Press.

7. Randol, K. M. (2011). Effective Leadership definition. Retrieved from [Link]

[Link]/kmr5279/blogs/pla/2011/09/effective-leadership-definition-of.
html

8. Sahu, R., & Bharti, P. (2009). Strategic Leadership: Excel Books.

9. Senge, P. (1990). The 5th discipline. Bantam Doubleday Dell Publishing Group.
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UNIT 3: CHANGE MANAGEMENT

3.1 Unit Introduction

Welcome to unit three about change management. In the previous unit you learnt about an effective leader. An
effective leader bring about positive change in an organization. In this unit, we will cover the following five sub-
units:

1. First we will define the concept of change management,

2. Then we will talk about change and changing people,
3. Thirdly, we will explore how to manage resistance to change,
4. The fourth sub-unit is the different steps to successful change management,
5. We will finalize by the principles and strategies of negotiation.

3.2 Unit Outcomes

At the end of this unit, you should be able to lead organizational change.

3.3 Definition of Change Management

What do you think is meant by change management?

Change management is a structured approach to shifting/transitioning individuals or teams from a current state to
a desired future state; it is an organizational process aimed at helping employees to accept and embrace change in
their current work environment.

1. Think of a change that you have experienced; then explain what others did to support
you during the change? Write down your reflection about this.
2. In your forum, share your responses about what happened and write the most helpful
answers on your note book.
3. In your large forum, share all the answers and also add anything from your own experi-
ence that is missing from the list.

After defining the concept of change, let us now discuss about change and changing people.

3.3 Change and Changing People

Change is constant and is inevitable; it can be managed if the environment is understood; it is a fact of life and does
not care who it hurts. Change can be traumatic through anxiety, fear and stress; it is a pre-requisite for organizational
growth and development. It seeks to add value. Change in one sub-system will affect other sub-systems and
ultimately the entire organization system. To change a sub-system or the entire system, relevant aspects of the
environment must also be considered.
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What do you think about the picture on the left?

Figure 3.3.1: Leading Change Framework

I know you were able to identity some of the concepts we will now discuss. The Leading Change Framework
incorporates three major elements each of which is required in order to successfully introduce change.

The first requirement for success is to be strategic– in your choice of a project and the timing of it, in developing a
vision and being able to communicate this vision to stakeholders being clear about the need for change and the
desired outcomes.

The second requirement for success is your ability to engage your stakeholders – to understand their motivations,
develop political support and build capacity and capability; they need skills and incentives to change.

The third requirement for success is being able to manage your project. This is more of a methodological approach
where you develop the action plan - define the deliverables, assign accountabilities and resources monitor progress,
develop a communication plan, monitor results, etc.

Note that the framework is not static and the elements overlap. In order to introduce change successfully you need
to attend to all three areas. If you don’t have a vision, you will have confusion – people may be able and ready
for change, they may have the resources and know what to do… they just don’t know why it is important. If you
overlook or underestimate a key stakeholder, your change could be sabotaged. If you don’t get the best team
members, your solution may fall short of what you hoped to attain. Without a well-articulated action plan – it won’t
be clear who is to do what and you may have a false start.

The framework is not static and the elements overlap. In order to introduce change
success-fully you need to attend to all three areas.
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Factors required for effective change management in organizations

For change to be effective, it has to address the factors represented in the figure below. These factors are
interrelated and each contributes in determining effectiveness of change. These are closely aligned to 8
steps of change management covered in more detail later on in this section.

Culture

Structure Leadership Activities

People

Let us now look at the People Factor.

But how do you change people?

Reflect and comment on this picture?

Write down your reflection in your notebook.

Figure 3.3.2: Changing People

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Changing people is not easy and it requires careful consideration. Knowledge and skills can be changed most
readily, demeanour – conduct and behaviour – can be changed over intermediate term while values, aptitudes and
cognitive style are not easily changed.

What are some challengers of changing people?

Figure 3.3.3: Means of changing people

There are three levels of changing people and each requires a different approach. These are:

1. Training and development: Knowledge is easy to transfer but on its own it does not bring. It is transferred
through training. Skills is the application of knowledge and acquired through development and practice
of acquired knowledge.
2. Coaching and Incentives: Demeanour – meaning conduct and behaviour are not as easy to change. They
are changed over a longer period of time through coaching. This is a process where the worker get direct
help and support to change certain behaviours such as treating people with care. Giving incentives when
people portray the change that you need is a way of changing behaviour. This could be both monetary and
non-monetary incentives. More on this will be covered in the HRM module.
3. Additions and replacements: These are methods used to bring more lasting change in people. Values and
aptitudes are what each leader should aim to change in people. The approach needed is more long time
in nature and involves modelling the values that you want and encourage them over time. For example
you may need to encourage a value of “the customer is king”. Then you model that what looks like through
a system like collect customer feedback and acting on it as much as possible and on a timely manner.
This could be through a simple thing like having a decision box that is opened by a senior manager. This
discipline can replace a discipline of complains and apathy in an organization.
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A small body of determined spirits fired by an unquenchable faith in their

mission can alter the course of history

Change is a game best shared – it is tough game to play alone. Leadership also implies followership, so finding
kindred spirits is important. Human beings often resist change. But just as in the case of the now famous Star Trek
quote from the Borg … “resistance is futile.”

1. In your forum, reflect about what changes are occurring in the environment? What will be
their implications for your organization?
2. What changes should you make in order to achieve your development objectives,
improve your performance?
3. What undesirable changes will occur in your organization if you do not take timely steps for
prevention?

After seeing how to change people, we’ll now explore about managing resistance to change.

3.4 Managing 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.

What are some reasons that make people to resist change?

Good! I believe you have thought about some of the following:

1. They believe it’s not in their interest to change;
2. They think the change is the wrong thing to do (If you knew what I knew);
3. They are skeptical about the possibility of success;
4. They don’t understand why change is happening (It isn’t relevant to them);
5. They don’t understand exactly what change is required;
6. They don’t have the time or resources to change;
7. They don’t think that they will be able to change (Fear of failure);
8. They feel they were not involved in the decision to change;
9. Lack of conviction that change is needed;
10. Dislike of imposed change;
11. Dislike of surprises;
12. Fear of the unknown;
13. Reluctance to deal with unpopular issues fear of inadequacy and failure;
14. Disturbed practices, habits and relations;
15. Lack of respect and trust in the person promoting change.

Strategies for dealing with resistance to change

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In your forum, reflect about some strategies for dealing with change resistance

Figure 3.3.4: Strategies for dealing with change resistance

3.5 Steps to Successful Change Management

Change is not just inevitable, it is also good. To make the most of change, you need to manage it well. Kotters
model summarised below outlines 8 steps of that will ensure that your change is successful (Kotter, 1996).

Read the 8 steps of Kotters on how to manage change.

Write down the ones that applied to you in a successful change that you have
experienced.
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Figure 3.3.5 Steps in Change Management (Kotter, & Rathgeber 2006)

1. Create a sense of the urgency of change: The greatest change will have little chance of success if it is not
fulfilling an urgent need. A need is urgent when it is of pressing importance to the organization. Ensure
that 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. When is urgency level high
enough? When about 75% of leadership is honestly convinced that business as usual is unacceptable.

2. Form a powerful coalition: Major change is difficult to accomplish and so a powerful force is required to
sustain the process. From a strong guiding coalition - one with the right composition of people. Three
characteristics seem to be essential in an effective coalition.

Figure 3.3.6: Forming Powerful Coalitions

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Position power – Enough key leaders in the organization

i. Expertise – in terms of discipline and work experience.

ii. Credibility – enough people with good reputation; high levels of trust and shared objective.
Employees want change messages to come from their direct supervisors, people that they
trust. In case a leader has low credibility, surround them with others who have it.
iii. Leadership – Include enough proven leaders to be able to drive and deliver the change
process.

Coalition members need to be addressed, managed and motivated. For example a sponsors responsibity
is more than signing checs and charters. They need to be the face and voice of the change that you want to
bring. Accrodng to reaserch, sponsors need to be:
• active and visible througout the project,
• Build a strong coalition through out the project and
• Communicate directy with other stakeholders.
Coalition members need to agree with the need for the change or the project and see the urgency for
the same.

3. Create a vision which is easy to communicate. Without clear and sensible vision, a change effort can easily
dissolve into a list of confusing and incompatible projects that can take the organization in the wrong
direction or nowhere at all. Be positive and optimistic in your language, presenting an inspiration picture
of your desired future rather than starting from negative problems. Can anyone in your organization easily
articulate your vision? If not it either needs attention or more effective communication. Take a few minutes
and write down the vision of your Jamii project. Then share it with a colleague.

4. Communicate the vision rigorously. Communication is done by both words and actions and the actions are
a more powerful way. Nothing undermines change more than the behavior by important individuals that
is inconsistent with their words. Try to ensure the message does not become garbled and misunderstood
on its way through the organization.

5. Empower others to act on the vision. The first stage in empowerment is successful communication of the
vision. 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. But change also
requires removal of obstacles. Do the employees in your organization truly have the capacity to act on
the vision? You may need to give them training and support. Have you analyzed the path to success?
Are there obstacles like old ways that get in the way of new ways? Are there personalities that hinder the
adaptation of new ways?

6. Generate short term wins. 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 to Celebrate short-term wins
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7. Build on the change. Consolidate improvements and produce still more change. Capitalize on your success
and increased sense of success in your organization. Use increased credibility to change systems, structures,
and policies that don’t fit the vision. Hire, promote, and develop employees who can implement the vision.
Reinvigorate the process with new projects, and change agents.

8. Make it stick. Institutionalize the new approaches. 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. Change sticks when it becomes “The way things are done here.”

(Kotter, J.P. (1995) Leading Change: Why Transformation Efforts Fail. Harvard Business Review, March/
April 1995)

Using the checklist for successful change initiative which is based on the Challenge
Model, discuss the following in your forum and write your answers in the “comments”
column of the following “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 forum, review as many of the other questions as time permits.
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Checklist for successful change initiatives

S/N QUESTION COMMENTS

1. Have you communicated the urgency of the change effort by framing the goal of
your Jamii project clearly?
2. Have you built a strong core team to support your Jamii Project?
Do you have a shared vision of the end result of the change initiative you are
3.
aiming to bring through your Jamii Project?
Are you including key stakeholders in planning and implementation of the activ-
4.
ities in your project?
Do you have examples of obstacles that we have overcome together as a result
5.
of the change initiative?
6. Are you sufficiently focused on results?
7. Do you have periodic celebrations of short-term wins?
Do you have continued senior leadership support for facing ongoing challenges
8.
as you implement your project?
Are new behaviors and values becoming increasingly visible at work? Name
9.
some.
10. Are changes incorporated in routine organizational processes and systems?

Well done! We have arrived at the end of our unit. In the last sub-unit we will talk about principles and strategies
for negotiation.

3.6 Principles and Strategies for Negotiation

Reflect about a situation you have had to negotiate with other partners to achieve your
goal. Write down what worked well for you in that experience.

Negotiation is a method by which people settle differences. It is a process by which compromise or agreement is
reached while avoiding argument and dispute. In any disagreement, individuals understandably aim to achieve the
best possible outcome for their position (or perhaps an organisation they represent). However, the principles of
fairness, seeking mutual benefit and maintaining a relationship are the keys to a successful outcome. Specific forms
of negotiation are used in many situations: international affairs, the legal system, government, industrial disputes
or domestic relationships as examples. However, general negotiation skills can be learned and applied in a wide
range of activities. Negotiation skills can be of great benefit in resolving any differences that arise between you
and others.

Other important principles of negotiation include:

1. Planning which involves defining the negotiation objectives;

2. Avoid a clash of wills by applying criteria or standards that are verifiable and independent;
3. Negotiations and their results have long term effects – be careful what you argue for because you
cannot easily change your position in the future;
4. May produce some compromises – begin negotiating once one has identified a range of acceptable
results (not just one desired option);
5. Be wise enough to know when not to negotiate;
6. Agreements where one side “wins” often fail.
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7. Show respect for the other side’s point of view. Always seek common ground and shared interest;
8. Negotiate in good faith. Find ways to show the other side you are sincere about reaching an agreement;
9. Communicate your position clearly. Make sure you fully understand the position and issues of the
other side;
10. Never argue or disagree within your negotiation team in front of the other side;
11. 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.

Remember the attitudes you must have while negotiating

Prisoners dilemma
The purpose of this exercise is to demonstrate that negotiation requires trust and how diffi-
cult it is to regain trust when it is lost
The objectives of the activity are:
• To identify the basic principles 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;
The expected objectives of the activity are:
• 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
• 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.

[Link]
9th February 2017
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The usefulness of this activity:

It has the ability to expose you 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”.

That brings us to the end of this unit on change management. Let us now review what you have learnt.

3.7 Unit Summary

For you, leader, change management must be a priority. It guides you in how you
prepare, equip and support your followers to successfully adopt change in order to
drive organiza-tional success and outcomes. While all changes are unique and all
individuals are unique, decades of research shows there are actions you can take to
influence people in their indi-vidual transitions. For you, change management
provides a structured approach for sup-porting the individuals in your organization
to move from their own current states to their own future states. This requires an
individual change management and negotiation abilities.
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3.8 References and Further Reading

1. Don Page; Servant Empowered Leadership; Hands-on Guide to Transforming you

and your Organisation, Power to Change Ministries inc. Langley BC. Canada.
2. Everybody’s Business: Strengthening Health Systems To Improve Health Outcomes
(WHO’s Framework for Action)
3. Gill Robison Hickman, Leading Organisations, SAGE Publications (2010)
4. Government of the Republic of Kenya. Kenya Vision 2030, Government Printer, Nai-
robi, Kenya
5. Ivancevich. Konopaske. Matteson, Organisational behaviour and Management, Mc-
Graw-Hill Companies (2011)
6. JICA, 5s Kaizen Manual
7. John P. Kotter, Leading Change. Harvard Business Press (1996)
8. Joint Commission International, JCI Accreditation Standard For Hospitals 4th edi-
tion(2011)
9. Management Services for Health, Managers who Lead, Cambridge, Massachusetts
(2005)
10. Michael Heath: Leadership Secrets; Harper Collins publishers
11. Peter M. Senge The Fifth Discipline, Random House Business Books, 2006
12. Rob Goffee, Gareth Jones: Why Should Anyone be led by you? Harvard Business
School Press
13. Stephen M.R. Covey, Speed of Trust, Simon & Schuster (2006)
14. Stephen R. Convey; Principle Centred Leadership: Simon and Schuster UK ltd(1999)
15. Stephen R. Covey, The 7 Habits of Highly Effective People, Franklin Covey Co. (2004)
16. Stephen R. Covey, the 8th Habit, Franklin Covey Co. (2004)
17. World Health Organisation ;World Health Report :Primary Health Care-Now More
Than Ever (2008)
18. World Health Organisation ;World Health Report, Health Workforce (2005)
19. World Health Organisation ;World Health Report: Health Systems Financing: The Part
To Universal Coverage (2005)
20. Robert Greenleaf, Servant Leadership, Paulist Print, New York, 2002
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UNIT 4: PRACTICING EFFECTIVE LEADERSHIP IN HEALTH

4.1 Unit Introduction

Welcome to the last unit in this Module on leadership. I agree with you that it has been a long walk from Unit 1.
I guess you are now ready to initiate change in your organization. Thus far, you have learnt about the leadership
styles to adopt, the characteristics you need to be effective as a leader and how to manage the changes you
effect.

This units starts by addressing key issues such as attitudinal change and how to improve the work climate in your
organisation. It also stresses the need for mentorship and also shares with you practical examples of inspirational
leaders.

4.2 Unit Outcome

At the end of this unit you should be able to practice effective leadership in healthcare
settings.

4.3 Influencing Attitudinal Change in the Work Place

Think of a facility that you have used before, like a hospital, a restaurant, a hotel or any
particular place.
Try to remember your experience there. Is it a place you will like to go back to?

If yes, why? And If No, Why not?

If your answer was NO, then could the reason have been BAD ATTITUDE of the service providers?

When you visit a facility, what gives you a lasting impression there is not the beauty or the grandeur of the place nor
even the services offered, BUT it is the attitude of those who offered the service. The workers there!! Yes. And that is
what determines if you would ever want to go back there or even bring others there.

Our attitude speaks volumes about us and about our organization. When government or our employees invest in
providing services, our attitudes alone is enough to chase people away from the service. Those who manage to
come cannot wait to step out.

The success of companies, large and small across the African continent lies in the attitudes and behaviours of the
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men and women that work for them. As a leader, you first must change your attitude for the better before asking
others to change. Your attitude to work, attitude to co-workers, attitude to customers, attitude to results, attitude
new ideas, attitude to change, attitude to failure, and many more MUST Change for the better.

What is attitude?

Attitude is simply said to be how you feel about something and how you communicate that feeling to others.

Have you ever considered why women (both educated or not) would leave a health facility with all
the technical expertise and skills, sophistication, good environment sometimes and possibly free ser-
vices and still go to a Traditional Birth Attendant or a quark for delivery services?

It is the attitude. We must change our attitudes if we want our clients back, achieve set goals, improve our health
indices, Our ATTITUDES must Change for good.

What are the components of attitude? Have you ever stopped to think about what attitude really
consists of?

There are several explanations to this by several psychologists in literature. The most acceptable explanations to
what constitutes attitude is found below.

Figure 3.4.1: Components of Attitude (Dhillon, 2012)

Hence, attitude has the Cognitive part, for example ‘I believe my co-worker is proud and lacks good manners’

And then the Affective part, which is the feeling part that is influenced by our emotions. For example ‘I don’t like my
co-worker, or am easily irritated by my co-worker, or I hate being on duty with her”

And then the Behavioural part. This is the part of our attitude that is expressed, that is what others’ read and see. For
example, I will keep to myself and not utter a word to this co-worker, or I will go to another unit and leave her to do
the work, I can’t stand being with her”.
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To help you in remembering this, the Components of Attitude can simply be explained using some-
thing as elementary as A, B, C
Affective; B- Behavioural; C- Cognitive. Good.

Now, how are attitudes formed?

It is good to also know how attitudes are formed. This may help in creating or influencing attitudinal change.

Attitudes can be formed from the following:

• Direct experience: Mere exposure to an event may influence our attitude towards it.
• For example: If you had ever experienced a health worker saving your life or the life of a loved one, it may
forever influence your attitude towards all health workers. And if it is the other way round, where you belief the
life could have been saved if not for a health worker, then forever, you may detest them.
• Classical Conditioning: A stimulus that elicits an emotional response is repeatedly experienced along with a
neutral stimulus that does not, until the neutral stimulus takes on the emotional properties of the first stimulus.

For example: Your boss gets you irritated. But your boss is often seen with this co-worker or client who has no
dealings with you. However, the more you see this co-worker or client with your boss, the more you also get irritated
at the client or co-worker. And then an attitude is formed. The client or co-worker gets you irritated and informs your
behaviour towards them.
• Operant Conditioning: This explains when attitudes are formed by a reinforcement system of reward or
punishment.
• For example, when a health worker is always praised for coming early to work, the tendency that he associates
praise to coming early is high and naturally will want to continue doing that.
• So also, a health worker can associate a funder to more incentives and any work related to them, means more
incentives. On the negative side, a health worker may associate a particular clinic day to getting home late, and
because of that associate every client coming as someone who will make him or her get home late. And all
these will inform their attitudes.
• Observational learning: This explains why some people take up the mannerism of their parents, or mentors or
leaders or role models and so on. They have watched and gotten so used to this person’s way of doing things
and naturally adopt it to sometimes without even knowing.

Why do we need to know all these?

It helps to explain why we behave in the way we do or helps to explain other people’s attitudes. Also, it becomes
instrumental in as methods by which we can improve our co-workers attitude to clients and to their work. For
example, the use of Operant Conditioning in cultivating a positive attitude among workers.

One other important thing about attitudes is how infectious it can be for both positive attitudes and negative
attitudes. This concept also speaks to Emotions.
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Remember that emotions influences the affective component of attitudes.

So, let us together look at what is called, the Betari Box

The challenging thing about attitude is that when one

person’s exhibits bad attitude in the work place, most often
times, others follow to do same. One persons’ bad
attitude influences others to be irritating, cold, sour and
all.

For example, refer to the Betari Box.

Hence, to promote good attitude in the work place,

someone should break the chain along the Betari box. You
can decide that it will be you.
You don’t have to allow another persons’ attitude or
behaviour affect yours.

Figure 3.4.2: The Betari Box

So, having said all, how do we improve our attitude and influence attitudinal change among our
colleagues or team members?

Watch this video entitled the Human Connection to Patient Care [Link]
watch?v=cDDWvj_q-o8 . Then write down the lessons you have learnt from this video in your
notebook

This video demonstrates the power of effectively listing to people and empathising with their situations. If
you could stand in someone else’s shoes. Hear what they hear. See what they see. Feel what they feel. Would
you treat them differently?
“Could a greater miracle take place than for us to look through each other’s eyes for an instance?” Henry David
Thoreau

First of all, attitudinal Change begins with YOU!!! You need to realise this

There are very simple things you expect from others towards you. Are you willing to do same to-
wards others? Think about it.

There are three steps in the process of attitude improvement:

• Identify the attitude you want to improve
• Resolve to develop those attitudes
• Use the image of you ideal personality as a model for you behaviour

The best way to reform oneself is to develop positive attitudes and eliminate negative ones. It is said that
the cheapest way to change YOU is to change your ATTITUDE, of course for the better.
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All you need to do more may be:

 A little more smiles.
 Make eye contact when speaking with customers
 Be polite and kind always
 When angry or upset, try to keep cool or be quiet, remember, emotional intelligence
 Be willing to always give your best at work
 See your customers as kings and must be treated with respect
 Believe everyone deserves respect, attention, simple explanations, patience
I would like you to give more examples of positive changes that can be made to improve attitude.
Also, write in clear terms how you plan to use the lessons learnt in this unit to first improve you
attitude to your co-workers and clients.

“Nothing can stop the man with the right mental attitude from achieving his goal; nothing on
earth can help the man with the wrong mental attitude.”-[Link]
“The greater part of our happiness or misery depends on our disposition and not on our circum-
stance”- MARTHA WASHINGTON

 Discuss examples of great employee’s attitude in your work place.

 What did the person do? Give clear example.
 Discuss examples of negative work attitude. Give a clear example of one incidence
 Make a list of positive and negative attitudes in your work place
 What can you do to encourage positive attitudes in your organization?

4.4 Improving the Workplace Climate

In this section, you will be exposed to practical approaches that will enable you to bring about change in your
workplace.

What is work place climate?

Before we get into this discussion start by watching the following video and then answer the questions that
follow.

Play the video titled “Work Environment (Bad)” using the link below:-
[Link]

The video shows different types of negative workplace environment.

• Which of the scenes in this video best describes your workplace climate or
environment?
• How do you feel when you think of going to work the next day?
• Do you look forward to each day at work, or you wish you can avoid going?
• Does working in your organization energize you, empower you, excite you,
encourage you, embolden you and enlighten you?
• Or does it dampen you, discourage you, distress you, disenfranchise you,
disillusion you and destroy something about you?
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Just as every organization is exposed to an atmospheric conditions and weather, so every organization also have a
type of climate.

Just as sometimes the natural atmospheric or weather condition of a place may affect work, so also the socio- or
psychological weather condition within a team, an office, a work place or an organization may become quite
unbearable for its members.

Just as the natural weather condition of a place can hinder work, so also the socio and psychological work place
climate can increase or reduce workers’ productivity.

Have you ever heard of the word organizational culture?

What is the difference between organizational culture and organizational or workplace climate?

Now we are going to examine the differences looking at Table 3.4.1

Table 3.4.1: Differences between Organizational Culture and Organizational Climate

Organizational Culture Organizational Climate
A system of shared assumptions, values and A set of measurable properties of the work environment,
beliefs that governs how people behave in based on the collective perceptions of the people who work
work places in the environment and demonstrated to influence their
motivation and behaviour.” (Singer, 2001)
It is the way of life of an organization. The It is how it feels like to work in an organization or how
unspoken assumptions of an organization that working in an organization make you feel.
is deeply ingrained It is peoples’ perceptions or feeling about their work place
Can be described as the personality of the Can be described as the mood of the organization
organization
Can be difficult to measure Can be easier to measure
Can be difficult to change /more resistant to It is easier to change or transform
change
Largely determines the work climate such as The climate can be made positive by effective leading and
the Management philosophies, employee managing practices even if the culture is discouraging
relations, organizational structure, the values
and norms, relationship between superiors
and subordinates.
Examples: Engage in Team work; Employee Examples: It feels good to come to work; A friendly and
engagement; Everyone goes for break at 2pm; relaxed atmosphere; A tense atmosphere; Mind your business
Recognition for good work; In meetings, the attitude; poor lightning; Choky and Clumsy offices; Paranoid
Seniors speak first; Frequent reference to the atmosphere;
code of conduct

Organizational Culture is the ‘who or what an organization is’ (The personality). While organization-
al Climate or work place climate is the ‘How an organization feels like’ (the mood of the organization)

Now, there are different types of classification of workplace climate. The type adopted in this unit is shown in the
table 3.4.2.
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Table 3.4.2: Types of Work place Climate

Positive work climate Negative work climate
Attractive Friendly atmosphere Anxiety
Sense of belonginess Feel isolated
Comfortable Uncomfortable work space
Not particularly under undue pressure even Embarrassing for lack of convenience facilities- toilets,
after deadlines are passed water
Though business like: but warm

I will like you to suggest more examples of the positive and negative types of work climate
using your personal experiences.

Now, why is it important to discuss the workplace climate?

Importance of the Work place Climate

This is because workplace climate has been found to have profound effects on the performance and success
of organizations. And, if a leader needs to make a change that may be simple and easy to do, improving the
work place climate is a way to go. And it yields great results. How workplace climate influences
organizational performance is expressed in diagram 3.4.3

Leading and managing practices

Work Climate

Employee satisfaction and motivation

Performance

Figure 3.4.3 : Factors influencing work climate and its effects (Johnson & Rodway, 2002)

Effect of Work Climate on the Organization

The working climate of an organization has been found to directly impact the motivation of its workers positively
leading to growth, efficiency and profitability thereby enhancing performance. All these are dependent or the
leading and managing practices of the leader within the broader context of the organizational culture.

The manager or leader of an organization have also been found to be the major determinant of the work climate in
an organization. A research by Goldman in 2001 found that 50 to 70 percent of employees link their work climate to
the characteristics of the leader. (Goleman, 2001).
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When you improve on your leadership and management skills and use that to improve the work
climate, the employees or your followers get motivated and begin to have job satisfaction.
This will improve their performance and you begin to get good results.
Then you are described as an effective leader, your results live beyond you.

Now, find below, practical things you can do to improve your work climate

Practices that can influence a positive work place climate (Freifeld, 2012)

Clarity: Leaders should communicate to their followers what goals or milestones are expected of them and be very
clear about it. Every team in an organization should understand the strategic direction of where the leaders are
taking the organization per time. If anyone is left out of this information, such persons will feel isolated, ostracised,
not needed, and gradually feel is not needed in the organization and stop to give his or her best, which will eventually
affect the overall climate in the organization and also impart negatively on their overall performance.

Challenge them with high Standards: Establish very high but yet realistic standards for your followers and look out,
be interested in their results and so regularly check their performance to encourage or challenge them on. Some
leaders dole out work, not necessarily because they need the results but because they only want to keep people
busy or engaged. If you the leader is equally working, charting new directions, surmounting problems, everyone
gets motivated and work towards having great results.

Provide support: Gain the commitment of followers by showing concern not only for results but for the workers.
Show that you care about them beyond the work. Provide support to them when needed. This helps them connect
both intellectually and emotionally to the work. This eventually brings out the best in them.

Responsibility: Leaders should also give room for creativity among the followers. They should encourage them to
initiate tasks and projects they think are important and support them on it. Of course, some adjustments may be
needful. And even such ideas are not implementable at the time, the leader should simply say let’s save this for
another time and not totally condemn it. Or even modify it and still allow the follower to take ownership of it and
lead it. This creates trustworthiness and enhances a positive climate.

Recognition: One of the needs identified by Maslow is the boosting of self-esteem. Leaders should endeavour to
recognize and often appreciate good performance and reward high performing followers. The leader should also
always provide honest, appropriate and timely feedback. All these will help the employees grow and attain to their
fullest potentials.

Teamwork: Carry everyone along by engaging them in team work. Ensure that not just a few people are being
engaged on all assignments. Even though there may be those with who may be low in performance or not as
skilled as others. Find a place for them and get them as engaged as others. This serves as a form of recognition
for them and challenges them to give their best and not disappoint your trust in them. It also makes everyone in
the organization feel important and relevant Encourage inter-departmental collaborations, plan retreats or parties
that brings everyone together, maybe for celebrating the success of a team. This will fosters a sense of belonging
promoting in the organization more cohesion, cohesion, mutual support, trust, and pride. (Freifeld, 2012)

Open Communication: Leaders maintain open communication with employees. They inform employees or followers
of their actions and are willing to modify their actions based on their followers’ reactions to it.

Concern for People: Leaders should be interested in the continuous development and career progression of the
followers.

Participative Decision-making: Leaders should develop shared vision. This means that the vision is generated by
all and merged into a common vision, hence shared. The followers should be involved in goal setting and decision
making. It gives them a sense of ownership towards the organization.

Change in Policies: There may be a need to change or modify some organizational policies like promotion, staff
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remuneration, human resource policies and more if these will help to improve the work climate and hence better
motivate the followers.

Technological Changes: The leaders may adopt improved work methods or employ more the advancement
in technology to improve the work process like changing from the use of manual typewriters to lap tops or the
transition from manual patient registration process to the use of electronic registration. This will in no small way
improve the work climate no matter the level of initial resistance. Especially if such a change process has been well
managed. Farokhi & Murty, 2014

Write down at least five of the practices described above that can specifically improve the work
climate in your organization

Now, concentrating only on improving the work climate may not be productive on the long run eventually for the
organization. Why?

As leaders achieve positive work climates, they will need to also work on a shift from a negative organizational
culture to a positive one. This is because, work climate is strongly related to a particular leader’s style. Any
change in leadership, to another leadership style that may not sustain such positive work climate changes, may
lead to the loss of all the successes recorded. However, a positive organizational culture will eventually outlive any
leader and lead to a more lasting organizational success.

Assessing the work climate

The following are some questions to ask and areas of focus when assessing work climates

Table 3.4.3: Assessment of Work Climates

Areas to Focus Sample Questions

Climate/Work Environment Do I know what is expected of me at work?
Employee to Employee Do I have the materials and equipment I need to do my work right?
Growth Opportunities At work, do I have the opportunity to do what I do best every day?
Job Satisfaction In the last seven days, have I received recognition or praise for doing good
work?
Job Value Does my supervisor or someone at work seem to care about me as a person?
Salary Is there someone at work who encourages my development?
Skills/Job Match At work, do my opinions seem to count?
Treated Fairly Does the mission/purpose of my company make me feel my job is important?
Trust of Management Are my co-workers committed to doing quality work?
Supervisor Relationship Do I have a best friend at work?
In the last six months, has someone at work talked to me about my progress?
This last year, have I had the opportunity at work to learn and grow?
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4.5 Mentoring

Now, you are welcome to the last sub-unit in the last unit of this module. Doesn’t that sound great?

You have seen thus far in this unit that you will need to lead a campaign of changing attitudes to positive ones,
and also improving your organizational climate. After doing all these, there is yet more to do- that is building
more leaders like yourself. To do this, you will need to coach and mentor protégés so that across the organization
there will be leaders of change.

The young employees of today are the future business leaders of tomorrow. As leaders, we have an obligation to
help our future by training and mentoring tomorrow’s leaders today.

How do you develop and keep the best young talent in an organization?

The answer is using a mentoring program. By using an effective mentoring program, the leaders of today can help
develop today’s talent into tomorrow’s leaders.

Leaders and Young Employees

Leadership and mentoring of young employees is a way senior employees can help drive success of a corporation or
an initiative. Young people graduate from academic institutions armed with academic knowledge and enthusiasm.
However, many people quickly realize that they lack the skills required to navigate and succeed in a corporate
environment.

When employees of different generations need to work together on projects, there is the potential for an unhealthy
rivalry and a contentious relationship. The young employee may feel the mature employee is stuck in their ways and
unwilling to try an alternative, and the mature employee sees the youthful exuberance as flighty and undisciplined.

According to Bernard Bass, leadership is a quality developed; it is not something people are born with. According to
Bass, there are three ways a person becomes a leader.

• There is the Trait Theory where personality traits lead people into leadership roles. Only a few people possess
the traits that make them natural leaders.
• Second, there is the Great Event Theory; an event happens that forces greatness and leadership from an indi-
vidual. There are dramatic events that have an effect on people bringing out qualities that a person did not
realize they had. Think of things like community disasters where an unlikely individual leads the masses.
• Finally, there is the Transformational Leadership Theory that states people choose to be leaders, and people
develop leadership over time.

Of the three theories presented by Bass, the Transformation Leadership Theory is the commonest method used by
individuals in becoming leaders. (Northcutt 2009)

Roles and Responsibilities of a Mentor

What is Mentoring?
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Mentoring is the process whereby the experienced employer offering professional advice and guide to a younger
employee, while serving as a teacher, advocate and counsellor. Functioning as a mentor is different from being a
coach.

A coach is a person who helps a person achieve a specific goal. The function of a mentor is not to correct and
remediate work behaviour. The role of a mentor is to offer professional advice and help the employee to understand
the corporate culture.
This is more like a karate instructor/karate student relationship and less like a coach/player relationship.

What is the difference between a mentor and a coach?

• Mentoring is a great way for senior employees to help the future leaders of tomorrow, and provides a way to give
back to the organization.
• Through the sponsorship of a mentor, the mentees will receive increased visibility and exposure within the
organization. The sponsor can help socialize the good work accomplished by their mentees through leverag-ing
their established contacts in the organization.
• The mentor can serve an important role by sharing experiences with the mentee. This allows young employ-ees the
ability to learn from the mistakes of others. The mentees receives all the benefits without making the same, possibly
career limiting, mistakes.
• The mentor can provide critical insights to the organization and help the young employee read and sense the
events going on around them. This helps the young employee recognize opportunities and avoid career limiting
mistakes.
• Succeeding in an established corporate environment is not easy. Young employees with an ambition to climb the
corporate ladder and make the most of their professional opportunities need to learn how to succeed.
• The mentor is normally a seasoned veteran who can provide a roadmap on how they and other successful
employees climbed the corporate ladder.

The Process of Mentoring

• The mentor and mentee should discuss where the mentee would like to end up.
• This information can help the mentor and mentee create a success plan based on the experience of the men-tor and
their peers.
• Each organization has a culture and life unique to itself; the mentor can offer advice on how to succeed in the
organization.
• The mentor can fuse professional advice with organization experience when offering advice to the young em-ployee.
The organizational knowledge of the mentor will guide the advice and critique offered by the mentor.(Borg)
• The mentor can help the mentee identify and learn new skills that will help the mentee succeed within the
organization.
• The mentee should discuss ideas and strategies with the mentor looking for advice to see how this can affect the
goals of the mentee within the organization.
• The mentor can help find new opportunities for the mentee and protect the mentee from career limiting or ending
opportunities.
• The mentor will need to function as the confidant helping with unwritten rules of the organization and is there to
listen when needed. (Borg)
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Similarities between Leadership and Mentorship

Are there differences or similarities between a leader and a mentor?

Leaders Mentors

Leaders have a vision and the ability to get The mentor’s vision is seeing the mentee reach their potential
people around them who will buy into their and having the mentee believe in a plan to reach the goal.
vision and achieve a result. The mentor functions like a leader by having the mentee be-
lieve and achieve the goals the mentor and mentee agree
The leader also trains and carry along his fol- upon
lowers or even leave them to take decisions
without him.

Leadership and mentorship go well together. Young employees are valuable organizational resources. Organizations
that provide leadership and mentoring to young employees can receive great dividends from time spent with them.

Benefits of Mentorship
Serving in the role of a mentor reinforces that the mentor is a SME (subject matter expert), and demonstrates
leadership qualities by sharing this expertise. Organizations sometimes fail to realize the obstacles the young
employee faces on a daily basis, the mentor can help with overcoming work-related obstacles.

Being an effective teacher requires knowledge about the areas the teacher is teaching. Being a mentor provides the
opportunity to enhance soft skills such as coaching, counseling, listening, and leadership.

Mentoring and leadership go together, a mentor will demonstrate leadership skills through the mentoring process.
(OPM Office of Human Resource Development)
Part of leadership is being able to resolve conflict in a way that is most beneficial to all parties. When leaders
function as mentors, they are acknowledging the generational differences between the two, and can help resolve
differences that may occur because of generational gaps.
As the mentor passes on knowledge, he/she can help shape the future of the organization for the better. This is one
case of one person making a big difference. If the mentor is successful with helping the employee, they can affect
every person in the organization the mentees meets. Expand the numbers and you can see how powerful this can
be.

Why Employees Should Seek a Mentor

The mentor can help reinforce that the knowledge and tools learned in school are correct and work in real life. Many
students need to take required courses as part of the curriculum, yet often students question why they need to take
certain courses.
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The mentor can help the student leverage some of their academic knowledge in a real-world setting. With a mentor,
the young employee receives exposure to areas of the organization they normally may not experience, or may not
experience until they have more time in the organization. The young employee may have ideas that may or may not
apply to the organization. The mentor can help vet ideas based on his or her experience within the organization.
In a leadership role, the mentor can help socialize the good ideas and help promote their mentees. The mentor has
a chance to demonstrate leadership by working with the mentee and helping to further the career of the younger
employee. This demonstration of leadership can help build trust and strengthen the bond between the two. (OPM
Office of Human Resource Development)

Candidate Qualities
Here are a few things to look for when selecting employees that are potential candidates for a mentoring program.
• There is the employee who is quiet and humble about their accomplishments, and does not boast about
what they accomplish. Colleagues that are more assertive many times overshadow these organization stal-
warts. This does not mean the assertive person is more capable, only that the quiet achiever needs mentoring
to bring out his or her best. These quiet, effective employees are great candidates for a mentoring program.
These employees usually have the desire and tools to succeed; they only need a mentor to cultivate their
strengths and help them meet their potential.
• Another candidate is the young employee who seems to be born a leader. These employees have the respect
of their peers, work well with others and have that “it” quality about them. These employees look to be future
leaders; a mentoring program can help accelerate that process and nourish their natural ability.
• Finally, there is the employee who asks for sponsorship from a mentor. The employee, or potential mentee
sees something in the mentor they can relate to, or qualities in the mentor they admire.

Not all employees are candidates for mentoring. Although all employees can benefit from mentor-
ship, some have no desire for a mentor and may become resentful if placed in a mentoring program

There are employees who come to work to do their job, and have no desire to get ahead. These employees may
see mentoring as nothing more than an added burden in an already dissatisfying job. A mentoring program may
actually have the reverse effect and cause an average employee to become a below average producer. This form
of passive resistance can be a poison in the organization. Adding this type of employee into a mentoring program
would be a waste of time and resources for both parties.

In Conclusion

The mentoring process should start and develop the leadership attributes in a mentee. Many organizations refer to
management as leadership and avoid the term management.

The mentoring partnership may be the first hands on experience with leadership for the mentee. There are many
similarities between leadership and mentoring. If the mentor is effective, the mentee will be eager to follow the
guidance of the mentor. Having people willingly follow a mentor and believing in the mentor is an attribute of
leadership. The mentor must provide a sense of trust in the mentee, and will slowly build the confidence of the
mentee as he/she starts to move towards his/her goals.

A leader wants to show how great their team is, so the mentor looks to socialize the good works of the mentee. A
good leader takes charge when the situation calls for it. The mentee must own some of the mentoring processes,
and this is a step towards building leadership. Forcing the mentee to take responsibility can start to plant the seeds
of leadership in the mentee. Being a mentor is a form of leadership.

The mentoring partnership allows a mentee to interact with a leader and start building leadership skills. The mentor
should slowly start to see leadership traits starting to appear in the mentee, and the mentee should see a change in
the mentor. The leadership provided by the mentor is a great way to help the future.
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Great. We have come to the end of Unit 4 and also the end of the module. I believe you have learnt a lot. Let us now
review what you have learnt in this unit.

4.6 Unit Summary

A few practical approaches to the practice of effective leadership have been discussed in this
unit. A few lessons learnt include:
• Attitude is how you feel about something or someone and how you communicate it to
other
• Attitude determines if you will be attractive or repulsive to others
• The Components of attitude are the Affective, Behavioural and Cognitive (ABC).
• Emotions affect the affective part of attitude
• Attitudes can be formed and learnt
• Attitude is infectious as explained in the Betari Box
• Attitudinal Change begins with YOU!
• To change your attitude, you need to identify and eliminate your negative attitudes and
develop the positive ones
• Work climate is the mood of the organization (the feeling you get from working in a place)
• Organizational culture is the personality of the organization
• Every workplace has a climate which may be negative or positive
• By employing leading and managing practices, the work climate is improved and this in-
fluences worker motivation and job satisfaction which eventually improves organizational
performance.
• Mentoring is different from coaching
• There are similarities between a mentor and a leader
• Not all young employees in the organization may benefit from a mentoring program
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4.7 References and Further Reading

Freifeld, L. (2012). 6 Management Practices for Affecting Workplace Climate - If you are a manager,
you control the thermostat. [Link]
workplace-climate Retrieved from [Link]
affecting-workplace-climate
Galer, J. B., Vriesendorp, S., & Ellis, A. (2005). Managers who lead: a handbook for improving health
services.
Goleman, D. (2006). Emotional intelligence: Bantam Books
Hockenbury, D. H., & Hockenbury, S. E. (2010). Discovering psychology: Macmillan.
Johnson, S., & Rodway, G. (2002). Management Strategies for Improving Health Services. Creating a
Work Climate That Motivates Staff and Improves Performance. The Manager, 11(3).
Kline, J. A. (2011). Leaders communicating effectively: Article prepared for AU-24, Concepts for Air
Force Leadership.
Parrott, W. G. (2001). Emotions in social psychology: Essential readings: Psychology Press.
Randol, K. M. (2011). Effective Leadership definition. Retrieved from [Link]
kmr5279/blogs/pla/2011/09/[Link]
Sahu, R., & Bharti, P. (2009). Strategic Leadership: Excel Books.
Senge, P. (1990). The 5th discipline. Bantam Doubleday Dell Publishing Group.
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APPENDIX I

JAMII PROJECT
INTRODUCTION

In the course of the training program, each participant will be required to identify an area that they plan to work
on in the next six months following the conclusion of the course. This workbook is a guideline for this JAMII
Project.

1. Participants and organizational details

1.1. Name of the Participant:

1.2. Position in organization:

1.3. Name of the Organization:

1.4. Country:

2. Identify the key statements for your organization

1 Mission statement:
2 Vision statement:
3 Core values
4 Strategic themes/directions

3. What are the major leadership challenges facing the organization and the health industry in your organization?

4. What are the major policy issues?

5. Identify two issues you plan to address

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6. Write a challenge statement

7. Write smart objectives for the selected challenge

8. What are your expected outputs and outcomes?

9. Stakeholders to be involved

Name Organization Position

 10. Action plan

KEY OBJECTIVE/ TASK BY WHO BY WHEN Expected Output/ Success Indicators INPUTS/BUDGET ASSUMPTIONS REMARKS
ACTIVITIES Outcome
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11. Budget

Prepare a detailed Budget in excel and use the summary figures in the action plan above.

12. Resource mobilization

How will you raise the resources required for the actualization of the Action Plan for Better Health?

13. Monitoring and Evaluation program

What is your plan for Monitoring and Evaluation?

14. Power point presentation

Prepare a power point presentation: A draft for your Learning Group 2 days before the final presentation.
A final power point presentation for presenting to the large Group on the last day. It should be 10 slides
covering the above areas. Use current data and statistics as much as possible. You may want to use your
organizational logo.
 MODULE 4
MANAGEMENT IN HEALTH
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LIST OF TABLES
Table 4.1.1 contains these categories of management skills and their descriptions according to Robert Katz 174
Table 4.3.1: Information required on aspects of the operations management system 187
Table 4.4.1: External Environment Analysis 197
Table 4.4.2: Assessment of Internal resources 199
Table 4.5.1 Accommodation 214
Table 4.5.2 Avoidance 214
Table 4.5.3 Collaboration 215
Table 4.5.4 Competition/Directive 215
Table 4.5.5 Compromise 215
Table 4.5.6: Conflict resolution skills and roadblocks 216
Table 4.6.1 domains of risks and their descriptions 217

LIST OF FIGURES
Figure 4.1.1 Management and Leadership 172
Figure 4.1.2: Managing versus Leading 172
Figure 4.2.1 Integrated nature of leading and managing model 177
Figure 4.3.2: Conversion of inputs into outputs 185
Figure 4.3.3: Conversion of inputs into outputs in a hospital 186
Figure 4.3.4: Responsibilties of Operations Management 186
Figure 4.3.5: Strategic Planning 188
Figure 4.4.1: Strategic Thinking Process figure 190
Figure 4.4.2 Generic Strategic Planning Process Model 193
Figure 4.4.3 Strategic Management Model 193
Figure 4.4.4 SWOT Analysis Matrix 200
Figure 4.4.5: Using SWOT analysis to develop organisational strategies 200
Figure 4.4.6: Goals, SMART Objectives and Strategic Options 203
Figure 4.4.7: Key Tasks in Strategy Implementation 204
Figure 4.4.8: Sample Action Plan 206
Figure 4.4.9: Team Development Process 210
Figure 5.1 Model of Styles to Handle Conflict 213
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MODULE 4: MANAGEMENT IN HEALTH

4.1 Module Introduction

Welcome to the fourth module on Management. In the last module you learnt about leadership in health. In this
module, you will learn about Management for health. The module is intended to enhance your ‘knowledge and
develop your competencies for effective and efficient strategic management of resources and risks to achieve
positive health outcomes.

The Module introduces you to basic concepts and principles of management in health. In addition, module four
covers the roles and functions of a manager in health system strengthening as well as the development and
implementation of strategic and operational plans. Furthermore, the module aims to enhance your understanding
of managing effective teams’ in health care delivery. Ultimately, the module addresses the concept of organisational
risk management. We trust that this will be equally exciting module as you explore the length and scope of
management in health.

4.2 Module Outcomes

By the end of this module you should be able to:

• apply the concepts and principles of management in health care delivery

• apply the functions and roles of a manager in health systems strengthening
• organize daily activities through operations management
• develop strategic plans to achieve organisational goals
• Apply team management skills for effective service delivery
• Manage organisational risks

4.3 Module Content

This module is divided into the following 6 units:
• Unit 1: Concepts and Principles
• Unit 2: Functions and roles of a manager
• Unit 3: Strategic planning
• Unit 4: Operations management
• Unit 5: Management of effective teams
• Unit 6: Risk Management in Health
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UNIT 1: CONCEPTS AND PRINCIPLES

1.1 Unit Introduction

Welcome to the first unit of module 4. This unit is made up of six sub-units. Firstly, unit one introduces you to the
concept of management in health. This is followed by the definition of management and then the characteristics of
management. Furthermore, the unit covers a topic on managing versus leading as well as managerial skill. Finally,
the unit addresses the principles of management.

1.2 Unit Outcome

By the end of this unit you should be able to apply the concepts and principles of management
in health care delivery.

1.3 Management in Health

Today’s manager faces complex situations that call for critical thinking and the examination of processes, structures
and behaviours, focussing on the changing nature of management in response to turbulent internal and external
environment necessary for management.

In particular, various theories are integrated into applied dimensions of successful business practices in the health
sector, and emphasis is on global management perspectives that one must consider.

Before you proceed, perform the following activity:

Activity 4.1
Using relevant examples, analyse the following statement “A manager-leader gets better
results than a leader-manager. Write your thoughts in your notebook.

1.4 Definition of Management

Let us now look at the definition of management. Various authors have defined Management differently and some
of these definitions include the following:

• Management is the effective use of resources to meet an organisation’s goal

• 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
• Management is an interdisciplinary, rigorous and valid endeavour that is integral to all human enterprise,
including Public Health (Robert Burk & Leonard 2011).

Before you move on to section 1.5, let us see how much you can deduce form the definitions of management
by the responding the below question.

What key components of management are included in these definitions?

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1.5 Characteristics of Management

Characteristics that define management are that, it is a process or a series of continuing and related activities.
It involves and concentrates on reaching organisational goals by working with and through people and other
organisational resources. Management is a cross- cutting discipline (Robert et al 2011.)

There are five components in this definition:

a. Working with and through others
b. Achieving organizational objectives
c. Balancing effectiveness and efficiency
d. Making the most of limited resources
e. Coping with changing environment

1.6 Leading and Managing for Results

How do management and leadership contribute to improved service delivery?

When applied consistently, good leading and managing practices strengthen organizational capacity and result in
high quality services and sustained improvements in health.
The models on figure .1 and .2, presents to you a comparison of what managers and leaders do in their work.

MANAGERS LEADERS
• Managers cope with complexity • Leaders cope with change
• Managers plan and Budget • Leaders set direction and shared values
• Managers organise and staff a • Leaders align people with the organisation
business and therefore empower them
• Managers control and solve problems • Leaders motivate people, including
through networks of informal
relationships

Figure 4.1.1 Management and Leadership

Managers Leaders
• Administer • Innovate
• Maintain • Develop
• Control • Inspire
• Short-term view • Long-term view
• Ask how & when • Ask what & why
• Initiate • Originate
• Accept the status quo • Challenge the status quo
• Do things right • Do the right things

4.1.2: Managing versus Leading

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Figure 4.4.2: Managing versus Leading

The above two figures (4.4.1 and 4.4.2) show that what leaders do and what managers do complement each
other to bring about the outcomes of strong health systems. For example while leaders set direction and shared
values, managers prepare plans and budgets to help actualise that direction. Leadership happens at all levels of
the organization and so organizations are encouraged to raise managers who lead. These health outcomes were
covered in module 1 and include:

a. Improved health
b. Ability to respond to legitimate health needs
c. Social and financial risk protection and
d. Improved efficiency

So we can conclude that effective managers are leaders.

1.7 Managerial Skills

Effectiveness in management requires possession of appropriate skills.
Managerial skills can be divided into the following three categories:
a. Technical skills: these involve applying education, skills and experience to effectively organise work.
b. Team building skills: These involve listening carefully and communicating clearly to develop and coordinate
an effective team or group.
c. Drive skills: These involve setting goals, maintaining standards and evaluating performance to achieve
effective outcomes involving costs, output, and product quality and customer service.
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Table 4.1.1 contains these categories of management skills and their descriptions according to Robert Katz
(1955).

Skill category Skills Description

Technical: Applying the 1. Technical expertise Skills acquired and experience; to

education, training, and understand and communicate key technical
experience to effectively details
organise the work
2. Clarification of goals and The is the ability to organise and schedule
objectives the work so 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 creativity Ability to originate ideas to correct and
develop ways to improve productivity

Team building: Listening 5. Listening for insights. Keeping aware of activities for your team.
carefully and communicating
clearly to develop and
coordinate an effective
group or team
6. Directing and Coaching Meeting your goals and standards. The
team’s skills are kept up to to the target
7. Solving problems as teams Helping your team contribute ideas to
improve their performance

8. Coordinating and Demonstrating a willingness to work with

cooperating others

Drive: Setting goals, 9. Standards of performance This is an effort to keep the

maintaining standards, and organisation moving, and
evaluating performance to willingness to be busy to aim
achieve effective outcomes higher
involving costs, output,
product quality, and
customer service
10. Control of details Overseeing the performance
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 pressure Urging others to perform by

shaping your activity to be
perceived as teamwork, not
domination
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1.7 Principles of Management

The application of management principles to guide decision making and management actions is an integral part of
management. Henry Fayol developed the following 14 principles of management:
Let us look at each in further detail.
1. Division of labour:
The essence of division of labour is specialisation that allows building of skills leading to productivity. Most
organizations in health are highly specialized as individual units but they lack the effective processes and
the interrelatedness.
2. Authority and responsibility:
Authority is the power derived from someone’s position in an organisation whereas responsibility is
duty or obligation assigned to a person by nature of the person’s position or function you cannot give
responsibility without authority.
3. Discipline
Employees must obey orders and consistently observe rules and regulations but this comes with good
leadership.
4. Unity of Command
Each work should have one boss so that lines of command are not conflicting.
5. Unity of direction:
People involves in the same kind of work must have same objectives. This ensures coordination of activities
in the organisation.
6. Subordination of individual interest
Individual interest must never supersede organisational interest. Management must ensure organisational
interest is paramount
7. Remunerations
The should be commensurate compensation for work done
8. Centralisation or decentralisation
This is determined by the type of organisation and the quality of personnel
9. Scalar of chain
A hierarchy is necessary for unity of command but lateral communication is also important in organisations.
Too many levels in the hierarchy affect communication
10. Order
Both material and social order are necessary for organisational effectiveness.
Organisations must ensure a systematic way of arranging activities and ideas
11. Equity
In organisations, Kindness and fairness in treating staff is important for equity
12. Stability of tenure
Employees work better if there is job security and career progress is assured to them. An insecure tenure
affect organisation adversely
13. Initiative
Allowing employees to be initiative is a source of strength for the organisation. As innovation may foster
effectiveness
14. Esprit de Corps
Management must foster morale of employees. Talent is needed to coordinate effort Managers must
encourage keenness; use each employee’s ability and reward without arousing jealous among employees.
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Before we conclude the discussion on principles of management, perform the following activity

Activity 4.2:
Discuss the application of any 7 principles of management in your organization.

Well done! You must have seen that in your organization these different principles are applied to different levels and
may be some are not being applied at all.
Let us examine two of these principles:

a. Division of labour – No one person should handle a task or a transaction form he beginning to the end. Take
Finance Department for example, one person should not procure medical supplies, receive those supplies,
keep the keys to the store, give out the supplies to the health workers and authorise payment for those
supplies and then pay for the supplies. Different people need to be involved to ensure accountability for
the supplies. So the person who requisitions the supplies should not be the same person that receives the
supplies and keeps the key to the store. At the same time, the person who makes payment for the supplies
should not be the same person who requisitions the supplies. The result of lack of separation of duties may
be fraudulent actions and loss of financial and medical supplies.

b. Authority and responsibility: These two go together. For example you cannot give a doctor the responsibility
to handle emergency cases and not give them the authority to us the ambulance in the organization. They
may receive a patient at night but because they have no authority to use the ambulance they cannot
transfer the patient to another hospital where they can be given immediate treatment and attention that
is needed. The result may be loss of a life that could have been saved. At the same time such a doctor will
be demoralised and demotivated.

You have come to the end of this unit. Let’s now review what you have learnt.
Self-Assessment Test
a. To achieve organizational health outcomes, a leader is more needed than a manager. True or false?

(Answer is f).
b. Once you have a responsibility, it is important to have the authority that goes with that responsibility.
True or false?
(Answer is T)

1.8 Unit Summary

In this unit we have learnt that management in health is a necessary area of focus in
today’s world due to the turbulent environment.

We also learnt that, management and leadership should be viewed as complimentary

concepts for organisational effectiveness. In the next unit we shall discuss functions of
a manager.

1.9 Unit References

Robert E; Burke, and Leonard, H, F (2011) Essentials of Management and

leadership in Public Health

Katz, R. (1955) Skills of an effective administrator

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UNIT 2: FUNCTIONS AND ROLES OF A MANAGER

2.1 Unit Introduction

Welcome to the second unit of the module on Management in health. In the previous unit, you learnt about
concepts and principles of management. In this unit you will learn about functions and roles of a manager. The unit
consist of three sections. Firstly, the unit introduces you to the integrated nature of leading and managing process.
A deliberation on the functions of a manager follows and then lastly the unit introduces the basic management
roles. Let us look at what is expected of you by reading through next section on the objectives.

2.2 Unit Objectives

By the end of this unit you should be able to carry the functions and
roles of a manager in health systems strengthening.

You are doing extremely well. Next let us see how leading and managing work in unison to enhance their impact on
the health system strengthening efforts for health outcomes.

2.3 Integrating Leading and Managing

MSH (2005) argues that leading and managing do not occur as independent entities. They are complimentary
in nature. Effective managers perform both leadership and management roles to support their teams to achieve
results. As indicated in figure 4.2 a manager scans the environment to identify challenges, focus and plan. Once
challenges have been identified, focussed and planned for, the manager aligns, mobilises stakeholders and
resources to implement the plan. The entire process involves inspiring the group and taking some control measures
through monitoring and evaluation. Figure 4.3 shows how leading and management is integrated.

Figure 4.2.1 Integrated nature of leading and managing model. Source: MSH, 2005
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When the integration of leading and managing is applied effectively organisational capacity is strengthened and
improved health outcomes are achieved.

Activity 4.3
Think of a challenge you have experienced in your organisation the last in few
weeks and how it was addressed?
How did these three components contribute to the outcome?

2.4 Functions of a Manager

Management is a process that is made up of different functions. None of the functions of a manager is more
important than the other. They are interrelated and complimentary to each other. In the following session you will
cover both the traditional as well as the contemporary functions of the management. Before you continue reading,
complete the following activity.

Activity:4.4
Write down in your notebook your functions as a manager and then compare your
answer with what you read in the following discussion.

The traditional functions of management are:

• Planning
• Organising
• Staffing
• Directing/Leading
• Coordination
• Controlling

The contemporary functions of management include:

• Planning
• Decision making
• Organising
• Staffing
• Directing
• Communicating
• Motivating
• Leading
• Controlling
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Before you proceed to a discussion on what the planning function of management mean, perform activity 4.5.

Activity 4.5
Reflect on an activity you have undertaken in your organisation.
Explain how you went about from planning to the execution of the plan. What would
you do differently?

Let us now see what Miner, 2016 says about the functions of management in detail. It looks like planning is
becoming more familiar to you after undertaking exercise 4.5. Before you embark on reading the next section
which you will find interesting like the previous sessions, write in your notebook the answer to the following
question.

What is planning?

Planning

Planning is defined as 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 and determining enterprise’s mission and goals.

Planning involves deciding in advance what, where, how, who and when to do perform an activity. 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

Organising

As a preparatory step for the presentation on organising as a function of management, engage in activity 4.6.

Activity 4.6
Think about the definition of organising and organisation
Differentiate between the meaning of effectiveness and efficiency
How is work organised in your organization?

Organizing is as a management process that involves the systematic arrangement of activities to foster organizational
effectiveness and efficiency. Whereas organisation refers to a system of consciously coordinated activities or efforts
of two or more persons (Chester Barnard)
At this point let us also differentiate the meaning of effectiveness and efficiency.
Effectiveness is defined as the degree to which objectives are met whereas efficiency refers to producing outputs
at minimum cost... So the two concepts are important to organisations because organisations strive to achieve
objectives at a minimal cost.

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
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• 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

Organizing ensures specialisation that is, different specialised activities are performed. There are well defined
jobs because people can be assigned work according their various specialisations hence leading to effective
job performance. Clarity in authority is also a benefit of organising because powers and lines of authority are
clarified, which fosters effective use of power and guards against misuse of power. Coordination in organising
ensures interrelatedness of departments as well as positions in the organisation to achieve results. Also effective
administration ensures that Jobs to be done by different managers are defined which leads to effectiveness and
efficiency in job performance. In addition, there is Growth and diversification which brings about efficiency and
effectiveness in an organisation brings leading to growth. Furthermore, there is a sense of security and clarity of job
positions and coordination brings about mental satisfaction and these results in a sense of security. Scope for new
changes in organising brings clarity and independence in job performance allows mangers to be innovative and
bring about new changes in the organisation and unlimitedly leads to productivity

Staffing

What do we understand by staffing?

Staffing is processes of employing and developing human resources to perform managerial and non- managerial
function within an organisation. Staffing involves several steps that include:

• Task analysis
• Job descriptions
• Plan for recruiting
• Recruitment process
• Hire and deploy
• Motivation
• Retention
• Exit

We will discuss staffing in detail during the HRH management module.

Directing / Leading

Directing is the process leaders use to influence followers to achieve organizational objectives through
change. Directing ensures quality performance of the job.

Coordination
Coordination 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. Coordination ensures 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. This
helps to strengthen the team.
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Controlling
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

Controlling is an importance aspect of management as it ensures that right things happen in the right way and at
the right time. If done well, the overall directions of individuals and groups are consistent with short and long range
plans. In addition, objectives and accomplishments are consistent with one another throughout an organisation.

Controlling helps to maintain compliance with essential organizational rules and policies establish objectives and
standards, actual performance and compare results with objectives and standards

Communicating
Communication is the process of transmitting information for the purpose of gaining common understanding
between the sender and the receiver. Communication is a management function that runs across all the management
functions. Modern technology has impacted communication both positively and negatively. These include how
technology facilitates the delivery of information in a timely manner to different networks. A manager needs to be
alert in managing communication in organisations. Good communication can foster organizational effectiveness
and poor communication can inhibit organizational effectiveness.

Communication runs across all the management functions.

Motivation

What is motivation?

Motivation is the process of stimulating a need for someone to take particular action. Health care managers like
in other disciplines are faced with challenges relating to motivating health care providers to deliver their services
effectively.

2.5 Basic Management Roles

Having learnt about functions of a manager in the previous session, this session introduces you to the Basic
Management Roles.

Due to the changing environment in the health sector, the role of today’s manager is challenging. To enhance your
understanding of the challenges faced by managers of today perform activity 4.7.
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Activity 4.7
From your experience, think of the impact of decentralisation of health service to the role
of the manager.

Make reference to:

a) service agreements/contracts
b) outsourcing of services

Share your experience in the forum.

A conclusion that can be drawn from the discussion on activity 4.6 is that the effectiveness of managers in achieving
organisational goals is determined by their level of performance in their managerial roles. Mintzberg identified
three types of managerial roles as:
• Interpersonal roles:
• Informational roles:
• Decisional roles:

1. Interpersonal roles are roles that involve coordination and interaction with employees and they involve
performing the following 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

2. Informational roles are roles that involve handling, sharing and analysing information. They involve performing
the following 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

3. Decisional roles require decision making. They involve performing the following 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.
- (Capenter, Baue, & Erdogan, 2012)

To conclude the unit on functions and roles of a manager perform activity 4.8
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Activity 4.7: The unorganised manager (Video)

Activity 4.8: The Unorganised Manager Video

Watch the movie and make an attempt to address the following questions.
• What management skills did the manager use to organise for results?Personal
reflection:
• Which management skills do you plan to strengthen? And How?
• Write your thoughts in the action section of your JAMII Project

2.6 Unit Summary

In this unit you have learnt about the traditional and contemporary functions
of a manager, their interrelatedness as well as the roles of a manager. In the
next unit, you will learn about strategic management approaches. But before
you move on to the next unit do some research on Strategic Management as prior
preparation and obtain a copy of your organisation’s strategic plan

SELF ASSESSMENT TEST

1. Indicate whether the following statement are true or false by inserting T (True) or F (False) against the statement

i. Organising is the most important function of a manager (Answer F)

ii. The informational role of a manager includes being a disseminator. (Answer T)

References and Further Readings

1. Capenter, M. Bauer, T & Erdogan, B (2012) . Management Principles v.1.0

2. MSH (2005) Leading and managing to achieve results.
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UNIT 3: OPERATIONS MANAGEMENT

3.1 Unit Introduction

Welcome to the unit 3. After build knowledge on the different roles and functions of a manager in unit 2, now
you are going to be introduced to operations management. This unit recalls the different functions of operations
management for more efficiency and effectiveness within health organization. For this module enables you to
organize daily activities through operations management.

3.2 Unit Outcomes

By the end of this unit you should be able to organize daily activities through operations
management.

3.3 What is Operations Management?

In this section, you will go through the definition of Operations so that you can have a wide understanding of the
process and deliveries.

What is Operations Management?

Definition of Operations Management

• Operations management is to design, operate, and improve of productive systems. Operations are a
function or system that transforms inputs into outputs of greater value.
• Operations management is the effective and efficient management of productive resources.
• Operations management entails the design and control of systems responsible for the productive use
of raw materials, human resources, equipment and facilities in the development of a product or service.
(CSCMP & Sanders, 2014)

What are the different functions of Operations?

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3.4 Function of Operations

Functions of management involves the management of systems or processes that creates goods and / or provide
services. There are four key functions of operations management. These are:
a. Designing – The design involves product development including the
characteristics of the products to be sold or provided. Product design takes into
account customer expectation. For example the product to be provided may be
HIV testing, provision of antenatal and postnatal care etc.
b. Planning – This involves the determination of how management will utilise the
available resources to meet the needs and to cope with different internal and
external environments.
c. Managing – This involves managing the various teams and people that are
involved in the operations of an organization.
d. Coordinating – This ensures that the various parts of the organization are well
interrelated for maximum efficiency in operations. Figure 3.1 below shows the
main departments of an organization of which operations is one. Finance and
marketing departments would need to coordinate well with operations for
efficient provision of health services.

Figure 4.3.1 The inter-relatedness of major departments in an organization

The difference between the cost of inputs and the value or price of outputs

Figure 4.3.2: Converson of inputs into outputs…..

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The following figure gives you an example of inputs, processing and outputs from a hospital.

Figure 4.3.3: Conversion of inputs into outputs in a hospital (Source: MDI 2015 Training

Activity: 4.8
Reflect on the different activities involved in operations management within your
organisation, describe the linkages.

Responsibilities of Operations Management

What are Responsibilities of Operations Management?

There ar 5 main reposnibilities of operations Managemtn. These are: palnning, organizing, staffing, directing ad
controlling or improving. The following table summarises these responsibilies of operations management and
idenfties some key roles involved in each resposibility.

Source: MDI training

4.3.4: Responsibilties of Operations Management……………. (Source MDI Training

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Activity 4.9
Demonstrate your understanding of the concept of operations management by responding to
the questions in the table below and send you responses:

Key questions Suggested Answers

What is operations management?

What are the similarities between all

operations?
What do operations managers do and
why is it so important?

Activity 4.10: Using figure 1 and based on your knowledge in the diagnosis,
treatment, care and support for HIV/AIDS, Cancer, Diabetes, Heart disease,
Tuberculosis and Malaria cases in any health services organization with which you are
familiar provide the information requested in table 2 below.

Table 4.3.1: Information required on aspects of the operations management system (Source: MDI)
Aspects of the operations Information Required
management system
The type and source of inputs

The types and range of goods/

services delivered as outputs
The kind of feedback information for
control of process inputs and process
technology
The nature of the transformation
(Conversion) Process

3.5 Strategy and Operations

Combining strategy and operations stems in identifying following key indicators:

 How the mission of a company is accomplished

 Provides direction for achieving a mission
 Unites the organization
 Provides consistency in decisions
 Keeps organization moving in the right direction

Strategic Operations Objectives

In any operational process, setting objectives is key to effective management perfomance:

1. Quaity should be high, consistent and sustainable
2. Flexibility is e.g. ability to provide standadized and customized products and services
3. Delivery is capabilitiesin terms of volume, rate and philosophy such as quick response
4. Cost efficiency is to reduce operational costs through improved productivity and waste elimination.
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Operations Strategy Formulation

For the well running of the health system, developing operations strategy is an asset to perform activities on timely
basis while using resources effectively and efficiently. Here are the diff erent step s in form ulating an oper ations
strategy:

1. Defining a primary task

• What is the organization in the business of doing?
2. Assessing core competencies
• What does the organization do better than anyone
else?
3. Determining order winners and order qualifiers
• What qualifies an item to be considered for purchase?
• What wins the order?
• Attributes: price, delivery reliability, delivery speed, and quality

4. Positioning the organization

• How will the organization compete?
5. Deploying the strategy

Here are the main components of Strategic planning:

Figure 4.3.5: Strategic Planning Source: MDI training 2016

What is the Scope of Operations Management

3.6 Scope of Operations Management

Operational managers are responsible for the day-to-day organizing and coordinating of services and resources,
liaising with clinical staff and other professionals, dealing with the public and managing complaints, and
anticipating and resolving service delivery issues. They are also required to plan and implement change. (https://
[Link]/explore-roles/operational-management)
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The different domains constituting the scope of operations Management include:

1. Supply Chain Management
2. Quality Management
3. Statistical Quality Control
4. Product Design
5. Service Design
6. Processes and Technology
7. Capacity and Facilities Design
8. Human Resources
9. Project Management
10. Supply Chain Strategy and Design
11. Global Supply Chain Procurement and Distribution
12. Forecasting
13. Inventory Management
14. Sales and Operations Planning
15. Resource Planning
16. Lean Systems
17. Scheduling

This will be covered in Module on supply chain management

3.7 Unit Summary

This unit provides you with a full understanding of operations management in terms
of definition, functions, strategy development and implementation and different
components.

Self-Assessment Test
Which of the following is not an input in a hospital:
• Doctors
• Laboratories
• Examination
(Answer: Examination, it is a process).

Which of the following is an output in a hospital:

• Medical supplies
• Therapy
• Healthy patients
(Answer: Healthy patients. Medical supplies is an input and Therapy is a process)

3.8 References and Further Readings

• CSCMP and Nada Sanders, 2014

• A Study of Process.” Boundless Business Boundless, 26 2016
• MDI training
• [Link] -roles/
operational-management
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UNIT 4: STRATEGIC PLANNING

4.1 Unit Introduction

Welcome to the fourth unit of our module on management in health. In the last unit you learnt about the
functions and roles of a manager. In this unit we shall look at strategy planning and its main steps from vision and
missions statements, goals setting to strategy formulation and implementation.

4.2 Unit Outcome

By the end of this unit you should be able to develop strategic plans to achieve
organisational goals

4.3 Strategic Thinking

What do you understand by the terms ‘strategic thinking’ and ‘strategic management?

Strategic thinking 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. Strategic thinking is a process of building a strategy to
solve a problem or handle a situation. We can find 4 processes in strategic thinking as shown in Figure 4.1:
• The process of organisation
• The process of scanning
• The process of viewing
• The process of driving forces

Figure 4.4.1: Strategic Thinking Process figure

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Let us consider each process in turn.

1. Organisation in strategic thinking

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.
Organisation in strategic thinking basically addresses the questions of HOW? For example: how to address
the problem?

2. Scanning in strategic thinking

In strategic thinking, scanning of a situation is key to become more aware of how to solve problems more
effectively, and how to distinguish between alternatives. Scanning enables you to understand the situation
better.

3. Viewing in strategic thinking

Viewing in strategic thinking provides you with different ways of thinking about a situation, helps 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 strategic
thinking itself allows you to see things from “higher up”.

4. Driving forces in strategic thinking

Driving forces usually lay the foundation for what health management teams want people to focus on
in their facilities and communities. Driving forces refer to the process of setting our vision and mission in
relation to the situation being thought about while bringing permanent solutions to problems.

To help you understand the process of strategic thinking, read through the following scenario and then
answer the questions that follow.

Activity 4.11
The case of Manyatta village
There has been prolonged heavy rains 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 prioritize their problems
• Prioritize the problem points for action
• Suggest solution (immediate and future) to the problems
• Identify the resources required
• Identify sources of the required resources

From this section, let us introduce the different competencies you need to develop and implement a strategic plan.
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Strategic Thinking Competencies

Strategic thinking competencies are the following:

1. Being able to clearly understand the situation out of critical interpretation
2. Being able to understand implications of strategic actions through a systems perspective
3. Being more determined, less distractible and intent focused
4. 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” Jeanne Liedtka,(1998),

5. Being hypothesis driven, ensuring that both creative and critical thinking are incorporated in strategy
making
6. Being responsive and intelligently opportunistic to good opportunities

Activity 4.4 Relevance of Strategic Thinking to Leaders and Managers:

- Can you recall any new idea that you established in your working
environment over years?
- What was the cause of your new idea?

Here are the different stages to understand and define a strategic plan:

4.4 Understanding Planning & Strategy

Start asking yourself the following questions:

• Why plan?
• Benefits of planning
• What is a strategy?
• What is strategic planning?
• What is operational planning?

4.4.1 Definition of a strategic plan

A strategic plan is visionary, conceptual and directional, tactical, focused, implementable and measurable guide.

4.4.2 Steps in Strategic Planning

The steps in strategic planning are:
- formulation is the process of elaborating the strategic plan
- implementation is the process of applying the strategic plan
- monitoring and evaluation is the process of controlling the strategic plan pre and post application

Figure 4.4.2 below shows you the main steps in strategic planning, while Figure 4.4.3 illustrates the different
components of strategic management
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Figure 4.4.2 Generic Strategic Planning Process Model

Figure 4.4.3 Strategic Management Model Source: ([Link]

After revising the different stages and components of a strategic plan, let us now go deeper in each of component
or stage in the eight step planning process.
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Eight Step Planning Process

1. Stating the vision, mission and values

2. Analysing the internal environment
3. Analysing external 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?

Why do we need one?

A vision statement:
1. Is achievable, even if far out in the future
2. Is inspirational, motivational, hopeful
3. Provides a clear picture of the future
4. Helps keep mission on track
5. Helps organizational focus
6. Has a possible team building effect
7. Reflects desired impact of the organisation in the future
8. Describes future aspirations
9. Defines the dream, long term, unconditional direction organisation is heading in

How “big” should your vision be?

1. The answer is how deeply do you care?

2. How much are you willing to change?
3. Every vision has a price
4. If stakeholders really want something, they must be willing to pay the price

Shared vision

In vision statement, lays the challenge of sharing the same vision.

Compare what happens when vision is shared within the organisation and when
vision is not all shared.

When there is no shared vision, people go in different directions. This will be like a game of football where every
player is scoring in their own goal post.
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Shared vision …
When there is a shared vision, people go in the same direction. There is only one goal post for the team

A strategic plan always has a vision and mission statements that are nurtured by values.

What is a mission statement?

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

Let us look at an example of a vision and mission statement from the Bill & Melinda Gates Foundation

With a Vision statement…

“…working for a more equitable world.”

The mission of our Global Health Program is:

To ensure that people in the developing world have the same chance for good health as people in the
developed world. We see a tremendous opportunity to save millions of lives through the development and
distribution of health tools and strategies – some new, some already in use.

What are values?

Values are:

1. Principles or commitments that organisational members stand for

2. Qualities and behaviours highly regarded by organisation as a whole
3. Define the ethical guidelines and standards that direct action in the organisation
4. Typically limited to 3-5
5. Deeply embedded
6. Withstand test of time
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Activity 4.5:
Look at the mission and vision statements of your organisations/institutions
• What would you change if you could?
• Re-write your statements

Please note: A strategic plan is a double edged activity performed within and outside the
organisation: hence the internal and external analysis of the environment

4.4.3 External and Internal Analysis in Strategic Planning

There are different approaches that can be used in environmental scanning in the strategic planning process. SWOT
analysis has been used for this together with deeper analysis of the external and internal environment. Another
tool is SOAR Appreciative Inquiry tool which looks at the following aspects represented by the acronym:
• Strengths
• Opportunities
• Aspirations and
• Results

In this section we shall use the SWOT analysis tool.

What is a SWOT Analysis Model?

SWOT stands for the following:

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

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
• A part from the SWOT analysis, you can analyse other factors in your environment through deeper external
analysis.
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We shall now look at the application of SWOT in external and internal environmental analysis.

a) External environmental analysis

An appreciation of the external environment in which you are operating in in critical to the success of your
institution. The external environment presents opportunities that you can take advantage of and threats that
you need to cannot change but for which you can use your strengths to counter. See the table below that
articulates aspects of external environment analysis and the goals of carrying out such an analysis.

Table 4.4.1 : External Environnent Analysis

External environment Goals of external analysis

Analyze opportunities & threats (challenges) in: • Identify and analyse current issues
• Trend analysis, e.g. performance of health • Detect signals of emerging issues
industry over a period of 5 years • Speculate on likely future issues
• Macro environment analysis, e.g. • Provide organised information
• Task environment • Foster strategic thinking
• Market analysis
• Client analysis

When analysing the external environment, you should take into account the key health statements and declarations,
such as:
• Priority areas as outlined in Ouagadougou Declaration
• SDGs

Activity 4.14
Name any other health statements and declarations you know

The priority areas as outlined in Ouagadougou Declaration are:

• 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

SDG goal 3
• Skilled attendants for every delivery are required to accelerate attainment of SDG goal 3
• 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
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Assignment 4.6
What are the opportunities and threats in each of the following external factors in your health
industry?
• Political
• Economic
• Social
• Technological
• Legal & lifestyle
• Competition

After analysing the external environment, you should then review your internal environment.

4.4.4 Internal environmental analysis

Internal analysis of your environment is assessing your weaknesses and strengths as an organization in relation to
the threats and opportunities in your external environment.

Internal environment
• Organisation strengths and weaknesses in three broad categories:
• Culture
• Structure
• Resources
• Organisational profile
• Key success factors

Goals of internal analysis

• Leverage strengths and core competencies
• Evaluate ways to create value for clients and stakeholders, current & prospective
• Answer the question: What can the organisation do?

Internal assessment

Internal assessment examines the following:

• 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?

• Our culture: what is our culture in terms of:

- Communication
- Planning
- Coordination
- Use of time
- Treatment of the customer
- Quality of service
• Our structure in terms of:
- Governing structures
- Leadership and management structures
- Organogram
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• Our Resources: how to assess our resources in relation to the following 7 Ms (Louise, 2015):
- Manpower: The right personnel for the right position is a sure bet for organizational effectiveness and
efficiency. Man in management is referred as a human resource
- Machinery: is basic tools and equipment (Microscopes, Centrifuge) to produce goods or to generate
services
- Money: is a medium that can be exchanged for goods and services and is used as a measure of their
values on the market
- Markets: is your target market and, realistically, what slice of it can you expect to capture?
- Methods (or command and control method): is primarily, the idea is that people do what you tell or
direct them to do. The goal here is to manage by making people identify with the goals you’re trying
to achieve
- Minutes (moments, momentum): is the fact that any market opportunities present themselves in a
window – of time, place, and available resources – to provide a supply for a specific demand. You may
have come up with an idea, but so have 50 others. The challenge becomes execution – who can take
that idea, cement it in reality, and attract the critical employees who will do a great job taking care of
customers, producing revenue and attracting investors?
- Materials: is basic ingredients (consumables, stationery, pharmaceuticals, optical goods) to provide a
service in an organization

There are existing critical success factors that indicate the nature of an organisation’s performance.

Critical Success Factors for Organisational Performance

Now that you know your vision and have assessed your external and internal environment, you need to identify the
critical success factors for your organisation’s performance.

To do this, you should ask the following question:

• How shall 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?

Activity 4.8:
Use the following table to assess the different aspects of your internal environment:
• What are the organization’s top strengths?
• What are the organization’s greatest weaknesses?
• What are the key success factors in your organization?

Internal Analysis Profile

Internal Resource Strong Weakness Slight Weakness Neutral Slight Strength Strong Strength

Table 4.4.2: Assessment of Internal resources

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Figure 4.4.4 shows a diagram of the SWOT Analysis Model

Figure 4.4.4: SWOT Analysis Matrix

All the information gathered so far using the SWOT model is used to develop organisational strategies. You do this
by identifying the opportunities in the external environment and matching them with the strengths in your internal
environment. Similalry, you identify the weaknesses in your internal environment that will hinder you from taking
advantage of the opportunities in your external environment and equip yourself better. Identify the strengths in
your internal environment and use them to fight the threats in the external environment. Identify the weaknesses
in your internal environment and prepare a defensive plan to counter the threats in the external environment.
Figure 4.5 below summarises these strategies.

Using the SWOT matrix to develop strategies

Figure 4.4.5: Using SWOT analysis to develop organisational strategies

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Activity: 4.8
From figures 4.4 and 4.5, extract scenarios of S-O, W-O, S-T, and W-T from your own
organisation and record them in your Jamii Project.

After analysing both internal and external environment you are ready to set clear cut goals.

4.4.5 Strategic goals

Goals are key results, stated broadly and qualitatively, that an organization has decided to target, given its stated
organization Mission, vision and awareness of the environment in which you are operating in. Establishing long-
term goals include:
• Generating alternative strategies
• Selecting strategies to pursue
• Best alternative – achieve mission and objectives

Examples of Goals & SMART Objectives

• 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 new-borns
 Increase MOH capacity to provide ANC, VCT/PMTCT, PMTCT plus and ART services

Defining Objectives

Objectives flow from the goals an organization has developed and offer a logical sequence for achieving a goal.
They enable goals to become operational.

Objectives
An objective is a specific condition that we want to achieve to help you 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
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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

Activity 4.9:

Practice writing goals and smart objectives,

When goals are clearly-cut then strategic plan formulation starts!

4.4.6 Strategy Formulation

Strategy formulation:
1. involves making decisions using data gathered
2. is a logical, sequential process
3. is a decision-making process
4. How to commit and how to leverage resources
5. How to respond to the external and internal environments
6. How to leverage the organisations core competencies
7. What actions to consider based on key success factors

Strategy formulation is based on creating value for the clients. There is value if the societal outcomes exceed the
societal resources

Key to obtaining a good strategy

Good strategies have three main characteristics after identifying a company’s core business. Good strategies:
 Involve identifying the existing customer groups, those whose needs are being addressed
 Involve identifying customers’ needs and noting those needs that are being met vs. those that are not
being met
 Determine how the needs are being satisfied, addressing the technologies and functions being performed
by organisations

Good strategies 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

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.
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What makes a good strategy?

A good strategy:

• is planned well in advance

• Anticipates what is likely to happen. It also considers what isn’t likely to happen but might happen anyway
• is flexible
• leaves room for alternative plans
• builds on the experiences of people
• Involves people
• 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
• is realistic and 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 and includes not only good ideas but steps to carry out those ideas

Figure 4.4.6: Goals, SMART Objectives and Strategic Options

4.5 Strategy Implementation

4.5.1 What is 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

Implementation helps a leader choose a more robust strategy and 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.
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Figure 4.4.7: Key Tasks in Strategy Implementation

Build:
What do you build to strengthen the implementation of your strategic plan?
• Build support structure
• Fill key positions
• Build distinctive competencies
• Link work assignments with performance targets
• Maintain results perspective
• Focus on achievement of performance targets

Budget
Link budget with strategy:
• Efficiency
• Equity
• Flexibility
• Fundability
And implement Administrative support systems
• Programs & Processes
• Policies & Procedures
• Timely information
• Formal Reports & Controls

Lead
Harness Organizational Commitment
• Motivated Teams
• Shared Corporate Culture
• Results Orientation
• Sense of Urgency
• Alignment of Performance & Rewards
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Exercise Strategic Leadership

• Articulate Vision
• Shape Values & Culture
• Manage Politics
• Communicate
• Build Consensus
• Nurture Skills

Strategy implementation involves:

1. Action planning
2. Developing programme
3. Developing projects
4. Budgeting for activities within the programs/projects

If these tasks are not addressed the success of our strategy implementation would be hindered.

Action Planning

What is an action plan?

What is an action plan?

Action plan is:

• a blueprint that shows how the organisation will achieve goals and SMART objectives
• a detailed map defining how a strategy will be implemented

Components of an Action Plan

1. Goal
2. Objectives
3. Activities
4. Responsibility
5. Timeline (duration & completion)
6. Costs
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Figure 4.4.8: Sample Action Plan

“Weak Leadership can wreck even the soundest strategies, forceful execution of even
a poor plan can often bring victory” (Sun Xi)

Activity 4.19: Assignment

A research carried out shows that “globally for 25 out of 45 countries (55%)” have evidence of
implementation of their plans:
• Identify the hindrances to implementation of the strategic plan of your organisation
and what action can you take to increase the implementation rate.
Write the answers in your notebook and then compare them with what you read in the
following discussion.

4.5.2 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

This section cannot be covered without opening a window on organisational planning that is inclusive of both
strategic and operational planning.
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4.6 Organisational Planning

What is organisational planning?

Organisational planning comprises both strategic and operational planning.

Operational planning is the process of identifying shorter-term and more specific activities necessary to implement
longer-term and broader strategy. It describes who, what, how and by when activities will be accomplished

Strategic Planning is a process of clarifying the organization’s purpose, assessing the environment in which the
organization is functioning, identifying desired results, and describing how results will be achieved. The systematic
process through which an organization agrees on and builds commitment among key stakeholders to priorities
that are essential to achieving its mission and are responsive to its operating environment.

4.7 Unit Summary

This section revises the different components of strategic planning and

processes included. Strategic planning is key to activity performance.

Self-Assessment Test
1. Which of the following is not a step in the strategic planning process?
• Strategy formulation
• Strategy implementation
• Strategy Monitoring and evaluation
• Developing a beautiful strategy manual
(The last one is not a step in strategic planning)

2. Indicate if the following statements are True or False:

• Strategy follows structure
• Structure follows strategy
(Answer – the first is F the second is T)

4.8 References and Further Readings

1. MSH
2. USIU, 2009
3. Jeanne Liedtka,(1998), “Linking Strategic Thinking with Strategic Planning”,
Strategy and Leader
4. L’ art de la guerre, (Sun Xi)
5. Neissa, Louise, (2015), Transcription de 7Ms of BUSINESS MANAGEMENT
6. [Link]
7. Ouagadougou Declaration
8. MDGs
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UNIT 5: MANAGEMENT OF EFFECTIVE TEAMS

5.1 Unit Introduction

This unit demonstrates different ways of building teams for more adherence to organisation culture and goals and
displays how to make good use of team management skills for effective service delivery. This unit outcome is to
use team management skills for effective service delivery

5.2 Unit Outcome

By the end of this unit you should be able to apply team management skills for
effective service delivery

5.3 Team, Team Building and Organisational Culture

In this section we shall discuss the tools and skills required by a manager in order to build teams for effectiveness
and efficiency purposes.

What is Team building?

A team is a collection of individuals, who highly communicate, directing their energies towards a known defined
goal, which is achieved through their joint, complementary efforts, for the benefit of all
SYNERGY: 1+1>2

Combined efforts of team members can achieve more than what single individuals can:

Together

Each

Achieves

More

Here are some key aspects 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
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Activity 4.20:
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

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

5.4 Relevance of Teambuilding in Health Systems Strengthening

• 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.

5.5 Process of Team Building

Building a team is a process that goes through different stages. These stages are not necessary that one stage must
end before the other starts as teams and team members are dynamic. At the same time every time a member leaves
the team or a new member join, the team dynamics change again and even for a mature team the stages can start
again al together.
The process of team building goes through the 5 stages of group formation. These are:

Stage 1 – forming
1. Provides structure, broad goals/norms/TOR and clarify task direction
2. Focuses on basic information, keep social distance
3. Allows for “get-acquainted time”, break the ice, create atmosphere of confidence and optimism
4. Members tend to feel suspicious and confused
5. Be visionary, inspiring, facilitate communication/interaction/active involvement
6. Members tend to accept the power & authority figure

Stage 2 – storming
1. Conflict evident but encourage participation, and appreciate individual differences
2. Leader is a facilitator, trainer, coach and role model
3. Acknowledge personalities & conflicts that emerge and resolve issues
4. Lack of unity & cohesiveness prevails hence guide others toward consensus
5. Get members to assume more task than people oriented responsibilities
6. Train on conflict resolution methods
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Stage 3 – norming
1. Teams emerge at the norming stage in group development
2. Coach and sponsor new norms “modus operandi”
3. Norms can be written or unwritten
4. Give feedback and support, clarify roles, norms and values
5. Plan celebrations for short term wins
6. Allow for less structure and promote discussion & contributions from all team members
7. Encouraging others to make decisions and assess relevance of norms to team productivity

Stage 4 – performing
1. Observe, inquire, facilitate and fulfil team needs and achieve results
2. Provides little direction and allow members to participate more in final decisions
3. Low amounts of two-way communication needed
4. Give positive reinforcement and support
5. Leader sets goals: team accomplishes, solves problems, share new information

Stage 5 – adjourning
1. Help team with options for renewal or termination
2. Effective active listening and provision of information in many different formats
3. Offer direction to move group back through initial stages and guide the process
4. Create opportunities for feedback, rewards & sanctions
5. Reflect and engage in continuous learning and improvement for the next task

Figure 4.4.9: Team Development Process

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What are the characteristics of a Team?

5.6 Characteristics of Effective Teams

• 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

5.6.1 Team Effectiveness

1. Team goals are developed through team interaction and agreement
2. Participation by all team members and roles are shared
3. 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
4. Leadership is distributed and shared among team members and individuals willingly contribute their
resources as needed (Francis and Young,1979)
5. Problem solving, discussing team issues, and critiquing team effectiveness are encouraged by all team
members.
6. 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.
7. Team member resources, talents, skills, knowledge, and experiences are fully identified, recognized, and
used whenever appropriate.
8. Risk taking and creativity are encouraged. When mistakes are made, they are treated as a source of
learning rather than reasons for punishment.
9. High level of interdependence among members
10. Team leader has good people skills & is committed to team approach
11. Each member is willing to contribute, relaxed climate for communication
12. Members develop mutual trust
13. Team and individuals are prepared to take risks
14. Clarity about goals and establishes targets
15. Roles are defined, team members know how to examine team and individual errors without personal
attacks
16. Team has capacity to create new ideas
17. Each team member knows he can influence the team agenda
18. Team decision making involves a process that encourages active participation by all members
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5.6.2 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
• 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
• 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

5.6.3 Causes of team failure

• Unclear goals and objectives
• Non-measurable goals
• Poorly defined boundaries and responsibilities
• Inappropriate leadership style and behaviour
• Ineffective meetings
• 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

Why is diversity management important in team building?

5.7 Managing Team Diversity

Team diversity refers to all the ways by which individual in a team differ. This relates to both individual differences
as well as organizational related characteristic differences. Team diversity is importance for the organization as it
provides an opportunity to view organizational challenges from multiple perspectives. However, if not managed
effectively, team diversity can negatively affect productivity. Conflict is a common occurrence that is inherent in
team diversity in organizations. The most common causes of conflict in health care settings is completion for scares
resource. Managers in health are faced with a challenge creating healthcare outputs with limited resources.
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5.7.1 Managing conflict

What is 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

The following are key components of conflict management;

• Control emotional responses
• Seek understanding
• Identify needs and common interests of self and others in the team
• Seek mutual benefit or purpose

To help you understand conflict management study Thomas-Kilman five Conflict –handling model in Figure 5.1

A model of styles to handle conflict

Figure 5.1 Model of Styles to Handle Conflict

In the model in Figure 5.1, animals have been used to represent reactions to handle conflict.
The Competitive/Domination is represented by a Shark: This is a power oriented type of reaction and
winning conflict is at the expense of others. Forcing vs. contending
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The Compromise represented by a Fox is intermediate in both assertive and cooperativeness. There is partial
satisfaction of both parties a focus on give & Take and these might include withdrawal from a threatening situation
Firm Vs. Flexible

The Collaborative/Integration is represented by an Owl. - This involves working with others to find solutions that
fully satisfies both parties. This might involve explores the issues mutually to understand it better in an attempt to
resolve without competition.

Avoidance is represented by a Turtle. It tries to ensure everyone wins. The best but most difficult and involves
refusing to become involved in conflict
Protecting vs. Withdrawing

Accommodating is represented by a Teddy Bear There is lack of assertiveness one party neglects own concerns
and focus is on satisfying the other party or yielding ones opinion to appease others and has an element of obeying
other persons orders unwillingly.
(Pat Sample, 2010)

You have learnt about the different styles of reacting to conflict in the previous session, now, proceed to Table 5.1
to 5.5 for a presentation of different styles of reacting to conflict, when to use each one of them and the dangers of
using each one of them inappropriately.

Table 4.5.1 Accommodation

Use Danger of inappropriate use

To build the relationship Your needs are not met

When the issue is relatively unimportant to you, but important You may begin to feel taken advantage of and
to the other person resentful
When you have less experience or expertise than the other
person
When preserving harmony and avoiding disruption are
especially important

Table 4.5.2 Avoidance

Use Danger of inappropriate use

When the issue or relationship is unimportant Conflict may fester until it escalates
To prevent an immediate conflict (e.g. inappropriate time, The relationship remains superficial
place, or feelings are escalated)
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.)
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Table 4.5.3 Collaboration

Use Danger of inappropriate use

To find a solution that integrates both sets of concerns, as they May waste time and energy on issues that are
are both important not important
To merge insights from people with different perspectives on As the process can take longer it may frustrate
a problem some people
When commitment and “buy-in” is needed to implement a
solution
When hard feelings have been interfering with an interpersonal,
working relationship

Table 4.5.4 Competition/Directive

Use Danger of inappropriate use
When quick, decisive action is important, such as emergencies May weaken relationships if it is perceived
that you won and the other person lost

When your core values need to be defended You receive less input and ideas from others

When it is important to you to have it your own way Others may not “buy-in” and sabotage the
decision

Table 4.5.5 Compromise

Use Danger of inappropriate use

When an agreement needs to be reached – time is important Nobody really gets what they want or need

When mutually exclusive goals prevent collaboration The focus becomes what you did not manage
to get re needs/wants
To achieve temporary settlements to complex issues
Problems reoccur as they were not fully
As a backup mode when collaboration or competition is explored and resolutions found that truly
unsuccessful work for those involved

Conflict resolution skills are an important aspect of managing teams in organisations. In table 5.6 you will learn
about conflict resolution skills and their road blocks.
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Table 4.5.6: Conflict resolution skills and roadblocks

Conflict resolution skills Road blocks to conflict resolution

Get the facts Name calling

Engage in Active/Reflective Personalizing issues

Listening
Sarcasm/Ridicule/Insulting
Defuse/manage anger
/negotiate outcomes Threats/Blaming/Inflexibility

Empathize and appeal to Defensive body posturing

cognitive restructuring
Offensive language
Deal with clashing Egos
- Styles Of Conflicts

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 Activity 4.15: (40 minutes)

You National TV station is giving you 3 minutes to advertise your team on TV.
What would you say about them?
Write down your advertisement and then share it in the online discussion.

Building an effective team is so important within an organisation so as to be strong enough to manage risks.

5.8 Unit Summary

In this unit you have learnt about characteristics of effective teams that included team
building, team diversity and conflict management. In the next unit you will learn about
risk management.

Self-assessment test
1. Storming is the first stage of group formation (True or False?) – Answer F
2. Effective teams do not experience conflict (True or False?) – Answer F
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UNIT 6: RISK MANAGEMENT IN HEALTH

6.1 Unit Introduction

This unit is made up of three sub units. At first, the unit introduces the learner to the definition of risk. This followed
by types of risk in health care organisations and lastly the unit covers management of risks in health care
organisations. At the end of the unit you will be able to manage organisational risks

6.2 Unit Outcome

By the end of this unit you should be able to manage organisational risks.

6.3 Risk Management

What is risk?

WHO (2002) defines risk as a probability of an adverse outcome or a factor that raises this probability. Hillson (2010)
defines risk as the effect of uncertainty on objectives. Both definitions attest to the fact that a risk has potential
negative impact on the outcome. However, Hillson’s definition underscores the fact that there may be many
uncertainties within organizations but not all of them may affect objectives of the organizations.

6.4 Types of Risks in Health Care Organization

In Table 6.1 you will learn about the 8 domains of risks in health care organisations as well as their descriptions.

Table 4.6.1 domains of risks and their descriptions (Robert L., 2014)
Risk Domains Descriptions
Operational Risks resulting from failed internal processes people or systems

Clinical/ Patient safety Results from failure to follow evidence based practices, include serious
safety events
Strategic Risk associated with focus and direction of the organisation.

Financial Risks associated with financial sustainability of the organisation may include
risks associated with malpractice litigation and insurance

Human capital Risks associated with employee selection, retention, staffing and turnover

Legal/Regulatory Risks associated with fraud and abuse, licensure and accreditation

Technology Include risk management information systems, electronic health records

and social networking

Hazard Risks related to facility management, parking valuables, construction, earth

quakes floods and fires
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6.5 Principles of Risk management

What is risk management?

Risk management is the coordination of activities to direct and control an organization with regard to risk. The
following are 11 principles to apply in managing risks

Eleven (11) Principles to risk management

1. Creates value
2. Be an integral part of organisational process
3. Be part of decision making
4. Explicitly address uncertainty
5. Be Systematic structured and timely
6. Based on the best available information
7. Be tailored
8. Take into account human and cultural factors
9. Be transparent and inclusive
10. Be dynamic interactive and responsive to change
11. Facilitate the continual improvement of organisation

Now proceed the description of each of the eleven principles

1. Creates and protects value

Risk management allows continuous review of process and system hence contribute to organizational
objectives

2. Be an integral part of organisational processes

Risk management should be an integral part of organizational governance framework there it should be
evident at both operational and strategic levels.

3. Be part of decision making

Risk management guide decisions in an organization and enables identification priorities and selection of the
most appropriate action

4. Explicitly address uncertainty

Allows for forecasting and allows agency to implement controls to minimize negative impact and maximize
positive impact on the organization.

5. Be systematic, structured and timely

Effectives and reliability on results is maintained though consistent application of risk management process
across the organization

6. Based on the best available information

Understanding of information and its relevance to risk management process is an integral aspect of managing risk
in organizations

7. Be tailored
Risk management in every organization need to include its risk profile and take into consideration the internal and
external operating environment
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8. Take into account human and cultural factors

Risk management has to recognize the contribution made by people and their culture in achieving organizational
objectives

9. Be transparent and inclusive

Stakeholder engagement in risk management process recognizes the importance of communication and
consultation in analysing and monitoring risk

10. Be dynamic, iterative and responsive to change

Allow flexibility in the process of managing risk and be conscious of the changing environment. Identify new risks
and consider the fact that risks no longer exist

11. Facilitate the continual improvement of organizations

Maturity in risk management entails overtime investment of resources and demonstration of continued achievement
of objectives by organizations
(Risk Management Fact sheet, 2010)

To conclude the session on principles of risk management proceed to Activity 4.21

Activity 4.21
Which of the principles of management have you applied in you organisation?
Which ones do you intend to apply and why?

6.6 Risk Management Process

Risk management is a step by step process that every employee should understand in order to be effective. The
process includes the following seven steps.

1. Employee education on risk management

2. Accurate and complete documentation
3. Departmental coordination
4. Prevention
5. Correction
6. Complaints
7. Incident report

Now you can proceed to the descriptions of each of the seven steps;

1. Employee education on risk management- This should include risk identification, prevention and
response strategy
2. Accurate and complete documentation- This provide information for future reference
3. Departmental coordination – This keeps everyone on the right page and leads to effectiveness of the risk
management process
4. Prevention- Prevention of what is preventable
5. Correction -address risks that are preventable promptly
6. Complaints- Handle complaints in order to reduce risks to the organization.
7. Incident report- Incident reporting ensures future reference
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That brings us to the end of this unit and indeed to the end of our module on management in health. Let us now
review what you have learnt in this unit.

6.7 Unit Summary

In the risk management unit, you have learnt about various definitions of conflict as well
as the application of conflict management principles. Also, you learnt about conflict
management steps

Self-assessment test
Read the following sentence and indicate if it is true (T) or false (F).
1. Risk management is a step by step process that only leaders should understand in order for an
organization to be effective. (Answer is F)
2. Review the following risk domain in health care and fill the gap with the missing one.
a. Operational
b. Clinical/patient safety
c. Strategic
d. Financial
e. Human Capital
f. Hazard
g. Legal/Regulatory

6.8 References and Further Readings

• Hillson D.A (2000) Project risk identifying causes risks and effects.
• Project Management network, Vol 14, 9 pg. 48-51 Fact sheet (2010) Risk Management
– Principles and Guidelines
• WHO , (2002) The world health report 2002- Reducing Risks, Promoting Health Life
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MODULE SUMMARY
The changing environment within which health care organisations exist has required consistent updates of the
managers ‘knowledge and skills demonstrated in this current module. This module content shows that efficiency
and effectiveness of health is an integral aspect of health system strengthening together with strategic and
operational management, team building and conflict resolution, risk management etc.

SELF ASSESSMENT TEST

1. Outline at least six the components of management
2. Explain the difference between authority and responsibility
3. State two risk domains in Healthcare
4. Explain why it is important to document risks (Incident report) in risk management

CORE REFERENCE MATERIAL

1. Nigel Slack, Stuart Chambers and Robert Johnston, 2008, Operations Management fifth edition, Prentice
Hall (FT) New York.
2. William J Stevenson, 2007 Operations Management (International student edition with global readings) 9th
edition, McGraw-Hill Irwin, Boston
3. Gagakuma, W. Ethiopian Civil Service University/Ghana Institute of Management Public Administration,
UCLA 2012 presentation
4. MDI Training
5. Jeanne Liedtka,(1998), “Linking Strategic Thinking with Strategic Planning”, Strategy and Leader
6. L’ art de la guerre, (Sun Xi)
7. Neissa, Louise, (2015), Transcription de 7Ms of Business Management
8. Ouagadougou Declaration
9. SDGs
10. Operational Managers, [Link]
11. Robert E; Burke, and Leonard, H, F (2011) Essentials of Management and leadership in Public Health
12. Fact sheet (2010) Risk Management – Principles and Guidelines
13. Hillson D.A (2000) Project risk identifying causes risks and effects. Project Management network, Vol 14, 9
pg. 48-51
14. By CSCMP and Nada Sanders, 2014
15. MDI training
16. Boundless. “A Study of Process.” Boundless Business Boundless, 26 May. 2016. Retrieved 09 Feb. 2017
from [Link]
management-10/introduction-to-operations-management-69/a-study-of-process-328-7195/
17. Robert E; Burke, and Leonard, H, F (2011) Essentials of Management and leadership in Public Health
18. Katz, R. (1955) Skills of an effective administrator
19. Capenter, M. Bauer, T & Erdogan, B (2012) . Management Principles v.1.0
20. MSH (2005) Leading and managing to achieve results.
21. Hillson D.A (2000) Project risk identifying cause’s risks and effects.
22. Project Management network, Vol 14, 9 pg. 48-51 Fact sheet (2010) Risk Management – Principles and
Guidelines
23. WHO , (2002) The world health report 2002- Reducing Risks, Promoting Health Life
24. Miner (2016)The Four Functions Of Management: What Managers Need To Know
 MODULE 5
HUMAN RESOURCE FOR HEALTH
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LIST OF TABLES
Table 5.1.1: History, Evolution and Development of HRM 227
Table 5.1.2 Provides a summary of the health related laws and regulations (statutes) in selected countries 238
Table 5.4.1 Effects Associated with Turnover 269
Table 5.6.1 Selected key indicators for monitoring and evaluation of human resources for health 300

LIST OF FIGURES
Figure 5.1.1: The HRH Action Framework 229
Figure 5.2.1: Process of HRH policy formulation and development 242
Figure 5.3.1: Process for developing the HRH Strategic Plan 245
Figure 5.4.1: Recruitment and Selection process 253
Figure 5.4.2: Performance management objectives 256
Figure 5.4.3: The Performance Management Process (Cycle) 256
Figure 5.4.4: Traditional appraisal tools 258
Figure 5.4.5: Traditional Feedback Versus 360o Feedback 259
Figure 5.4.6: The Five-step MBO process 260
Figure 5.4.7: The balanced score card 261
Figure 5.4.8: Types of Rewards 262
Figure 5.4.9: Characteristics of effective reward schemes 263
Figure 5.5.1: Difference between education and training 274
Figure 5.5.2: Identification of training needs 275
Figure 5.5.3: Training needs assessment & planning steps 277
Figure 5.5.4: On-the-job training methods 278
Figure 5.5.5: Off-the-job training methods 279
Figure 5.5.6: Career Development Activities 280
Figure 5.5.7: Steps in Succession Planning 282
Figure 5.6.1: Differences between M & E 290
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MODULE 5: HUMAN RESOURCES FOR HEALTH

5.1 Module Introduction

Congratulations for successfully completing Module 4. Now you are ready for Module 5 on Human Resources for
Health. This module will equip you with knowledge, skills and attitudes to manage human resources for health
with an aim of improving health outcomes.

5.2 Module Outcomes

By the end of this module you should be able to:
• Outline the evolution and context of HRH
• Apply human resource policies in health care management
• Effectively plan for human resources for health
• Perform the functions of HRH in health service delivery
• Monitor and evaluate effectiveness of human resources for health

5.3 Module Content

This course is divided into the following 6 units:

• Unit 1: Context and Evolution of Human Resources for Health

• Unit 2: Human Resource for Health Statutes and Policies
• Unit 3: Human Resources for Health Planning
• Unit 4: Functions of HRH Management
• Unit 5: Human Resources for Health Training and Development
• Unit 6 HRH Monitoring and Evaluation

You will start by studying Unit 1 of this module which looks at the context and evolution of Human Resources for
Health.
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UNIT 1: CONTEXT AND EVOLUTION OF HUMAN RESOURCES FOR HEALTH

1.1 Unit Introduction

Welcome to Unit 1 of Module 5. This unit has six sections namely:
i. Overview of HRH, Evolution of human resources management
ii. Global HRH crisis
iii. Human Resources for Health Action Framework
iv. Current trends, emerging issues and practices in HRH
v. The Linkage between human resources for health and health systems strengthening.

1.2 Unit Outcomes

By the end of this unit you will be able to outline the evolution and context of HRH

Let us now begin by discussing the underlying context of human resources for health. This will help you to appreciate
the current situation of human resources in the health sector.

1.3 Overview of HRH

Human resources for health (HRH) are widely recognized as the most important assets and pillar of any health
system. However, many countries are faced with severe shortages of this important human capacity. This has
resulted in weak health systems with a limited capacity to achieve their national health goals. In spite of its central
role in attaining health outcomes and its potential contributions to other development objectives, investment in
health workforce is still largely perceived as a consumptive sector rather than a contributor to socio-economic
development.

Within many health care systems of various countries, increased attention is being focused on human resources
management (HRM). Specifically, human resources for health is one of three principle health system inputs. As
arguably the most important of the health system inputs, the performance and the benefits the system can deliver
depend largely upon the knowledge, skills and motivation of those individuals responsible for delivering health
services.

The balance between the human and physical resources is also essential to maintain an appropriate mix between
the different types of health promoters and caregivers to ensure the system’s success. Due to their obvious and
important differences, it is imperative that human capital is handled and managed very differently.

We now want to define two main concepts that are key in this module. They are human resources for health and
human resources management.

How would you define human resources for health?

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There are numerous definitions of human resources for health. According to (WHO 2006), Human
resources for health refer to all people engaged in actions whose primary intent is to enhance health or the
stock of all individuals engaged in the promotion, protection or improvement of population health. Human
resources for health are either technical or support. Examples of technical staff include clinicians and nurses
while the support staff include the ambulance driver and the hospital finance manager.
Human resources for health are those individuals with health and non-health vocational educational and
training working in the health services industry (WHO 2009).

Human resources for health are all categories of health workers from specialists, physicians, surgeons
through to community health workers (WHO 2010)

HRM is a distinctive approach to employment management that seeks to achieve competitive advantage
through the strategic deployment of a highly committed and capable workforce, using an array of cultural,
structural and personnel techniques. (Storey, 1995).
HRM is a managerial perspective that argues the need to establish an integrated series of personnel
policies to support organizational strategy. (Buchanan and Huczynski, 2004).
HRM is a strategic approach to managing employment relations that emphasizes that leveraging
people’s capabilities is critical to achieving competitive advantage, this being achieved through a distinctive set
of integrated employment policies, programmes and practices. (Bratton and Gold, 2007).
Now, that you know the key concepts on HRH, you can proceed to section 2, which discusses how human
resources management has evolved through the years.

1.4 Evolution of Human Resource Management (HRM)

Lancet (2015) summarizes the milestones in the history, evolution and development of human
resources management (HRM) over five periods:

i. Pre-world war II,

ii. Post World War II
iii. Social Issues Era;
iv. Cost–Effectiveness Era
v. Technological Advancement Era

The characteristics of HRM under each of the periods is summarized in Table 1.1. You can now go through
each of the characteristics that distinguish each of the periods.
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Table 5.1.1: History, Evolution and Development of HRM

Period Time HR Factors/Issues/Characteristics
Pre-World War 2000BC – • Mechanisms for selecting tribal leaders;
II 1000BC • Recording and dissemination of knowledge about safety; health,
hunting and gathering of food
• Use of employee screening techniques by the Chinese
• Use of the apprentice system by the Greek.
• Emergence of Scientific Management Theory
• Start of industrial revolution that led to replacement of cottage
industries by large factories;

1700 – 1900 • Rise of large workforce occasioned by immigrant workers

• Introduction of personnel function mainly for keeping workers records
• Rise of middle level supervisors
• Maximum exploitation of workers
• Increase in child labour
• Widened gap between workers and supervisors
• Poor working conditions
• Rise of labour unions to agitate for workers’ rights
• Expansion of personnel function to include welfare and administration
mainly in UK and USA.
1920 – 1930 • Rise of motivation practices occasioned by the Hawthorne studies,
various attempts at employee satisfaction begin to be implemented
such as better wages and good working conditions

Post World 1945 – 1960 • The Human Relations Movement shaped the management ethos of the
War II time;
• Emphasis on employee productivity through various motivation
techniques
• Emphasis on welfare issues
• Emergence of job description which improved recruitment and
selection
• Emergence of compensation and evaluation strategies
• official recognition of trade unions in various countries mainly in UK
and USA
• Emergence of collective bargaining for increased employee welfare
• Enactment of a significant number of employment laws
• Emergence of computer technology and use in record keeping
• Emergence of job analysis
• Expansion of the personnel function to include recruitment, labour
relations, training, benefits and government relations divisions
• First HRM software Comprehensive Occupational Data Analysis
Program (CODAP) developed in the USA mainly for job descriptions
and assigning roles;
• Advancement of computer technology to include payroll, inventory
and accounts.
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Period Time HR Factors/Issues/Characteristics

Social Issues 1963 – 1980 • The Civil Rights Movement shaped the management thinking of
Era the time; the civil rights act (1964) brought in affirmative action,
abolished all forms of discrimination and ushered in equal employment
opportunity
• Transition from personnel management to human resources
management
• Increased computerization of the HR function for accuracy, speed,
storage and reporting of HR data; Development of Human Resource
Information System (HRHIS)
• Increased trade unionism led to better working conditions and terms of
employment
• Adoption of various laws on occupational health and safety, retirement
benefits and tax regulation
• Emergence of employee participation in management decision
making, increased employee training and employment
Cost– 1980-early • Increased automation of the workplace to boost production; -Shift from
effectiveness 1990s employee administration to employee development and involvement
Era • Emphasis on efficiency and effectiveness through adoption of
technology;
• Emergence of hard and soft HR approaches
• Emergence of employee return on investment debate
• on employee as an unnecessary cost to be minimized/eliminated or a
vital resource to be developed
Technological 1990 – • This era is shaped by increasing forces of globalization, rapid change
Advancement present occasioned by tremendous technological breakthroughs and pressure
Era for increased efficiency
• Cut throat competition characterize all industries
• Emergence of Strategic HRM
• Emergence of business process reengineering strategies recognition of
intellectual capital
• Increased strategies for recognition, rewards, motivation, greater
awareness of the HR role as a strategic business partner
• Emergence of improved strategies for attracting, retaining,
development and engagement of talent; emergence of workforce
evaluation methods such as balanced scorecard, performance appraisal
techniques
• Emphasis on contribution of HRM to competitive advantage
• Human resource planning techniques
• Diversity management; talent management; emergence of e-HR
• e-training, e-recruitment, telecommuting, flexible work arrangements,
virtual teams; work life balance; social media currently informs
transformation of HRM
• Improved networking
• Influence of mass media
• Ethics
• Green economy
• New world order.
Source: Lancet (2015)
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Now that you have finished section two, you will proceed to learn about the global HRH crisis.

1.5 Global HRH Crisis

The world population is growing in line with global increase in birth rate, hence the need to have a corresponding
increase of HRH available to match the growing population and also address a high disease burden. However, World
Heath Report (2006) show a global health workforce shortage of about 4 million workers, worse in poorer countries
where health needs are the greatest. While there may be continuing debate about the exact magnitude of the
shortage of health workers, there can be no doubt that in most countries with a high disease burden there are not
enough health workers to do the job.

The major challenges leading to the global HRH crisis are:

Coverage
• Work environment
• Competencies

In a report presented by the Joint Learning Initiative (2004), three major challenges leading to the global HRH crisis
were identified. These were:
• coverage;
• work environment ; and
• competencies

a. Coverage: the issue of inadequate number and inadequate skill mix of HRH affect population coverage in terms
of quality healthcare delivering services.

b. Work environment : The HRH expects better remuneration to meet the basic needs of the individual. As such
poor remuneration of HRH affects performance at the workplace. Healthcare service is dynamic and requires
upgrading of knowledge, skills and attitude periodically through career development. In view of this, lack of
opportunities for career development prevents HRH to deliver best practise at the work environment. The
function of HRH is link to the availability of other health systems such as consumables ; tools and equipment a
the workplace. Therefore, lack of supportive health systems may render HRH ineffective

c. Competencies: acquisition of appropriate knowledge, attitude and skills after appropriate training to enable
HRH render healthcare service. The client to receive quality healthcare is at risk when the HRH lacks appropriate
knowledge, attitude and skills. The opportunity for HRH to undertake continuous learning allow the individual
access to best practices. When HRH lacks the opportunity for continuous learning, performance in terms of
updated healthcare delivery service is affected. HRH works effectively and efficiently when in teams with a clear
system of communication and command. The creation of teamwork require leadership with innovations. The
failure to create conditions for leadership and entrepreneurship would also account for HRH crisis.

Well done for successfully coming to the end of the global HRH crisis unit.
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Provide a response to the activity below.

State the three major challenges leading to the HRH global crisis

Well done. I believe you gave these responses as the major challenges leading to the global HRH crisis:
i) coverage,
ii) work environment and
iii) competencies.

Now that you have completed this section, next we will discuss the HRH Action Framework.

1.6 Human Resources for Health Action Framework

You have probably faced a challenge in your country or workplace related to HRH. The comprehensive HRH Action
framework discussed in Figure 1.1 below is designed to assist managers and policy makers like you to develop and
implement strategies to achieve an effective and sustainable health workforce. The framework will help you address
staff shortages, uneven distribution, gaps in skills and competencies, low retention and poor motivation among
other challenges (WHO, 2005) by analysing issues and providing recommendations according to the following six
action fields.

The framework will help you address staff shortages, uneven distribution, gaps in skills and competencies,
low retention and poor motivation among other challenges (WHO, 2005) by analysing issues and providing
recommendations.

Figure 5.1.1: The HRH Action Framework

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The HRH Action Framework diagram includes six clickable Action Fields (HR Management Systems, Leadership,
Partnership, Finance, Education and Policy) and four clickable Phases (Situational Analysis, Planning, Implementation
and Monitoring & Evaluation). To ensure a comprehensive approach to a HRH challenge, you will eventually need
to address all Action Fields and Phases of the Action Cycle. However, the Framework is constructed so that, based
on your particular areas of interest, you can select any Action Field or Phase and drill down to access relevant tools
and guidelines, indicators and resources. You can also learn more about indicators to measure the Improved Health
Workforce Outcomes resulting from the implementation.

Influencing Factors
While the HRH Action Framework is applicable in all countries, the way you use it will be influenced by the elements
specific to your country context (for example, the economy, the political situation), including the labour market
(the capacity of the health workforce in general, international labour influences). The outcomes of applying the
Framework will also be influenced by the strength of other components in your health system (for example, the
availability of drugs and equipment, the level of technology available, the number and condition of health facilities).

Having learnt about HRH Action framework, carry out the activity below.

Go to Figure 1.1 on HRH Action Framework and choose the action field on Policy and note its
definition, areas of intervention and indicators. Move on to the next action field until you have
studies all of them.

Action Field: Policy

Definition: Legislation, regulations, and guidelines for conditions of employment, work standards, and
development of the health workforce.

Areas of Intervention
• Professional standards, licensing and accreditation
• Authorized scopes of practice for health cadres
• Political, social and financial decisions and choices that impact HRH
• Employment law and rules for civil service and other employers.

Indicators
• HRH policies in place
• Appropriate scopes of practice defined for all cadres.

Action Field: Policy

Definition: Obtaining, allocating and disbursing adequate funding for human resources.

Areas of Intervention
• Setting levels of salaries and allowances
• Budgeting and projections for HRH intervention resource requirements including salaries,
allowances,education, incentive packages, etc.
• Increasing fiscal space and mobilizing financial resources (e.g., government, Global Fund, PEPFAR,
donors)
• Data on HRH expenditures (e.g., National Health Accounts, etc.)
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Indicators
• Salaries and allowances competitive in local labour market
• Salaries and allowances equitable between cadres of health workers
• National health accounts routinely collect data on HRH expenditure.

Action Field: Education

Definition: Production and maintenance of a skilled workforce.

Areas of Intervention
• Pre-service education tied to health needs
• In-service training (e.g., distance and blended, continuing education)
• Capacity of training institutions
• Training of community health workers and non-formal care providers.

Indicators
• Ratio of graduates of pre-service training programs to projected demand by type of health worker
• Attrition of students in pre-service training programs
• Pre-service curricula updated periodically (e.g., within last three years)
• In-service training coordination and evaluation mechanisms in place
• Student/teacher ratios by pre-service institutions and cadres.

Action Field: Partnership

Definition: Formal and informal linkages aligning key stakeholders (e.g., service providers, sectors, donors, priority
disease programs) to maximize use of resources for HRH.

Areas of Intervention
• Mechanisms and processes for multi-stakeholder cooperation (inter-ministerial committees, health worker
advisory groups, observatories, donor coordination groups).
• Public-private sector agreements
• Community involvement in care, treatment and governance of health services.

Indicators
• Mechanisms in place for coordination (e.g., other key ministries, donors, service providers including private
sector providers, professional associations, etc.)
• Agreements in place between MOH and other health providers.
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The way you use the HRH Action framework will be influenced by the elements specific
to your country such as political and economic situations

Bravo learner for successfully using the framework to address HRH challenges in your country.

You have successfully completed this section on the action framework for HRH. Next we shall discuss the current
trends, emerging issues and practices in HRH.

1.7 Current Trends, Emerging Issues and Practices in HRH

The purpose of this section is to give you an opportunity learn more on emerging issues, current trends and
practices in human resources for health practices experienced in your work place.

Introduction

The world of work is rapidly changing and the health sector is not left behind. As a part of organization, Human
Resource Management (HRM) must be prepared to deal with effects of changing world of work and their implications
to health service delivery. As a rule, human resource management has to venture into new trends in order to remain
relevant. Below are some of the trends common in HRH are:

• Task shifting/Task sharing

• Globalization
• Work-force diversity
• Technology

Activity

Write down in your note book any one emerging trends, emerging issue and practice in HRH
in your country

Great attempt! Now compare your ideas with what you read in the following discussion.
a) Task shifting / Task sharing
World Health Organization (2008) defines task shifting/sharing is the rational re-distribution of tasks among
health workforce team in which specific tasks are moved from highly qualified health workers to those who
have fewer qualifications in order to make more efficient use of available resources( WHO, 2008)

Task sharing/sharing is a team-based care where medical care provided to a patient is by a set group (team) of
different health professionals with different roles that maximize the skills and abilities of each team member
(USAID 2012)

Team-based care differs from traditional care in which a physician was either the only or the primary point of
contact with the patient. Team-based care is designed to enable different health professionals to achieve their
full potential and improve quality, reduce costs, and increase access to health services.

Task shifting/sharing has emerged because of severe shortages and imbalanced distribution of trained health
workforce posing a threat to achieving universal health coverage.
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b) Globalization and its implications

Work and business today does not have national boundaries – it reaches around the world. The
rise of multinational corporations places new requirements on human resource managers. The HR
department needs to ensure that the appropriate mix of employees in terms of knowledge, skills
and cultural adaptability is available to handle global assignments. In order to meet this goal, the
organizations must train individuals to meet the challenges of globalization. The employees must have
working knowledge of the language and culture (in terms of values, morals, customs and laws) of the host
country.
Human Resource Management (HRM) must also develop mechanisms that will help multicultural
individuals work together. As background, language, custom or age differences become more
prevalent, there are indications that employee conflict will increase. HRM would be required to train
management to be more flexible in its practices. Because tomorrow’s workers will come in different
colors, `nationalities and so on, managers will be required to change their ways. This will necessitate
managers being trained to recognize differences in workers and to appreciate and even celebrate these
differences.

c) Work-force Diversity
In the past HRM was considerably simpler because our work force was strikingly homogeneous. Today’s
work force comprises of people of different gender, age, social class, sexual orientation, values, personality
characteristics, ethnicity, religion, education, language, physical appearance, marital status, lifestyle, beliefs,
ideologies and background characteristics such as geographic origin, tenure with the organization, and
economic status and the list could go on. Diversity is critically linked to the organization’s strategic direction.
Where diversity flourishes, the potential benefits from better creativity and decision-making and greater
innovation can be accrued to help increase organization’s competitiveness. One means of achieving that is
through the organization’s benefits package. This includes HRM offerings that fall under the heading of the
family friendly organization. A family friendly organization is one that has flexible work schedules and provides
such employee benefits such as childcare. In addition to the diversity brought by gender and nationality, HRM
must be aware of the age differences that exist in today’s work force. HRM must train people of different age
groups to effectively manage and to deal with each other and to respect the diversity of views that each offers.
In situations like these, a participative approach seems to work better.

d) Technology
With the current technological advancement and its projection in the future, it has brought in new eyes in the
face of HRM. A number of computerized systems have been invented to help in the HRM of which they are
seen as simplifier of HR functions in companies. Large or multinational organizations using some of the human
resources information systems are reaping big. You do not have to stay in a particular location to do your duties
but you can do on a mobile basis. For instance the paper work files are being replaced by HRMIS which may be
tailor-made or Off the Shelf. These systems help in handling many data on a chip other than having a room full
of file shelves.
What HRM is concerned with here is the safety (confidentiality) of the data/information of staff, and therefore it
is at the forefront of having to train personnel in operating such systems and developing the integrity of such
personnel to handle the sensitivity of the matter.
Therefore, for HRM to continue showing relevance it has shifted to providing health services to staff through
health insurance, sensitization, and free medical treatment bills. This has seen high results in not only in
performance but also in attraction and retention of highly qualified personnel.
Congratulations for completing sub-unit 5, next you will look at the last sub-unit that deals with linkage of HRH
and HSS
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1.8 Linkage between HRH and HSS

HRH is the most important aspect of health care system. Why is this? Take a minute to think about it and then
complete the activity below.

Activity
Write two reasons why HRH is an important aspect of the health care system

Well done. Now compare the reasons you have stated with the following discussion.

According to (USAID, 2015), there are six internationally accepted core components of the health care system.
These are:
i. human resources for health
ii. health finance
iii. health governance
iv. health information
v. medical products, vaccines, and technologies
vi. and service delivery

A well-performing healthcare system requires strengthening to achieve sustained health outcomes. Indeed, HRH
involvement is implicit in services delivery. HRH represents one of the largest element cost in terms of remuneration.
The effectiveness of HRH rests on the ability to mobilise and manage other components in the health care system
strengthening (HSS). The absence of HRH would halt the functionality of HSS. Therefore, there is a strong linkage of
HRH and HSS

Congratulations, you have successful completed this unit on the context and evolution of Human Resources for
Health unit 1. Let us now review what you have learnt.

1.9 Unit Summary

In this unit you have learnt about basic concepts used in HRM, the evolution of HRM
and the 6 components of the health action framework. We have also considered the
current trends, emerging issues and practices in HRH, the linkage of HRH and HSS,

Now get ready to start unit 2 that deals with Human Resource for Health Policies,
Plans and Strategies
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1.10 References and Further Readings

1. Armstrong, M. (2010). Armstrong’s Essential Human Resource Management
Practice: A guide to People Management. London: KoganPage
2. Dal Poz MR et al. (eds). (20009) Handbook on monitoring and evaluation of
human resources for health, Geneva, World Health Organization
3. Fallon F & McConnel C R (2014) Human Resources Management in Health Care-
Principles and Practice
4. Moser, C.O.N (1993). Gender Planning and Development: Theory, Practice and
Training, Routledge, London.
5. WHO guidelines on HRH Policy Development and Planning;
6. WHO, (2006) The world health report: Working together for health, Geneva
7. WHO, (2016) Global Strategy on Human Resources for Health: Workforce 2030,
Geneva
8. Recommended References
9. Global Journal of Human Resource Management (2015) Vol.3, No.3, pp.58-73,
Publishers: European Centre for Research Training and Development UK (www.
[Link])
10. World Health Organization (2010). Human Resources for Health Observer.
Models and tools for health workforce planning and projections. Geneva, WHO
([Link]/iris/bitstream/10665/44263/1/9789241599016_eng.pdf, accessed
3 February 2017
11. CapacityPlus (2017) Action Framework
12. WHO (2010) Global Code of Practice on the International Recruitment of Health
Personnel

Now get ready to start Unit 2 that deals with Human Resource for Health Statutes, Policies and guidelines
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UNIT 2: HUMAN RESOURCES STATUTES AND POLICIES

2.1 Unit Introduction

Well done for completing unit 1 of Module 5. Welcome to unit 2 of the Human Resources for Health module.
In unit 1 you learnt about the evolution of HRH, Global HRH crisis, the Human Resources for Health Action
Framework, the current trends, emerging issues and practices in HRH as well as the linkage of HRH to health systems
strengthening.

In this unit, you will learn about HR statutes, policies and guidelines. The purpose of this unit is to give you an
appreciation of HRH statutes, policies and guidelines. This forms the basis of management of HRH.

2.2 Unit Outcome

By the end of this unit you should be able to apply human resource policies in health care
management.

2.3 Functions of HR Statues and Policies

It is necessary for countries to have a legal framework in which management of HRH is grounded. The most important
statutes are the labour laws and regulations that govern and regulate the management of human resources. This
also includes the registration and accreditation of health facilities.

Improvements have been made over the last decade in ensuring that countries have the same guidelines in
reviewing or developing Human Resources for Health policies, plans and strategies (WHO 2010). The World Health
Organisation (WHO) in 2006 developed guidelines to assist countries within the African region to review or develop
Human Resources for Health policies in manner that sought to ensure that African countries’ HRH policies are
comprehensive and consistent whilst being adapted to country situations. WHO and other stakeholders have
continued to support countries to review/develop HRH statutes, policies and guidelines

The middle levels of health care management contribute to the development and implementation of the HRH
policies, plans and strategies hence it is critical that they be involved it the review/development processes. Senior
managers are more involved in policy review or development.

Do you now appreciate the background to HRH statutes, policies and guidelines ? We will now move to sub-unit 1
of this unit where we will discuss the statutes that relate to HRH.

2.3.1 HRH Statutes

Statutes embody laws and regulations that regulate how workers are managed. They are enacted by
legislative branch of a government, an act of a corporation or of its founder intended as a permanent rule and
an international instrument setting up an agency and regulating its scope or authority. This includes laws,
regulations, acts, enactments, rules and resolutions. Labour laws are the body of laws, administrative rulings, and
precedents which address the legal rights of workers and their organizations. Labour or employment laws are
designed to protect both workers and employers.

Statutes provide the legal framework in which HRH activities are conducted e.g. employee Resourcing, Performance
Management, Reward Management, Labour Relations, Employee Wellness, Exit Management, Orientation and
induction, Education, Training, Development, bargaining, registration, arbitration, and accreditation of facilities.
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Enforcement of labour laws and guidelines is provided for in the statutes and varies from country to country.

Now attempt the activity below.

Activity:
List the laws and regulations that govern Human Resources Health in your country.
How are these statutes enforced?

Now compare your answers with the list on table 1.1.

Good labour laws are as good as their enforcement. Legislation is useless without law enforcement to back it up. In most
countries health professionals can only be employed subject to registration with the relevant regulatory body whilst
health facilities can open and continue to operate subject to approval of the regulatory body.

Take Note:
The list of statutes might not include recent laws.

Table 5.1.2 Provides a summary of the health related laws and regulations (statutes) in selected countries.
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Name of statute and country

Cote d’Ivoire Ghana Kenya Malawi Uganda Zimbabwe

• Labour Administration • Labour Act, 2003 (Act • Employment Act • The Labour Rela- • Employment Act • Labour Amend-
– Regulation, Decree No 651) (2007) tions Act, 1996 2002 ment Act 2015
Ordinance 2008 • Holidays Act, 2001 • Labour Relations Act • Malawi Employ- • Employment Regu- • Health Service Act
• Employment Policy, (Act 601) (2007) ment Act, 2000 lations 2011 • Health Professions
promotion of employ- • Labour Regulations • Work Injuries and • Workers Com- • Public Holidays Act Act 28/2004 CAP
ment and employ- 2007 (LI 1833) Benefits Act (2007) pensation Act 1965 27:19
ment services • National Health In- • Occupational Health • Occupational • Minimum Wage • Health Service Reg-
• Conditions of em- surance Regulations, and Safety Act Safety, Health Advisory Board and ulations
ployment, Regulation 2004 (2007) and Welfare Act, wages Councils Act • Bi-partite Negotia-
decree 1996 • National Labour Com- • Labour Institutions 1997 • Occupational Safe- tion Panel Regula-
• Occupational Safety mission Regulations Act (2007) • Technical, ty and Health Act tions
and Health Regula- 2006 • Allied Health Profes- Entreprenuerial 2006 • Health Service Reg-
tion, Decree, Ordi- • Allied Health Profes- sions Act 2011 and Vocational • Labour Union Act ulations
nance sionals Act (Act 857, • Public Health education and 2006 • National Aids
• Maternity protection, 2013) Officers (Training, Training • Labour Disputes Council (NAC) Act
Decree, Ordinance registration and • (Arbitration and Chapter 15/14 of
1996 licensing) Act No 12 Settlement) Act 2000
• Freedom of Asso- of 2013 2006
ciation, Collective • Health Bill, 2015
Bargaining and
industrial relations –
Regulations, Decree,
Ordinance 1998
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Take Note:
It is important for you to be aware of the statutes that govern human for health
management. You can always to refer to them from time to time.

Great work, I am sure you were able to list the appropriate statutes that are applicable to human resources for
health in your country. Now you will cover section 2 on the HRH policies.

2.4 HRH Policies

We will start this unit by discussing the definitions of key concepts in HRH policies.

The WHO (2006) “defines health policy as “decisions plans and actions that are undertaken to achieve specific
health care goals within a society. An explicit health policy can achieve several things: it defines a vision for
the future which in turn helps to establish targets and points of reference for the short and medium term. It
outlines priorities and the expected roles of different groups and it builds consensus and informs people”.
Countries are expected to review or develop HRH policies, plans and strategies that respond to the needs in the
national health policy.

“A national human resources for health policy is an expression of commitment to the HRH goals and a guide
for action for health personnel. Such a policy describes the priorities that a country wants to achieve in the area of
HRH as it responds to implementation of health priorities adopted by a country. It also identifies the main
strategies for attaining those priorities. The policy also provides a framework within which human resource
activities can be coordinated and implemented. Usually, the policy encompasses a country’s vision for short-
term, medium-term and long-term HRH development. The HRH policy should be within the context of and
consistent with the overall national health policy.” (WHO 2006)

The HRH policy therefore facilitates planning, supports decision making, provides a basis for monitoring
and evaluating performance whilst providing an opportunity for key stakeholders in health to contribute
either technically or financially to policy development.

Now that we have covered the definitions it is also important to appreciate the approaches considered
when reviewing or developing HRH policies and strategies.

There are two major approaches to Human Resource policy development, the traditional approach and
the alternative approach.

The Traditional approach understands policy as a cyclic process, the different stages of which can be
separately analyzed. 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. (Dussault G and Dubois C - 2004)

According to Dussault G and Dubois C (2004) unlike the Traditional approach, the Alternative approach places
more 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 actions justified.
It is crucial that current and up to date information (evidence) be available to inform the HRH policy
review/development process.
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Key stakeholders in HRH also need to be involved in the process of formulation of the policies which have the
following key components.

Key components of an HRH Policy

• Foreword – The foreword is normally given by the Honourable Minister of Health, Head of the Employing
authority or the Permanent/Secretary for Health.
• Background – the background provides the reasons for the policy development.
• Statement of mission, vision and policy objectives – The mission, vision and policy objectives are detailed in
relation to HRH.
• A statement of the issue which the policy addresses – in most cases the HRH policies address the under listed
- the production and supply of HRH;
- The country’s competency needs;
- Management and utilization of HRH; and
- Research into HRH development.
• Main assumptions of success of the policy – what key considerations are made in development of the policy.
• Implementation Framework – the policy should clearly state how the key issues will be implemented.
• Institutional mechanisms of achieving policy objectives – The policy document should also detail the
institutional arrangements for achieving the objectives outlined in the policy.
• Monitoring and evaluation – The Policy should include a section on how it will be monitored and evaluated.
• Funding mechanisms – It is very important for the policy document to state how the HRH policy will be funded.

Armed with the information above you will need to appreciate how policies are formulated before you can
contribute to the HRH policy review or development process.

2.4.1 HRH Policy Formulation Process

The components of the HRH policy that you discussed, arise from the policy formulation process which you are
now going to discuss.

Moser (2003) defines policy making as “the process of social and political decision making about how to allocate
resources for the needs and interests of society, concluding in the formulation of a policy strategy.” The HRH
policy formulation process is informed to a large extent by the National Health Policy of the country as well as the
international, regional and national policies on human resources for health. Efforts should be made to align the
objectives of the national HRH policy with those in the National Health Strategic Plan.

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
competing demands for attention, and accompanied by lobbying, campaigning and tradeoffs. The influence of
major stakeholders e.g. donors, multinational corporations, professional associations and other powerful groups
may have to be compensated. A robust Country Coordination and Facilitation (CCF) will ensure the involvement
of stakeholders ranging from relevant government ministries, development partners, regulatory bodies and
professional associations as well as civil society.

Various authors on HRH policy developed call on the need for development of evidence-based human resources
policies which are gender mainstreamed. It is also important that HRH policies and procedures include strategies
on improving gender equity in recruitment, training and distribution.
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Figure 5. 2.1: Process of HRH policy formulation and development

Summary of the key steps in HRH Policy development

1. Setting up of multi–disciplinary working group or committee, most countries have Country Coordination and
Facilitation mechanisms or HRH Task Forces to oversee this with the help of consultants in either the review or
development of HRH policies.
2. HRH situation analysis report, summarize the major findings in the situation analysis highlighting the major
HRH challenges that would require policy direction namely in human resource planning and financing,
Employee Resourcing, Performance Management, Reward Management, Labour Relations, Employee Wellness,
Exit Management, orientation, induction, education, training and development as well as HR audits.
3. Establish the vision/mission of HRH should be guided by the national health vision.
4. Consensus for the HRH policy – the draft of the HRH policy whilst done by the Technical team or consultant will
need to be shared with the CCF/HRH Task Force which ensures representation of the major stakeholders.
5. Finalization and adoption of the HRH Policy should be at the highest possible level. In some countries approval
is done by the Minister whilst in other countries approval is done by the Cabinet.
6. Dissemination of the policy is important, therefore it needs to be planned and budgeted for. An official launch
will ensure that the document is shared with all relevant stakeholders to guide development of plans and
strategies by various players in education and training and the health facilities.
7. Monitoring and evaluation should be done through the HRH plan.
8. Review of the policy should be after 5 years noting the changes in the field of HRH. Other countries review their
policies after 15 years in line with the international health guidelines. The HRH policy should be reviewed earlier
should there be major shifts in policy.
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Activity:
Now take a copy of your HRH policy or download the guidelines on the following
website [Link]/node/434
Does your HRH policy comply with the guidelines provided.

2.4.2 HRH Policy Implementation

You have covered the policy development process and you want to learn how HRH policies can be implemented.

Activity
• In what ways is the HRH policy in your country implemented?
• List the HRH sub-policies that you are aware of.

Implementation of the HRH policy is through strategic and operational plans. It is important that the policy be
publicized through a launch and shared with all relevant stakeholders so that the existence of the policy is known
by all relevant stakeholders. In some countries the HRH policies are on the relevant websites.

Most countries develop sub-policies to guide procedures and processes in recruitment, compensation and
reward, Training and Development, deployment, retention, wellness, gender mainstreaming programmes as a
way of implementing approved the HRH policy. Gender issues need to be included in HRH policies so that gender
disparities in HRH are addressed gradually.

WHO (2010) recommended the strengthening of HRH directorates/departments/units within the Ministries of
Health as one of the strategies of strengthening HRH policy and planning.

You have now come to the end of this unit on human resource statutes and policies. Let’s now review what you
have learnt.

2.6 Unit Summary

In this unit you have learnt about various HR statutes and their functions as well as
the HR formulation and implementation process. In addition we have considered the
issue of employee relations.

Now get ready to start unit 3 on planning for Human Resource for Health.
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UNIT 3: HUMAN RESOURCES FOR HEALTH PLANNING

3.1 Unit Introduction

Welcome to the third unit of the HRH module. In the last unit we discussed human resource statutes and policies
and how the policies are formulated and implemented. . In this unit you will learn about planning for human
resources for health. We shall look at the process and tools used in HRH planning, HRH indicators and workforce
planning. HRH planning process is a vital step in making sure that the policies we discussed earlier become a reality.

3.2 Unit Outcome

By the end of this unit you will be able to effectively plan for human resources for health

3.3 HRH Planning Process

What does planning entail?

Planning involves the process of implementation of the policy, often resulting in the production of a medium to
long term plan Moser (2003). Countries review or develop HRH Strategic Plans (normally 3-5 years) guided by the
HRH policies. Out of the HRH Strategic Plans operational plans normally one year are developed to implement the
policy. The objective of Human Resources for Health Planning is best summed up by the International Council of
Nurses “The objective of HHRP is to provide the right number of health care workers with the right knowledge, skills,
attitudes and qualifications, performing the right tasks in the right place at the right time to achieve the right pre-
determined health targets”

According to the WHO’s Global Strategy for Health Workforce 2030, HRH plans should be costed, financed,
implemented and continually refined to address:

• the estimated number, category and qualification of health workers required to meet public health goals and
population health needs;
• the capacity to produce sufficient and adequately distributed qualified workers (education and effective
regulation policies); and
• the government and labour market capacity to recruit, deploy and retain health workers (economic and
fiscal capacity, and workforce deployment, remuneration and retention through financial and non-financial
strategies).

In the majority of cases the format of the plan is guided by the thematic areas in the HRH Policy as determined by the
country specific situation detailed in the National Health Plan/strategy. Meaningful HRH Strategic plans are based
on evidence from the Human Resource for Health Information System, HRH Country Profiles and Observatories.
Gender should be mainstreamed in all HRH Policies and programmes.

HRH Plan - The WHO (2004) defines an HRH Plan as an overall mapping of at least 3-5 years that contains a detailed
analysis of human resources for health challenges and issues, strategies, objectives and activities likely to solve the
identified priority issues and challenges during the given period.
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Human Resources for health planning – According to the WHO (1978) HRH planning is the process of estimating
the number of persons and kinds of knowledge, skills and attitudes they need to achieve pre-determined health
targets and ultimately health status objectives. Health workforce planning has been defined “As the systematic
assessment of future human resources needs and the determination of the actions required to meet those need.”
Ripley D E (2014)

Workload Indicators of Staffing Need (WISN) – According to WHO, WISN is a management tool that provides
health managers with a systematic way of making staffing decisions in order to manage the valuable resource
effectively.

Most countries struggle to review or develop their health workforce plans due to limited capacity, resources and the
economic environment that make planning difficult. It is important that the HRH strategic Plan provides guidance
as well as availability of the relevant financial, technical and human resources in undertaking health workforce
planning.

Like the review/development of the HRH Policy, the review/development of a Strategic HRH Plan is also headed
by the Human Resources Directorate/Department of the Ministry of Health. This also requires the involvement of
all key stakeholders in HRH as provided for the CCF guidelines developed by WHO. WHO (2006) also provides the
guidelines to be utilized by countries in developing HRH Strategic Plans.

Well done on progressing to this stage. You will now discuss the actual steps in developing and HRH Plan with
strategies for implementation that are shown in Figure 3.1.

Figure 5.3.1: Process for developing the HRH Strategic Plan

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The section briefly discusses each key step of the HRH process.

The following is a summary of the key steps in the process for developing the HRH Strategic Plan

It is important that the major stakeholders with an interest in HRH be involved to ensure buy in as well as raise
awareness of gaps in technical and financial support.

• HR Head in MoH leads the preparatory work – Development of Terms of Reference for the work including
technical expertise if so required.
• Multi-disciplinary/sectoral working group (CCF/HRH Task Force) set up or consulted – the group of key
stakeholders is key in informing the review/development of the HRH strategic plan
• Collecting all relevant documents, HR policy, situation analysis – the Consultant or lead person in the review
of development of the HRH Strategic plan will need to get all the relevant documentation at national, regional
and international level.
• Developing zero draft of HR plan – the zero draft will need to be shared and discussed and presented to
stakeholders for their input.
• Stakeholder inputs into HRH plan – once the stakeholders have made their input the consultant or lead person
consolidates and prepares a revised draft
• Revision of draft with stakeholder inputs – the draft is presented to key stakeholders for their endorsement and
confirmation of accuracy and comprehensiveness of content.
• Costing of final plan led by health economist/planners – It is crucial that the plan be costed by experts so that
the financial input is known.
• Final approval by relevant authorities – approval at the highest level is done by Cabinet if it is taken as a national
document. In other countries, the HRH plan is approved by the Minister of Health.
• Printing and dissemination of plan to all stakeholders –Printing and dissemination is important if the plan is to
be known and implemented. Currently most countries take advantage of technology and share the Strategic
Plan via the net or make it accessible via various websites.
• Implementation and monitoring of plan at all levels – It is important that the HRH plan be implemented at all
levels through planning in line with the Strategic plan.
• Evaluation and revision in last year of plan – The HRH plan will need to be evaluated mid-year after 3 years and
revised for the next 5 years

Most African countries have developed HRH Strategic and operational plans that are either being reviewed and
have been reviewed whilst a few are yet to develop these plans. Countries like Ghana, Sudan amongst others have
developed and uploaded their HRH plans onto the Global Health Workforce Network (formerly the Global Health
Workforce Alliance) website.
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3.4 HRH Planning Tools

As we mentioned earlier, there are a number of tools developed by WHO to assist countries to plan for Human
Resources.

There are various health workforce projection tools most of which are computer aided.
The health workforce tools rely largely on information on available staff and the existing services to make projections
for the future guided by the National Health Plan/Strategy. WHO has a workforce supply and requirements projection
model, a software that can assist in the long-range planning of health personnel? WHO also has a health workforce
model which is a computer based workbook outlining a step-by step process for producing a workforce plan for
use in contexts with small population sizes. The United Nations Development Programme developed an integrated
health model, a spreadsheet application which supports countries in health systems planning by means of costing
all required public resources, including human resources for delivering an integrated package of care under UNDP.
(WHO 2010)

Current models that have been developed and used include Western Pacific Workforce Projection tool, iHRIS
Plan software package tools, trend, regression analysis, meta and econometric analysis as well as the Workload
Indicators of Staffing Needs (WISN). Of all the tools mentioned, the tool that has gained prominence in informing
HRH Strategic Plans in most African countries is WISN.

Before you proceed attempt the following question.

Which tool is used in your country for HRH Planning?

You now know the tools used in HRH planning. Next let us look at HRH financing.

3.5 HRH Financing

Before you reinforce what you already know about HRH financing attempt the question.

Who funds the implementation of HRH plans in your country?

Health financing in detail inclusive of HRH financing will be discussed in detail in module 7.
In most African countries the biggest allocation of the health sector budget from the government goes towards
salaries, yet the countries still do not have the adequate numbers of health workers to respond to the health
challenges in their respective countries. Limited funding towards health and indeed HRH means that the conditions
of service, availability of tools of the trade and conduciveness of the working environment is negatively affected for
health workforce.

There have been calls through the Abuja declaration for countries to allocate 15% of their total budget to health.
Most countries are yet to achieve this target. Most countries have mixed funding for health which in most cases
includes support from the Global Fund, GAVI, other pooled funding and individual donors. The UN family also
complements government efforts by supporting various health programmes including HRH.
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There were calls at the 2012 Conference for Ministers of Health and Finance held in Tunis in 2012 for the need
for both Ministries of Health and Finance to jointly identify and allocate additional resources to the health sector.
(Garbayo AA et al. 2012). The Ministers of Health and Finance agreed to increase financing for HRH to improve
availability, accessibility, acceptability and quality of health care.

The World Health report 2006 and the Global Atlas of the Health Workforce 2012 list major areas to be included in
HRH policies and plans for costing, mobilising and accounting for appropriate funding under two themes
the key issues of “more money for HRH” as
• Increase external aid for HRH;
• Improve planning and targeting of external; aid from in-service training to pre-service training and expansion
of employment capacity;
• Develop better and transparent tracking mechanism for HRH expenditures and donor contributions to HRH;
• Collaborate with the private sector to contribute services to supplement public sector services;
• Utilise Country Coordination Facilitation Process (CCF) for increased investments and improved sustainability
for HRH; and
• Use Labour market analysis and other tools to improve efficiency.

“More HRH for the money”

• Improve skill mix and task shifting to reduce production costs of health services.
• Use health workers from the communities increase rural retention and health outcomes.
• Improve motivation and retention of health workers by implementing appropriately designed financial and
non-financial incentives
• Usage of continuous professional development and performance assessment reviews improve HRH productivity.
• Information and Communication Technology has a positive impact on education and motivation of health
workers.

It is important therefore to have costed HRH Strategic and operational plans to facilitate resource mobilisation or
to assist in the identification of possible support areas and costs thereof.

Now that you have covered the HRH financing, you are ready to move on to the last section of this unit on HRH
indicators.

3.6 HRH Indicators

Workload indicators of staffing needs has gained prominence because of its scientific and acceptable in the health
sector HRH planning.

How is WISN used?

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WISN can be used to determine how many health workers are required to undertake the actual workload at each
level. Managers are able to utilize WISN to estimate staffing requirements to deliver expected services as well as
to calculate workload and time required to accomplish tasks. The WISN results can be used to compare staffing
between health facilities and administrative areas.

The use of WISN has gained popularity in HRH circles as managers have found the tool useful in determining how
best to improve current staffing and this includes redistribution of existing staff. WISN facilitates for the planning
for future staffing needs guided by resource availability, current trends in HRH and service provision which include
redundancy of some posts and creation of new ones.

The WISN tool also assists planners to assess current performance gaps whilst examining the impact of different
employment conditions and staffing. Through WISN study results, managers will be able to assess workload pressure
and allocate staff appropriately.

Do you now understand what WISN is? Good, next we shall discuss in brief the steps in using WISN at country
level.

Steps in using WISN

WISN studies have been done by the HR managers and the committees recommended by WHO teams or by
consultants/experts in WISN. The committees are Experts Working Group (EWG) drawn from relevant professional
bodies, the Technical Working Group (TWG) to implement the WISN study and the Steering Committee to make the
policy decisions. Decisions have to be made at country level on the level and depth of staff categories to be covered
by WISN and facilities to be studied.

Once staff categories and health facilities have been selected the TWG working on its own or with technical assistance
from a consultant needs to determine the resources required to undertake the WISN study. The TWG estimates the
staffing requirements to deliver expected services and calculates workload and time required to accomplish tasks.
With the assistance of the EWG the TWG compares staffing between health facilities and administrative areas and
makes recommendations on either increasing or redeploying of staff for consideration by the Steering Committee
or Ministry of Health’s top management team.

WHO (2016) compiled a list of country experiences in use of WISN for other countries to learn from. Countries
like Botswana, Kenya, Ghana, Namibia, Rwanda, Democratic Republic of Congo have had different experiences in
implementing WISN. Others are still to undertake WISN.

Well done for completing the section on HRH planning and the tools used. Now you have the opportunity to assess
your appreciation of WISN by attempting the case study.
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Scenario/Case study:
Choose any two country experiences on WISN from the following website - [Link]/
hrh/governance/en/
What are the listed benefits of using WISN results in the selected countries.

Congratulations on your effort. I am sure you have amongst your answers the benefits of using WISN in planning
in the different countries and the challenges encountered during the study.

Take Note:
Involvement of key stakeholders is important to informed review/development of policies
and effective implementation of the HRH plans.

You have come to the end of this unit on HRH planning. Let us now review what you have learnt.

3.8 Unit Summary

Congratulations on completing this unit. In this unit you have learnt about the HRH planning
process and the tools used for planning. We have also looked at HRH financing and indicators.

In the next unit we shall discuss functions of HRH management.

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3.9 References and Further Reading

1. MoGCSD, 2005. Gender Budgeting for Lower, Local Governments Trainers Manual for
Uganda Ministry of Gender, Labour and Social Development, Kampala
2. Moser, C.O.N (1993). Gender Planning and Development: Theory, Practice and Training,
Routledge, London.
3. Nyoni Jet al. (2006) Policies and Plans for Human Resources for Health: guidelines for
countries in the WHO African Region. Brazzaville: WHO Regional Office for Africa)
4. Ripley D E (2014) How to determine future workforce needs from [Link]/
articles/how-to-dtermine-future-work-force-needs
5. S.K Singhateh, UNFPA, 2004. Guidelines/checklist for Mainstreaming Gender, Culture and
Human Rights in Planning and Programming Process
6. Sylvia Chant and Matthew C. Gutmann (2002). ‘Men-streaming’ gender? Questions for
gender and development policy the twenty-first century. Progress in Development
Studies 2(4), 269–282
7. WHO (2010), A framework for national health policies, strategies and plans
8. WHO (2016) Workload Indicators of Staffing Need: selected country implementation
experiences. Geneva
9. World Health Organization (2006). World Health Report 2006: working together for
health, Geneva, WHO
10. World Health Organization (2010). Human Resources for Health Observer. Issue no 3
Models and tools for health workforce planning and projections. Geneva, WHO (apps.
[Link]/iris/bitstream/10665/44263/1/9789241599016_eng.pdf, accessed 3 February
2017)
11. WHO 2010, Health Human Resources Planning and the production of health:
Development of an analytical framework for the needs-based health human resources
planning
12. World Health Organization (2010). Workload Indicators of staffing need (WISN) Users’
Manual. Geneva.
13. WHO (2010). Human Resources for Health Observer: Issue No 6. Policies and practices of
countries that are experiencing a crisis in human resources for health: tracking survey,
Geneva
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UNIT 4: FUNCTIONS IN HUMAN RESOURCES FOR HEALTH MANAGEMENT

4.1 Unit Introduction

Welcome to Unit 4 of Module 5. In the last unit you learnt about HRH planning. In this unit we will discuss the
functions of HRH management. In particular, you will learn about employee resourcing, performance management,
reward management, supervision and support, training and development and exit management. Let us start by
reviewing our unit outcome.

4.2 Unit Outcome

By the end of this unit you should be able to perform the functions of HRH in
health service delivery

4.3 Employee Resourcing

Employee resourcing is a strategy is concerned with ensuring that the organization obtains and retains the people
it needs and employs them efficiently. It focuses on identifying (recruitment and selection) of the best people
for employment and retention within an organization. In this sub-unit you will cover recruitment, selection and
retention of HRH which are the components of employee resourcing.

However, before we get deeper into this subject, attempt the following activity on recruitment and selection
practices.

Activity
Name three ways you use in your organization to advertise job openings

Well done! We shall look at the various ways of advertising job openings

Recruitment and Selection

Recruitment and selection are usually used interchangeably. Let us define the two terms;

Recruitment means announcing job opportunities to the public in such a way that a good number of suitable
people will apply for them. It involves locating and attracting adequate human resources to fill existing vacancies.

Selection on the other hand is a process of weeding out the unsuitable candidates and finally arriving at the most
suitable one. It means choosing from that numbers recruited, those applicants who are most likely to succeed in the
jobs. An interview is the most widely used technique for selection.

It is not always the case that every post that falls vacant should be filled. A post
should be filled according to the needs of the organisation.
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Recruitment and Selection Process

Figure 4.1 below summarizes steps in recruitment and selection of HRH. The steps may however vary from one
institution to another.

Declaration of a • user department shall declare the vacant post t o Human

vacant post Resources department

• involves collecting, analyzing and presenting information

Job Analysis about the content of jobs so as to develop a job description,
job specification & performance indicators

• Announcing to potential candidates availability o vacancy.

Advertising this can be done through newspapers, website, recruitment
agency, word of mouth, notice boards etc. Recruitment
sources can be internal or external

• It entails excluding, from the list, those applicants who do

Shortlisting
not have the requisite qualifications or competencies

• Finally the selection panel will identify the most suitable

Final Selection candidate(s) from the shortlist. Most commonly used
selection method is interviews.
• Verifying that applicants are as they presented themselves to be
Reference checks
from past employers/persons known to them
• Communicate the offer of employment to the successful
candidate. The offer letter should include the job
Placement responsibilities, work schedule, rate of pay, starting date and
all the relevant details
• new employee is introduced into his/her job and organization
Orientation

Figure 5.4.1: Recruitment and Selection process

The labour market spreads over the entire globe and an organisation simply draws from a
small fraction of that market.

Activity
Explore the sources of recruitment in your organisation. Is the recruitment source best suited
for your organisation?
Well done, I am sure your answer included the sources discussed below.

There are two recruitment sources which are internal and external sources. Internal source comprises HRH who
are currently holding other positions in the organisation. Recruitment through internal source involves job
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posting, placing the vacancy notice on company bulletin boards, employee publications, and corporate intranets
or anywhere where the organisation can communicate with employees. Internal source provides the following
advantages to the employer:

• It generates employees who are familiar with the organisation

• It reduces unrealistic expectations of the job from the new employees as internal employees have
knowledge of the organisation’s vacancies and their requirements
• Filling of posts by opening up to internal recruitment is cheaper and faster than recruiting from outside the
organisation.

Regardless of the advantages offered by internal recruitment, organisations have good reasons for external
recruitment. Some organisations experience challenges in having a pool of entry level cadres (e.g. Government
Medical Officers) and probably specialised upper-level positions (e.g. specialist doctors) and will need to look from
outside. In this case the organisation may need to use anyone of the following intermediaries:

• advertise the post in newspapers or magazines;

• use both Public and Private Employment Agencies; or
• attract newly qualified graduates from Universities and Colleges.

Studies have shown that bringing outsiders has the following advantages:

• External recruits bring new ideas to the organisation;

• External recruitment brings new ways of doing business. Using only internal recruitment may result in the
organisation ending up with HRH who think alike and are poorly suited for innovation.

For external recruitment organisations usually use referrals, direct applications, advertisements, employment
agencies, schools and websites.

HRH Retention Strategies

HRH retention strategy is concerned with preparing plans for retaining the health workers a health institution/
MOH needs. Retention is ensuring employees stay longer in the organization.

Attempt the activity below.

Activity
As a manager of a functional organisation, what retention strategies would you come up with
for your staff.

Well done for offering those suggestions and now let us look at the various strategies.
A successful strategy should involve a number of integrated factors that need to be successfully combined to
provide the most attractive combination to potential employees.

If the healthcare industry shall retain the HRH it must be committed to creating a working environment that is,
• Rewarding;
• Challenging and satisfying;
• Safe and secure;
• Focused and proactive;
• Fair;
• Equitable; and
• Legislative compliant
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In order to bring the above philosophy to fruition departments dealing with HRH management need to:

• identify, attract, employ and retain employees who are appropriately qualified and have the skills and
experience for the position.
• Ensure that employees are engaged under contracts of employment that contain levels of remuneration,
benefits, terms and conditions of employment that are competitive at national, regional and global level.
• recognise the benefit of a balance between the development and promotion of existing employees versus
the attraction of employees with new experiences.
• assist employees to develop and maintain a balance between family and work.
• promote equal opportunity and recognise diversity in the employment environment.
• identify and resolve issues in an open and timely fashion having regard for the employees’ right to be dealt
with dignity, respect and according to the principles of natural justice.

It should however, be noted that development and implementation of retention strategies for HRH can be at
global, country and organisational levels.

Now you need to appreciate that not all staff is worth retaining.

Importance of Employee Retention

Why is it important to retain HRHstaff?

The following are some of the reasons for retaining staff:

• retaining institutional memory

• avoiding interruption of client service
• stopping more turn overs (if one employee leaves more will want to leave).
• Maintain goodwill of organisation
• enhancing efficiency
• maintaining the limited pool of competent workers

Having mastered the skill of recruitment and selection and retention of employees let us move on and see how
the hired employee can be made assist in achieving organisational goals.

4.4 Performance Management

This section will look at the definition, objectives, cycle, and performance appraisal, tools for performance
management and performance indicators. You will also cover performance appraisal

4.4.1 What is Performance Management?

Performance management is a means of getting better results from the organization, teams and individuals
by understanding and managing performance within an agreed framework of planned goals, standards and
competence requirements. It is the continuous process of improving performance by setting individual and team
goals which are aligned to the strategic goals of the organization, planning performance to achieve the goals,
reviewing and assessing progress, and developing the knowledge, skills and abilities of people.
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4.4.2 Performance Management Objectives

Performance management objectives in any health institution aims at achieving these objectives as outlined in
figure 3.2 below

Figure 5.4.2: Performance management objectives

4.4.3 The Performance Management Cycle

The performance management cycle can be broken down into four major activities:
• performance planning,
• performance coaching and mentoring,
• performance measurement and evaluation and
• performance feedback and documentation.

The performance management cycle is in illustrated below in figure 4.2 below;

Figure 5.4.3: The Performance Management Process (Cycle). Source: Adapted from Nel, Werner,
Haasbroek, Poisat, Sono, and Schultz (2008)
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Now let us discuss each of the stages in detail.

1. Performance planning
Performance management must be adequately planned. Performance planning includes the following processes:

a) Setting the direction of the organisation and defining expectations

The supervisor and employee meet to review the employee’s duties and responsibilities and the criteria that will be
used during the performance evaluation.

b) Determining employee goals and objectives

Standards used to measure the employee’s performance at the end of the performance management cycle are
agreed between supervisor and supervisee. The departmental goals must be aligned with the goals of the employee
in order to facilitate employee “buy-in,” and giving the employee a chance to decide whether the performance goals
are fair and achievable.

Determining the evaluator and the evaluation method to be used. The person conducting the evaluation and
the method to be used must be agreed upon upfront. The basis upon which performance will be measured
and the evidence that will be used to establish the different levels of performance will be agreed.

c) Developing an action plan

The supervisor and supervisee agree on specific times for formal progress reviews towards meeting the agreed
goals. Finally, they draft a document containing all the key points of their discussions, agreement and responsibilities
regarding the achievement of these set goals.

2. Performance coaching and mentoring

During this phase, the supervisor conducts checks on progress, explores causes of poor performance and provides
coaching and mentoring to the employee. The following steps should be included in this stage:

a) Conducting progress reviews

The supervisor engages the subordinate as often as possible in order to get feedback on the level of
performance. It is important that crucial performance constraints are identified early and corrective action
taken before the problems balloon into a crisis and substantial losses are incurred.
b) Exploring causes of poor performance
The supervisor must examine the causes of poor performance among his/her employees. The following possible
reasons may contribute to employee poor performance problems:
• Personal problems such as divorce
• Alcoholism
• Depression
• Lack of enthusiasm
• Lack of competency
• Fear of failure
• Failure to revise knowledge in the job
• Poor time management
• Poor management and
• Job insecurity
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3. Performance measurement and evaluation

In measuring performance, it is important to establish which aspects of an individual’s performance an organisation
needs to measure. During this stage, the supervisor reviews the employee’s performance results, strengths, skills,
and competencies.

4. Performance feedback and documentation

During this stage the supervisor reviews the employee’s performance results, strengths, skills, and competencies.

4.4.4 Performance Appraisals

Performance appraisal is an event concerned with determining how well employees are doing their jobs,
communicating that information to the employees and establishing a plan for performance improvement. It usually
entails periodic review of performance so as to find out how well an employee is performing in comparison with
what is expected. It is the judgment of an employee’s performance in a job, based on considerations other than
productivity alone. Other common terms used for performance appraisal is performance review, performance
assessment and performance evaluation. Appraisals usually occur at the review stage in the performance
management cycle

A number of tools are used by institutions for performance appraisals. These tools include

• Traditional feedback includes essay, critical incident, ranking and checklists

• Contemporary tools include 360 degrees feedback, Management By Objectives (MBO) and Balanced
Scorecard

Descriptions of traditional performance management tools is summarized in figure 3.3 below.

essay Supevosor periodically describes employee

performance at any length

critical Any positive or negative event that occurs out of

incident ordinary is written up andretained for next formal
performance discussion

ranking emplyees in a team are compared and ranked against

each other

checklists Supervisor decribes employee performance by

choosing/ticking against some prepared statements

Figure 5.4.4: Traditional appraisal tools

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Contemporary appaisal tools

a) 360 degree feedback

In this method an employee is evaluated by the supervisor, a peer (co-worker), a junior staff, client, self etc
forming a 360 review/cycle as demonstrated in figure 4.4 below

Figure 5.4.5: Traditional Feedback Versus 360o Feedback

Activity
List the advantages and disadvantages of the 360 degree appraisal method

Compare your answers with the list below.

Advantages of 360 degrees appraisal

1. Offers a more comprehensive view towards the performance of employees.

2. Improves credibility of performance appraisal.
3. Such colleague’s feedback will help strengthen self-development.
4. Increases responsibilities of employees to their customers.
5. The mix of ideas can give a more accurate assessment.
6. Opinions gathered from lots of staff are sure to be more persuasive.
7. Not only manager should make assessments on its staff performance but other colleagues should do, too.
People who undervalue themselves are often motivated by feedback from others.
If more staff takes part in the process of performance appraisal, the organizational culture of the company will
become more honest.
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Disadvantages of 360 degrees appraisal

1. Takes a lot of time and can be complex in administrationExtension of exchange feedback can
cause troubles and tensions to several staff.
2. It requires training and important effort in order to achieve efficient working.
3. It will be very hard to figure out the results.
4. Feedback can be useless if it is not carefully and smoothly dealt.
5. Can impose an environment of suspicion if the information is not openly and honestly
managed.

b) Management by objectives (MBO)

MBO is a systematic and organized approach that allows management to focus on achievable goals and to attain
the best possible results from available resources aims to increase organizational performance by aligning the
subordinate objectives throughout the organization with the overall goals that management has set. Ideally,
employees get strong input to identify their objectives, timelines for completion, and so on. MBO includes
ongoing tracking and feedback in the process to reach objectives

MBO process is summarized by a five-step process as shown in figure 4.5 below.

Figure 5.4.6: The Five-step MBO process

c. The Balanced Scorecard

The Balanced Scorecard is a framework designed to translate an organization’s mission and vision statements
and overall business strategy into specific, quantifiable goals and objectives and to monitor the organization’s
performance in terms of achieving these goals. The Balanced Scorecard stems from the idea that assessing
performance through financial returns only provides information about how well the organization did prior
to the assessment, the Balanced Scorecard is a comprehensive approach that analyzes an organization’s overall
performance in four ways, so that future performance can be predicted and proper actions taken to create the
desired future.

The balanced score card assesses the employee on four areas as described in figure 4.6 below.
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•includes how well the company is doing financially with revenue and
expenses
Financial •in a government hospital this component could be measured on how well
the hospital uses financial resources received from the government as
budgetted, this component cascades down to the various departments

•includes such areas as customer satisfaction, delivery of product and

quick response to customer issues
Customer
•in a government hospital, the health worker will be assessed on increase
in uptake of services like antenatal services etc

•relates to the internal processes the company uses to get the work done
Process •in a government hopital, an employee will be assessed on timely and
quality service to the patient as per guidelines,professional code of
conduct, workplan and service charter

•refers to how much the company has learned and improved during the
years of operation
Learning & Growth •in a government hopital, an employee will be assessed on the knowledge
and skills they acquired in the year including renewal of licensure through
cpd points, growth and promotions, increased responsibilities, etc

Figure 5.4.7: The balanced score card

Which performance management tool/system do you use in your organization?

Now that you have realised that performance management is critical in achieving organisational goals it is now
time to explore the concept of supportive supervision which is also grounded on performance management.

4.5 Reward Management

In the last two section we discussed the different stages and processes of recruitment and selection and
performance management. In this unit we shall cover an types of rewards, characteristics of effective reward
schemes, benefits of reward management and motivation. Let us start with an introduction to reward
management

A sound reward management program has benefits for employers, employees and all other stakeholders
including the economy at large.

Let us define key concepts in reward management.

What is an employee reward?

Employee rewards are all forms of pay or rewards going to employees and arising from their employment.
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Total Rewards include monetary and non-monetary rewards used to attract, motivate and retain employees

Reward Management refers to formulation and implementation of policies and strategies that aim
to reward people fairly, consistently and equitably in accordance to the value they bring to the organization.

Reward management should be consistent, fair and equitable

4.5.1 Types of Rewards

There are two major types of rewards – financial and non-financial rewards. Figure 4.7 below gives a summary
of financial and non-financial rewards

Figure 5.4.8: Types of Rewards

Activity
List any three financial and 3 non-financial rewards implemented in your
organization
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4.5.2 Characteristics of effective reward schemes

Figure 4.9 below outlines some of the characteristics of effective reward schemes

Figure 5.4.9: Characteristics of effective reward schemes

Having learnt the principles of reward management we now move on to the principles of employee motivation at
the work place.

4.6 Employee Motivation

Motivation plays a critical role in achieving goals and business objectives. It is important for both organisations
that work in a team-based environment or in a workplace comprised of workers who work independently.
Ensuring that each employee’s workplace goals and values are aligned with the organisation’s mission and vision
is important for creating and maintaining a high level of motivation. That can lead to higher productivity,
improved work quality and financial gain across all departments.
Motivation has become increasingly important for organisations of all sizes that want to achieve their organisational
objectives in a competitive environment. Helping all employees maintain a high level of motivation can help keep
employees committed to working hard and contributing as much value as possible to the organisation.

Now attempt the following question.

Activity
How do you define workplace motivation?

Well done! Compare the definitions you provided with the ones provided below.

4.6 .1 What is Motivation?

Motivation is defined as follows:
• It is the driving force by which people achieve their goals. It is either intrinsic or extrinsic
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• 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

4.6.2 Work Motivation

Work motivation is the process that initiates and maintains goal-directed performance. Motivation generates
the mental effort that drives us to apply our knowledge and skills. Without motivation, even the most capable
person will refuse to work hard. It prevents or nudges us to convert intention into action and start doing
something new or to restart something we have done before.

4.6.3 Components of Motivation

There are three major components to motivation namely:
• activation,
• persistence and
• intensity.

Activation involves the decision to initiate behaviour, such as enrolling for the course on Governance, Leadership
and Management.

Persistence is the continued effort towards a goal even though obstacles may exist, such as taking more Governance,
Leadership and Management courses in order to earn a degree although it requires a significant investment of time,
energy and financial resources.

Intensity can be seen in the concentration and vigour that goes into pursuing a goal. For example, one student might
pass this module but without much effort, while another student will study regularly, participate in discussions and
take advantage of research opportunities outside of class.

4.6.4 Types of Motivation

There are two main types of rewards namely;
i. Intrinsic
ii. Extrinsic rewards

Intrinsic motivation
This type of motivation arises from within the individual, such as taking nursing as a profession for personal
gratification. Intrinsic motivation is defined as the process of carrying out an activity for its inherent satisfactions
rather than for some separable consequence. When intrinsically motivated a person is moved to act for the fun or
challenge entailed rather than because of the external pushes, pressures, or rewards.

Extrinsic motivation
This type of motivation arises from outside the individual and often involves rewards such as trophies, money, social
recognition or praise. Although intrinsic motivation is clearly an important type of motivation, most of the activities
people do are not, strictly speaking, intrinsically motivated. This is especially the case after early childhood, as the
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freedom to be intrinsically motivated becomes increasingly curtailed by social demands and roles that require
individuals to assume responsibility for no intrinsically interesting tasks.

4.7 Supportive Supervision

What is 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. Supportive supervision assists the subordinate
in growing professionally to meet organisational goals.

Beyond simply overseeing employees’ responsibilities and tasks, managers can play a key role in making their
employees feel supported and motivated and, as a result, more productive. Particularly in challenging environments
where resources are scarce and the needs of the community are vast, making employees feel valued and supported
is essential. Supportive supervision is a key way to achieve this. By employing supportive supervision, managers can
not only create a healthy work environment, but can improve and sustain the performance and satisfaction of their
most valuable asset: the people in their organization.

Is supportive supervision conducted in your organisation?

4.8 Employee Relations

Employee relations offers consultation, facilitation and resolution strategies for workplace issue. Employee
assist in communication between employees and supervisors, corrective action and planning, disciplinary
actions and explanations/clarifications of policies and procedures.

The employment relationship existing between an employer and an employee may be regarded as the core of
Employee relations.

According to Salamon (2000) employee relations encompasses a set of phenomena, both inside and outside the
workplace, concerned with determining and regulating the employment relationship. The subject deals with the
different historical and cultural forms of this relationship and the social mechanisms, institutions and laws which
regulate and control the relationship.

Workplace issues handled may include industrial conflicts that may arise due to
• Physical working environment
• Remuneration packages
• Management philosophy and style
• Any threats to security of tenure
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Dissatisfaction at work can be caused by one or a combination of factors.

Attempt the following question and write the answer in your note book before moving to the next section.

Activity
Taking your organisation as a case study state the major causes of
employee dissatisfaction.

Thank you for successfully completing sub unit 3.4. We now proceed to Unit 3.5 which looks at employee
wellness.

4.9 HRH Wellness

This section will look at the definition, pillars and benefits of HRH wellness.

What is an employee wellness?

Employee wellness is an organized, employer-sponsored program that is designed to support employees (and,
sometimes, their families) as they adopt and sustain behaviours that reduce health risks, improve quality of life,
enhance personal effectiveness, and benefit the organization’s bottom line.

Employee wellness should be strategically and integrated to improve and promote health and fitness in the work
place.

There are six pillars that simultaneously support the success of wellness programs:
• Multilevel Leadership
• Alignment
• Scope, Relevance, and Quality
• Accessibility
• Partnerships and
• Communications

Benefits of Employee Wellness Programmes

Attempt the activity below on wellness programmes benefits

Activity
List the benefits derived from well managed wellness programmes which you are
familiar with.
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Well done. Now compare you answers with the benefits outlined below.

The following are some of the benefits which may be derived from well managed employee wellness
programmes. They could be for the employee and the employer:

For the employee:

• Weight reduction
• Improved Physical Fitness
• Increased stamina
• Lower level stress
• Increased well-being, self-image and self esteem

For the employer:

• Enhanced recruitment and retention of health employees
• Reduced healthcare costs
• Decreased rates of illness and injuries
• Reduced employee absenteeism
• Improved employee relations and morale
• Increased productivity

Activity
List the benefits derived from well managed wellness programmes which you are
familiar with.
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4.10 Gender Mainstreaming

This section discusses the role of gender mainstreaming in managing HRH. Now let us define some of the
terms commonly used when defining gender.

Sex:- This represents the genetical, biological and physical identity of a person. All people are born male or females
but they grow up to become boys and girls. However, being male or female is universal to everybody regardless of
race, religion, ethnicity and nationality

Gender:- Refers to socially constructed identity, roles, norms, behaviors, activities and attributes that a given society
considers appropriate for men and boys, women and girls.

Gender mainstreaming:- The process of assessing the implications for women and men of any planned action,
including legislation, policies or programmes, in any area and at all levels. It is a strategy for making the concerns and
experiences of women as well as of men an integral part of the design, implementation, monitoring and evaluation
of policies and programmes in all political, economic and societal spheres, so that women and men benefit equally,
and inequality is not perpetuated.

The ultimate goal of mainstreaming is to achieve gender equality.

Mainstreaming includes gender-specific activities and affirmative action, whenever women or men are in a
particularly disadvantageous position. Gender-specific interventions can target women exclusively, men and
women together, or only men, to enable them to participate in and benefit equally from development efforts. These
are necessary temporary measures designed to combat the direct and indirect consequences of discrimination.

Gender mainstreaming requires both integrating a gender perspective to the content of the different policies, and
addressing the issue of representation of women and men in the given policy area. Both dimensions – gender
representation and gender responsive content - need to be taken into consideration in all phases of the policy-
making process.

It also entails bringing the experience, knowledge, and interests of women and men to bear on the
development agenda. It involves identifying the need for changes in that agenda such as changes in
goals, strategies, and actions so that both women and men can influence, participate in, and benefit
from development processes. The goal of mainstreaming gender equality is thus the transformation
of unequal social and institutional structures into equal and just structures for both men and women.

There are various gender mainstreaming principles which include:

• Identification of issues and problems across all area(s) of activity should be such that gender differences
and disparities can be diagnosed.
• Establishment of adequate accountability mechanisms for monitoring progress.
• Assumptions that issues or problems are neutral from a gender-equality perspective should never be made.
• Gender analysis should always be carried out.
• Clear political will and allocation of adequate resources for mainstreaming, including additional
financial and human resources if necessary, are important for translation of the concept into practice.
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• Gender mainstreaming requires that efforts be made to broaden women’s equitable participation at
all levels of decision-making.
• Mainstreaming does not replace the need for targeted, women-specific policies and programmes,
and positive legislation; nor does it do away with the need for gender units or focal points.

Gender mainstreaming addresses gender inequalities in society through policies.

You have successfully completed the section on gender mainstreaming which gave you insights into what
gender mainstreaming is and the various principles of gender mainstreaming. Let us now look at how to manage
employee exit.

4.11 Exit Management.

This section looks at how to manage health worker exit.
Exit management is the process within organisations dealing with the termination of service. It can be voluntary
and involuntary.

Voluntary exit – If the employee initiates the termination process when the employer still wants the employee to
stay, this is called voluntary exit. Examples include employee leaving to take a job elsewhere – resignation and early
retirement.

Involuntary Exit - When termination is initiated by the organisation this is involuntary exit. In most instances there
is a reason for the termination e.g. economic, discipline and change in government.

When managing the employee exit process remembered that both types of
termination are costly to the organization.

Table 5.4.1 Effects Associated with Turnover . Source: Noe R.A. (2009)
Involuntary Termination Voluntary Termination
Recruiting, selecting and training replace-ments Recruiting, selecting and training replace-ments

Lost productivity Lost productivity

Lawsuits Loss of talented employees
Workplace violence

Exit management is a good practice in HRHM but is not compulsory. Now let us take a look at the process of exit.

The exit interview is an important tool for HR when determining employees’ satisfaction index. In keeping abreast
with the levels of employee engagement all employees who leave the service should be able to participate in this
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interview. However, it is encouraged that we must leave them free to participate or not in this exit interview. The
following forms some of the questions which may be contained in an exit interview questionnaire:

• What was the most satisfying aspect of your work?

• What was the least interesting aspect of your work?
• What would you change in your job?
• To improve our work environment, what changes would you make?
• Do you have any advice to help us find a good candidate to replace you?

In ending an exit interview it is good practice to

• End the interview on a positive note
• Retrieve the objects allocated to the employee
• Thank the employee for his/her years of service within the organisation

Thank you for successfully completing your study of Unit 3 of Module 5. We hope the information in this unit will
assist you in your day-to-day management of HRH.
You have come to the end of this unit. Let us now review the important points that we covered this module.

4.11 Unit Summary

In this unit you discussed HRH resourcing, performance management, reward

management, employee relations, employee wellness, gender mainstreaming in HRH
and exit management.

4.12 Unit References and Further Reading

1. Deci E. L & Ryan R. M. (1985). Intrinsic Motivation and Self-Determina-tion in

Human Behaviour. New York: Plenum.
2. Fallon (Jnr), L.F. and McConnell, C.R. (2014). Human Resource Man-agement in
Health Care: Principles and Practice. Burlington: Jones and & Bartlet Learning
3. Gellerman S. Management and Productivity (1963). New York: American
Management
4. Lawler.E.E. Pay and the Organisational Effectiveness (1971). New York: MacGraw-
Hill.
5. McCourt W. and Eldridge, D. (2003). Global Human Resource Man-agement:
Managing People in Developing and Transitional Countries. Northampton:
Edward Edgar Publishing, Inc.
6. Noe.R.A. [Link], (2009). Fundamentals of Human Resource Management. New
York: McGraw-Hill
7. [Link]
[Link],
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UNIT 5: HUMAN RESOURCES FOR HEALTH TRAINING AND DEVELOPMENT

5.1 Unit Introduction

Welcome to unit 5. In module 4, you learnt about functions of HRH management. In this unit you will learn
about HRH training and development. In particular, you will learn how to conduct employee induction and
orientation, education, training and development. The purpose of this unit is to enable you manage HRH
training and development process

5.2 Unit Outcome

At the end of this module you will be able to manage training and development process
effectively

Let us start with a brief introduction on what HRH training and development is all about.

5.3 What is HRH Training and Development?

Human Resource Training and Development (HRD) is a set of systematic and planned activities designed to
provide HRH with the necessary knowledge, skills and attitudes to meet individual and organizational goals
as well as current and future job demands. HRD comprises organized learning activities within an organization
aimed at:
• improving performance and;
• personal growth for the purpose of improving the job, the individual, and the organization

Continuous learning and development activities in an organization ensure a continued supply of highly qualified
workforce. It is therefore important for an organization to create a learning culture which encourages both individual
and organizational learning.
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HRD starts when an employee is recruited in the form of induction and orientation. Continuous learning takes place
throughout the stay of the employee in the organization in form of:

• education
• training and
• Development programmes.

Induction and orientation, Education, Training and Development are the four components of HRH training and
Development. Let us now discuss each of these components in detail. We shall start with induction and orientation.

Take Note:
Components of HRH training and development are:
• Induction and orientation
• Education
• Training
• Development

5.3.1 Induction and Orientation

Induction is a process where a new employee is introduced (welcomed) to the institution/organization and
work environment. This includes a session where the new employee is taken through the mission, vision,
policies and expectation including reporting/leaving time, working hours, dress code etc.

Orientation on the other hand is a well-designed programme aimed at helping a new employee adjust faster and
easily to the new organization. It includes familiarizing new employee with their work unit/department, role and
work culture and helps in integrating the employee in the new organization. This means orientation takes a longer
time

Both the supervisor and co-workers play crucial roles in orientation of employees. Specifically:
• A supervisor serves as an information source and also as a guide for new employees
• Co-workers on the other hand socialize the new employee into organization and help them learn norms of
the work group and organization

During an orientation the person conducting the orientation:

• Gives information to a new employee
• Clarifies duties and responsibilities
• Communicates work expectations
• Provides all required resources
• Introducing new member to co-workers
• Assists new employee to touring work facilities
• Provides assistance where need be in executing tasks/allocates a co-worker to assist the new employee
where need be in executing tasks

Having learnt what induction and orientation is, carry out the activity below .
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Activity:
As a supervisor in a health institution explain four benefits of a well-designed
orientation programme

Well done for attempting the activity above. I am sure some of your answers included the benefits of a well-
designed orientation programme listed below:

• Helps reduce stress and anxiety of new employees

• Reduces workplace accidents
• Enables new employee fit in the culture of the organization faster
• Improves productivity by communicating to the employee the expectation and providing support and
required resources
• Enhances employee retention
• It serves as a motivational tool for new employees
• Enhances employer image

Let us now look at Education which is the second component of HRH training and development.

5.3.2 Education
Education is a systematic learning usually enabling a learner to develop a sense of reasoning and judgement.
Education usually prepares one for future job(s) by furthering their knowledge and occurs in an institution.

Learning goes hand-in-hand with education. Learning is a process where one acquires new knowledge, skills and
competencies; it is also an outcome where demonstrates knowing something they did not know before. It is a
continuous process which enhances existing capabilities as well as development of new skills and knowledge in
readiness for future roles and responsibilities.

Education programmes usually take longer time to complete and are mainly academic in nature. In Kenya for instance
a Diploma program takes a minimum of two years while undergraduate degree takes minimum of four years for
fresh secondary school leavers. Education programmes require minimum entry requirements for learners to join/
enrol to them. Examples of education programmes include; Diploma and degree courses in nursing, pharmacy,
project management, medicine, community health, nutrition, human resource management etc.

The two main types of education programmes are:

i. Pre-service
ii. In-service

Pre-service education is one provided to a future/potential health worker before they practice the chosen profession.
Example: when a student completes secondary school, he/she may opt to join medical school to do a degree course
in medicine with the hope of being a medical doctor in future.
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In-service education is one provided to health workers who are already practicing their various professions and
would like to enhance their knowledge and skills academically. Example: a pharmacist with a bachelor’s degree may
enrol for master’s degree in pharmacy.

Having learnt about education, let’s now look at training as the third component of HRH training and development

5.3.3 Training
Training is the use of systematic and planned instruction activities to promote learning (Armstrong, 2006). It
involves the use of formal processes to impart knowledge and help people to acquire the skills necessary for them
to perform their jobs satisfactorily. Training addresses deficiency in job skills revealed through low performance.
Training in an approach an organization can utilize so as to promote learning.

Having learnt about education and an introduction on training, attempt the question below:

Identify two differences between education and training

Well done learner! I believe you identified the differences shown in figure 5.1.

Figure 5.5.1: Difference between education and training

Before engaging employees in training; it’s important for any manager to know what competencies
respective employees lack. It is therefore important to have a plan showing what, when, who and why a
training is needed. A training needed assessment will give the reason as to why the training is needed while a
training plan will show what to train in, when and who to train.

Let us now look at training needs assessment and training plans

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Training Needs Assessment (TNA) and Training Plans

Any training within an organization must aim at improving the knowledge, skills and competencies of human
resources in order to improve performance. Training needs assessment (TNA) is a systematic identification of
training needs within an organization. TNA therefore, serves as a diagnostic tool in identifying which individuals
and teams to train and also which areas to train the individuals and teams in.

A training plan is a schedule showing the training which employees need to undertake over a specific period of
time in efforts to address training needs revealed by TNA.

Why should an organization conduct a TNA?

A TNA gives organization-wide training and development requirements. This is essential in preparing a training
plan. Specifically TNA will enable an organization to:

• Identify the gaps between and required current skills, knowledge and competencies.
• identify the content for a training
• develop a training plan
• form basis for evaluating a training plan
• maximize use of resources

To identify training needs; current level of performance must be compared to desired level of performance. If
current performance is lower than desired performance then a performance gap results as shown in figure 5.2.

Figure 5.5.2: Identification of training needs

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Training needs = Desired capability - Current capability

TNA is a tool used to identify training needs.

Training is not always the solution to underperformance. It is therefore important

to carry out an objective TNA so as to justify the need for training or otherwise.

We have noted that it’s not only training which leads to low performance. There are other factors. Before we discuss
them, answer the question below in your note book.

Activity
Name three other factors besides lack of required knowledge, skills and
competencies could be attributed to low performance of a health worker?

Congratulations for naming the factors! I am sure you answers included the following:
• Lack of resources
• Poor leadership
• Unrealistic targets
• Lack of supportive supervision
• Unclear expectations

Now let us look at the steps in training needs assessment and planning;
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Training Needs Assessment & Planning Steps

Training needs assessment and planning occurs in a series of steps as summarized in figure 3 below;

Step 1: Determine the desired health institution Step 2: Link Desired Outcomes With Employee Behavior
outcomes
• Identify the desired critical competencies, (behaviors and
•The training goal should correspond to a health associated knowledge, skills, abilities & personal characteristics)
institution objective that are linke to desired health institution outcomes
•Objective can be specific to an individual • Data may be collected through interviews, focus groups or surveys.
employee, team or the entire institution data collected should reveal importance of each compency in
achieving desire outcome

Step 3: Identify Trainable Competencies Step 4: Evaluate Competencies

•Determine whether employees have the critical competencies.
•Evaluate critical competencies in step 2
•This can be done using Competency evaluations; and Tests or
required by employees
assessments.
•From the competencies identify trainable
•Performance evaluation surveys are best used to evaluate
competencies
observable behaviors. Supervisors perform the evaluations

Step 5: Determine Performance Gaps Step 6: Prepare a Training Plan

•Set standards for performance Prioritise training needs for individuals, teams and organization
•Measure employee performance and as a whole basing on the importance of the training needs in
determine whether it matches the desired achieving desired outcomes.
performance
•identify training needs

Step 7: Plan for the training Step 8: Conduct a Cost Benefit Analysis
Cost the training plan according to the training •Establish whether the training bridges the
budget performance gaps and evaluate against the cost of
Determine how best to train the employees as per the training
training plan (training methods)

Step 9: Training Evaluation

•Conduct a training evaluation to establish
whether the training actually bridged the
competency gaps identified

Figure 5.5.3: Training needs assessment & planning steps

Next you will see the various training methods which can be used to train employees
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Next you will see the various training methods which can be used to train employees

Training Methods

Training methods can either be classified either as:

• On-the-job i.e done within the work environment /as part of work or
• Off-the-job i.e training outside the work environment

On-the-job training methods

On-the-job training methods refer to new or inexperienced employees learning through observing co-workers or
managers performing the job and attempting to imitate their behaviour. Different on-the-job training methods
are described in figure 3 below;

• Trainee receives a one-on-one training from an experinced

Mentoring professional. It is long-term and ongoing relationship
focusing on personal and/or career development

• Trainee receives a one-on-one training from an experinced

Coaching professional. It is short-term and task-oriented in nature. It
enables a trainee focus on a specific task where he/she is
experincing difficulties

• Training by moving employees through a series of related

jobs. The employee thus receives job knowledge and gains
Job Rotation
experience in the different jobs. Example a nurse may
rotate between out-patient, in-patient, out-reach and
specialised services (e.g pediatrics, ophthalmic, dental)

• This is a work-study training method with both on-the-job

and classroom experinces. it is also known as internship or
Apprenticeship field practicum. students undertaking an education
programme are attached to a 'real work' environment so as
to apply the knowledge and skills learnt in their course.

Figure 5.5.4: On-the-job training methods

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Off-the-job training methods are refer to situation where the trainee learns outside the work environment. Figure
5 below describes off-the-job training methods

• Exposes trainees to replica/mirror of real scenarios at the work

Simulation place. Simulations represent real-life situations; with trainees’
decisions resulting in outcomes that mirror what would happen if
they were on the job. Example: demonstration of first aid on a
manikin for nursing students

• The trainer delivers the training using spoken words. Traditionally

Lectures lectures are one-way, however this has changed over the years
with increased use of audi-visuals and student presentations

• Trainees act out job roles assigned to them. For instance one
Role Playing trainee may act out a a supervisor and the other one a sub-
ordinate and act out a work place scneario e.g summoning the
sub-ordinate for coming late to work repeatedly

• Are descriptions of a work place scenario usually presenting a

Case Studies management problem and the learner is expected to analyse the
case, deduce prblems and suggest probabale solutions to the
identified problem.

• It is also known as in-tray method. An institution's memos, e-

In-basket method mails, minutes, reports, letters etc are printed and placed in a
tray/basket. The trainee is expected to pick a document
randomly and make decisions with regard to the issue at hand.

Figure 5.5.5: Off-the-job training methods

Take Note:
eLearning is a mode of delivery of learning and not a training method. Other delivery
modes are face-to-face, mLearning and blended learning (combination of face-to-face &
eLearning)

Having learnt about training, let’s now look Development which is the last component of HRH training and
development

5.3.4 Development
Development is concerned with ensuring that a person’s ability and potential grows through the provision of
learning experiences or through self-directed (self-managed) learning (Armstrong, 2010). It is a process that enables
people to move from a current state of understanding and capability to future state where higher skills, knowledge
and competencies are required.
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It is important to note that development entails both personal and career development championed by both the
organization and individual employees. A number of development initiatives exist in an organization; they include:

i. career development
ii. professional accreditation
iii. Succession planning.

Career Development
Career development focuses on identifying individual employee interests, values, competencies, activities and
assignments needed to develop skills for future jobs (development). Career development includes both individual
and organizational activities (Gilley, Eggland, & Gilley, 2002). Figure 5.6 below shows the individual and organizational
career development activities

Individual activities
• Career planning - continually ensuring job fits with
personal values, interests, skills & prefernces
• Career awareness - expanding knowledge of possible
career paths
• Utilization of career resource centres - offer career &
employment counselling, workshops, seminars..

Organizational activities
• Job Postings - includes appointments, transfers,
deployments...
• Mentoring - guidance to less knowlegable/experienced
staff
• Career Counseling - help employees know and understand
self & work
• Career Development Seminars & Workshops
• Human Resource Planning - plan to ensure adequate
supply of required workforce at all times
• Career Pathing - showing employees possible higher roles
they can take up in future & the competencies, personal
characteristics, performance and experince required to
progress along the various paths

Figure 5.5.6: Career development Activities

Which organizational career development activities described in figure 5.6 do you utilize in
your institution to develop your employees?

I. Professional Accreditation

Professional accreditation of health workers is a requirement in a number of African countries. Professional

accreditation also known as professional certification is certification earned by a person as proof of qualification to
practice a given profession. The practice in many countries for professional accreditation is that one must:

• Have pre-requisite academic/professional qualifications

• Earn minimum number of continuing professional development (CPD) points for the given period of
accreditation
• Practice their professional as per laid down code of conduct (practice)
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Professional accreditation is important in regulating a profession as it standardizes professional code and

also ensures continuous learning/updating of knowledge, skills and attitudes. If executed well, professional
accreditation raises the standards of practice in a profession.

Attempt the activity below and write your answers on your notebook

Activity:
Identify one profession in health in your country that has a professional accreditation policy/
framework/guidelines and;
How it is CPD in the profession regulated? Are there any major successes/failures? Any best
practices?
Discuss any 3 benefits and 3 challenges of professional accreditation of health workers

II Succession Planning

According to Armstrong (2006), succession planning is the process of assessing and auditing the talent in the
organization in order to answer three fundamental questions:

• Are there enough potential successors available – a supply of people to continually fill key positions in the
longer term?
• Are they good enough?
• Do they have the right skills and attributes for the future?

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 in key positions leave the organization.

When the size and organisational resources permit, the succession plan should provide guidance and
development of those already employed by the organization. Employees whom the management believes have
the knowledge, skills and experience and who wish to have more responsibility, can be trained to fill specific key
positions

In succession planning, organisations should:

• assess their present and future HRH needs based on their plans, strategic goals and objectives, or
their priority programmes and projects
• develop a plan to fill the vacancies of those in authority who leave or are promoted
• develop capabilities of existing employees to meet future needs
• fill key positions that fall vacant with employees already prepared for the positions
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Figure 5.5.7 below shows the steps an organization may adopt in succession planning

Figure 5.5.7: Steps in Succession

Planning Attempt the questions below

What are the:

Benefits of good succession planning?
Challenges in succession planning?

Well done! Now compare your responses to the benefits and challenges in succession planning described below;

Benefits of good succession planning

Any institution which invests in succession planning will enjoy a number of benefits which include;
i. Increases the level of employee engagement through career planning, a challenging work, training and
development, career advancement and development horizontal
ii. Improves the capacity of the organisation to achieve its business objectives through pools of qualified
candidates for positions and key sectors
iii. Allows managers to better appreciate the capabilities and skills, experience, diversity, language skills and
interest in learning of their employees
iv. Prevents the loss of institutional memory when employees leave the organisation
v. Facilitates the achievement of the goals of official languages and
​​ employment equity through targeted
development initiatives
vi. Allows for cost savings through the creation of a more committed and productive workforce
vii. Creates a public service more efficient and effective in the long run
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Challenges in succession planning

Despite the numerous benefits an organization will enjoy by implementing succession plans, there are a number of
challenges that may affect this. The challenges include:

• 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
• 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

Take Note:
Emphasis on continuous(life-long) learning through education, training and
development is critical for success of any institution.

5.4 Unit Summary

Congratulations for successfully completing unit 5. In this module you covered the
four components of HRH training & development which are;
• Induction and orientation
• Education
• Training, and
• Development
In the next unit you will cover HRH Audits.
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5.5 Unit References and Further Reading

1. Armstrong, M. (2006). A Handbook of Human Resource Management Practice.

10th Ed. London: KoganPage
2. Greenberg, C. I. (2016). How to conduct a Training Needs Analysis. Retrieved
February 3, 2017, from Xpert HR: [Link]
conduct-a-training-needs-analysis/6716/
3. Fallon F & McConnel C R (2014) Human Resources Management in Health
Care- Principles and Practice
4. Fallon (Jnr), L.F. and McConnell, C.R. (2014). Human Resource Management in
Health Care: Principles and Practice. Burlington: Jones and & Bartlet Learning
5. Noe. R.A. [Link], (2009). Fundamentals of Human Resource Management. New
York: McGraw-Hill
6. Gilley, J. W., Eggland, S. A., & Gilley, A. M. (2002). Principles of Human Resource
Development. Cambridge: Basic Books.
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UNIT 6: HRH MONITORING AND EVALUATION

6.1 Unit Introduction

Welcome to unit 6 on Human Resources monitoring and evaluation. In the previous unit you covered HRH training
and Development. In this unit you will learn about Human Resources Health monitoring and evaluation. This will be
effectively done through the use of human resources for health information systems(HRHIS), country health profile
and health observatories. The purpose of this unit is to acquaint you with the important concepts and steps in HRH
audits for decision making.

6.2 Unit Outcome

By the end of this unit you should be able to conduct HRH monitoring and
evaluation.

6.3 HRH Audit

A HRH audit is a comprehensive method to review current HRH policies, procedures, systems and documentation
to identify needs for improvement and enhancement of the HRH function as well as compliance with ever
changing rules and regulations (Ulrich, 1997). It involves systematically reviewing information from HRHIS and HRH
observatories against HRH indicators.

Audits should focus on unbiased examinations and evaluations of HRH systems and processes if they are to be useful
at country level. Whether conducted internally (by employees of the organization) or externally (by consultants), an
audit of HR systems can help you do the following:

• Demonstrate that management complies with board policies on treatment of staff.

• Ensure that your HR practices comply with country laws.
• Find improvements you could make in administrative [Link] for expansion and growth by
taking your HR systems to the next level.

The following approaches are adopted for purpose of evaluation:

• Comparative approach: Managers identify a competitor organization as the model. The results of their
organization is compared with that organization.
• Outside authority approach: The auditors use standards set by an outside consultant as benchmark for
comparison of own results.
• Statistical approach: Statistical measures for performance are developed considering the company’s
existing information.
• Compliance approach: Auditors review past actions to calculate whether those activities comply with legal
requirements and industry policies and procedures.
• Management by objectives (MBO) approach: This approach creates specific goals, against which
performance can be measured to arrive at final decision about organization’s actual performance with the
set objectives.
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In HRH audits, managers gather data from HRH Information Systems, observatories and other HRH documentation
which have specific indicators for tracking progress. Information from the audits ultimately informs HRH decision
making.

Next we can define some key concepts commonly used in HRH audits as defined by WHO (2009).

Data:- Characteristics or information, often numerical, that are collected through observation. Data can
be considered as the physical representation of information in a manner suitable for processing, analysis,
interpretation and communication. Data can be:

• Qualitative- Qualitative data is descriptive information

• Quantitative - Quantitative data is numerical information.

Indicator:- A parameter that points to, provides information about or describes a given state. Usually represented
by a data element for a specified time, place and other characteristics, it gives value as an instrument used in
performance assessment.

Monitoring:- a constant process of collection and use of standardized information for Verification of progress
towards defined objectives, use of resources and degree of achievement Results and impacts. It normally involves
verification according to indicators and objectives of Results. Together with information on evaluation, monitoring
and Notifications, decision-makers and stakeholders should be given the Need to verify whether the implementation
and results of a project, program or project as planned and to manage the project on a regular basis.

Monitoring is also giving a return on the project to its employees, implementers and beneficiaries. Reporting allows
all gathered information to be used in decision-making for the improvement of project performance.

Evaluation:- The systematic and objective assessment of an ongoing or completed initiative, its design,
implementation and results. The aim is to determine the relevance and fulfilment of objectives, efficiency,
effectiveness, impact and sustainability. The development of an evaluation framework entails consideration of a
range of matters, including identification of the types of data that could inform an evaluation.

Take 5 minutes and respond to the questions below on your note book.

Activity
What is the difference between data and information?

Well done!

Having looked at an introduction to HR audits, you will next look at sub-unit 1 on Human Resources for Health
Information System (HRHIS)
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6.4 Human Resources for Health Information System (HRHIS)

Human Resources Information System (HRIS) is used to collect, record, store, analyze and retrieve data about the
human resources of the organization and their respective activities. Human Resources for Health Information
System (HRIS) is used to collect, record, store, analyze and retrieve data about the human resources for Health and
their respective activities.

Dearth of reliable HRH information in most African countries makes planning difficult for decision makers at various
tiers of the health system. Human Resource information and data collection are fragmented and incomplete, with
various stakeholders collecting and collating bits and pieces in the absence of any common data source or human
resource management information system.

This greatly reduces the ability of decision-makers to access and use accurate and timely data to improve the
effectiveness and efficiency of the workforce, which is critical in order to meet national health objectives. An
improved Human Resources for Health Information System (HRHIS) is an essential tool needed to improve HRH
policies as well as workforce planning and development.

There are two basic goals for having the employee information system. These are:

• Administrative, that is, reduce costs and time of information processing.

• To provide decision support, that is, to assist managers and employees in making effective decisions.

Now respond to the questions below on your note book.

Activity
List 5 benefits of having a functional HRHIS.

Well done, now compare your responses with the discussion below

The analysis and strengthening of national HRH information systems are intrinsic components of efforts to
strengthen databases on health personnel. An evaluation of the capacity of a country’s HRH information system to
support the decision-making process may include the following:

• Relevance of the system;

• Validity of the information contained in the system;
• Compatibility between sources of information (allowing comparisons within and between countries and
over time);
• Level of fragmentation of information within the system, in order to allow in-depth analysis of Issues
relevant to HRH strategic planning.
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Importance and uses of HRHIS

• Education and Training – to make sound decisions about education and training, quantity and type
• Registration – to ensure qualified supply
• Deployment – to meet needs
• Management – of personnel; tracking movements,
• Planning – future needs
• Advocate for more workers
• “De-ghost” the payroll, by ensuring that former employees do not continue to receive payment
• Address mal-distribution of existing workers
• Track health workers who are leaving and determine why they leave, where they go, what they actually do
when they get there
• Influence policies on staffing norms, recruitment, deployment, career path development and continuing
professional development.

Now attempt the activity below

Remember it is not enough to collect information, but it is important to use for

decisions.

Well done for completing sub-unit 1, you will now look at sub-unit 2 on HRH observatories.

6.5 HRH Observatories

A National HRH Observatory is a platform where key HRH stakeholders from all sectors concerned interact on HRH
matters in addressing the HRH challenges in the country with the use of valid and reliable HRH information (WHO,
2012). The objective of the Observatory is to provide opportunity for stakeholders to jointly review and monitor HRH
situation and strengthen the HRH Information System (HRHIS) as well as to attain collective view and coordinated
efforts for HRH development in the country. HRH observatories can help managers to:

• Gather, analyse and disseminate data and information

• Monitor the health workforce and labour market
• Carry out research and knowledge production
• Advocacy and the facilitation of policy dialogue and policy development
• Capacity development

HRH Country Profile provides information on country specific HRH information which is useful in HRH
observatories. HRH country profile is a good instrument for HRH observatory in designing effective policies,
programs and interventions to maintain competent HRH for effective delivery of health services.

HRH country profile is a reference document giving the HRH situation in a country. It is designed to assist health
sector managers and policy makers including partners in taking decisions that may require statistical evidence on
the current situation and trends of health workforce in the country. WHO
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HRH country profiles main components include:

• Country context – demography, health status
• Country health system
• Health worker situation – distribution, age, stock, trends
• HRH production
• HRH utilization
• Governance of HRH

The data sources which feed the observatories, country profiles and HRIS can be generated from:
• Population census
• Labour force surveys
• Health facility assessment
• Health worker training institutions
• Civil service registry payrolls
• Professional and regulatory body registries

Having looked at HRH observatories, carry out the activity below

Activity
Follow the link below and choose a country’s profile to evaluate the HRH situation. In your
own opinion does the HRH situation in the profile project the current health worker status in
that country? [Link]

Congratulations on completing this section, you will next look at HRH indicators.

6.6 HRH Indicators

There are core indicators for HRH analysis which reveal what needs to be monitored and evaluated in HRH.
Effective monitoring and evaluation of HRH in countries requires agreement upon a core set of indicators at the
subnational, national and international levels to inform decision-making among national authorities and other
stakeholders.

Monitoring and evaluation processes involves identification of key indicators and can be managed at different
levels. The credibility and objectivity of monitoring and evaluation depends very much on the evaluating team.
Sometimes managers use monitoring and evaluation interchangeably yet they are distinct although interrelated
as shown in figure 5.1.
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Figure 5.6.1: Differences between M & E

The ongoing and consistent measurement of these indicators allows monitoring of how HRH-related
programmes and policies are being implemented. Once the baseline data have been generated, an evaluation
framework can be established with periodic targets for analysis in terms of change and progress over time, that
is, whether activities have been implemented in the right direction in accordance with the original plans and
strategic objectives.
Table 5.6.1 Selected key indicators for monitoring and evaluation of human resources for health

Indicator Description Numerator Denominator Measurement/comparability issues

Basic indicators of HRH stock and distribution
Stock (and density) Total number of health human Total number of health workers in a (Total population of the same Definition and boundaries of HRH, such as
of HRH resources (relative to the population) given country country) by occupation (e.g. physicians, nurses, etc.),
industry or training – with distinction between
headcounts versus job positions
Skills mix Distribution of HRH by occupation, Number of physicians, nurses and Total number of health workers Occupational classification – with distinction
specialization or other skill-related midwives (or other categories of health between headcounts versus job positions (with
characteristic service providers) positions weighted for full-time equivalency on
the basis of working hours)
Geographical Distribution of HRH by geographical Number of health workers in rural areas Total number of health workers Definition of rural (or other geographical
distribution location (or other epidemiological, administrative delimitation)
or economic region)
Age distribution Distribution of HRH by age group Number of health workers of a given Total number of health workers
age group
Gender distribution Distribution of HRH by sex Number of female (or male) health Total number of health workers
workers
Indicators of HRH labour activity
Labour force activity Proportion of HRH currently active in Number of persons with health-related Total number of persons of Occupational/educational classifications as well
rate the labour force skills active in the labour force working age with health-related as age range for labour force eligibility
skills
Employment/ Proportion of HRH currently Number of persons with health- Total number of persons with Definitions of labour force participation and
unemployment rate employed (or unemployed) related skills currently employed (or health-related skills active in employment status
unemployed) the labour force
Industrial sector Distribution of workers by industry Number of persons employed in health Total number of persons Industrial classification
of activity services industry currently employed
Institutional sector Distribution of health workers by Number of health workers employed Total number of health workers Definition of operating authority of the place of
sector of activity in the public (versus private or work
nongovernmental) sector
Dual employment Proportion of HRH currently Number of health workers currently Total number of health workers
employed at more than one location employed at more than one location
Continues…
Indicator Description Numerator Denominator Measurement/comparability issues
Occupational Average occupational earnings and Total income from labour over a Total number of health workers Distinction between net/gross income, sources
earnings and income among health workers given period (from wages, practice or of income, non-monetary benefits, as well
income business) among health workers as definition of reference period for income
reporting
Indicators of HRH productivity
Absenteeism Days of absenteeism among health Number of days of employee absences Total number of scheduled Delimitation and reporting of causes of
workers over a given period in the health working days among absenteeism (e.g. duty absence, sickness or
workplace employees over the same other emergency leave, maternity or parental
period in the same place leave, unauthorized absence)
Provider Relative number of specific tasks Specific tasks performed over a Total number of specific tasks Delimitation of tasks in terms of quantity/quality
productivity performed among health workers given period (e.g. ambulatory visits, performed over the same
immunizations, surgeries) by a given period among all health service
health service provider providers
Indicators of HRH renewal and loss
Workforce Ratio of entry to the health workforce Number of graduates of health Total number of health workers Educational classification as well as processes of
generation ratio professions education institutions in the professional credentialing/ deployment for new
last year graduates
National HRH Proportion of nationally trained Number of health workers who received Total number of trained health Occupational/educational classifications across
self-sufficiency health workers their professional training in the workers in the same country the country of origin and receiving country for
reference country foreign-educated workers
Workforce loss ratio Ratio of exits from the health Number of health workers who left the Total number of health workers Delimitation and reporting of reasons for exit
workforce active labour force in the last year (e.g. retirement, mortality, out-migration, career
break or change)

Source: WHO (2009)

Having looked at HRH indicators, carry out the activity below.

Activity
Identify 4 indicators that are used for monitoring HRH in your country.

You have now come to the end of this section on HRH indicators. You will now look at on HRH data for decision making
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6.7 HRH Data For Decision Making

One of the major misconceptions about effective use of HR data in decision-making might be summed up as follows:
“Build or gather data and they will use it”. There is now sufficient experience to know that it is not enough to make
data available. Therefore, health system planners and decision-makers need to be educated about the information
contained in their systems in order to utilize it for asking questions and then making decisions based on the informed
answers.

Data-driven decision-making (DDDM) is an on-going collaborative process of making informed HR policy and
management choices based on appropriate analysis of relevant data and information. Evidence-based decision-
making is not a onetime solution or a standard tool to be applied ad hoc or at random. Rather, it is an ongoing
knowledge-driven process that requires continuous collection, analysis and sharing of data, because that is the only
way in which trends—both positive and negative—can be discovered and acted upon (Doyle, 2002).

DDDM is divided into three functional areas:

• Collection, integration and dissemination of data

• Regular analysis, quality review and reporting of data procedures for acting on the data to influence policy
and practice.

The way in which data are gathered and presented can also influence decision-making and policy formulation.
Compelling data that have been gathered, synthesized and disseminated with a strong advocacy tends to capture the
attention of senior decision makers as opposed to data shared in the form of routine reports that are only distributed
in management meetings or one department. Accurate HRH information can be used as a road map for organizations
to proactively address challenges or opportunities in a rapidly evolving and complex HR market place.

There are ten fundamental pillars to aid HR managers, practitioners and policy analysts in building a bridge from HR
data and reports to effective HR policy and management decisions:

1. Making Use of the Data: Health sector leaders need a process in place for analysing reports and information,
getting it to the right decision-maker at the right time, and ensuring the power and resources to act on the data.
If this process is faulty, DDDM can produce uninformed (and incorrect) decisions or shift the focus away from
priority issues.
2. Developing a Culture of Inquiry: Effective data utilization requires a mindset that actively invests in a culture of
inquiry that helps people question the status quo.
3. Context Matters: The context is the overall environment or setting in which HR data are being gathered, analyzed
and used to make policy and management decisions. It is important for HR planners and managers to understand
the various dimensions and determinants of the context within which data are used to make decisions, as it is
essential for effective policy-making and practice
4. Aligning Different Forces, Interests and Beliefs: HR information is obtained from multiple sources. These
connections and relationships will need to be acknowledged and aligned by HR planners and managers for the
decision-making process to be fruitful. Otherwise, there is potential for conflict, paralysis or failure to use the data.
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5. Preparing for Data Skeptics: Data users determine the usefulness of a data set by asking such questions as: What is
new here? How is this different from what we already know or have?

6. The Power of the individual: Individuals are key participants in decisions about how data should or should not be
used, as it is individuals who decide whether to accept or reject new data findings.

7. The Power of the Organization: Several organizational factors bear on the decision- making process: The extent to
which new ideas are welcomed by management figures, and the kind of support available for innovation of action. The
extent to which data can generate perceptions of legitimacy, an environment of trust and collaborative partnerships
among different players within the same organization and among the various organizations that needs to work.

8. Navigating Difficult Conversations: From time to time data will produce instances that involve difficult conversations
within a team or organization that can cause instability or chaos. This normally happens when new data challenge a
particular status quo or policy issue that has been in place for a long time, in ways that lead to differences in opinion
among team members.

9. Process and Relationships: the nature of relationships between the potential data users within an organization is one
of the most critical dynamics determining success or failure. However, this dynamic is often underestimated or even
overlooked in the process of DDDM.

10. A Journey, Not a Destination: DDDM it is an ongoing knowledge-driven process that requires continuous collection,
analysis and sharing of data, because that is the only way in which trends—both positive and negative—can be
discovered and acted upon.

DDDM is a dynamic, collaborative process; it is a core function that must be embedded into the ethos of ministries of
[Link] planners and managers need to lead this journey and act as agents of change.

Congratulations! You have come to the end of this unit and indeed the end of this module. Let’s first review what you have
learnt in this unit.

6.8 Unit Summary

In this unit you have learnt that a HRH audit is a systematic process of reviewing
information from HRHIS and HRH observatories against HRH indicators. In addition
we have discussed HRH observatories and their uses, HRH indicators which reveal
what needs to be monitored and evaluated, and how to make effective use of HRH
data for decision making.

You have come to the end of this module on Human Resources for Health. In the next module you will learn about
Health Management Information Systems. You can now take a well deserved break before you attempt the following
self assessment test. Good luck!
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Module References

CORE REFERENCE MATERIAL: Training Manual

Fallon F & McConnel C R (2014) Human Resources Management in Health Care- Princi-
ples and Practice
Global HRIS Strengthening: IHRIS software suite – IHRIS Plan: Workforce planning and
modelling software [Link]
[Link]
[Link] [Link]
ance/forum/en/
WHO (2012) Human Resources for Health Observatories: contributing for policy deci-
sions based on evidence
McQuide, P., J. Stevens, and D. Settle, Technical Brief 12: An Overview of Human Re-
sources for Health (HRH) Projection Models. 2008, Capacity Project: Chapel Hill, NC.
[Link]
WHO (2006) guidelines on HRH Policy Development and Planning;
WHO, (2006) The world health report: Working together for health, Geneva
WHO (2009) Handbook on Monitoring and Evaluation of Human Resources for Health
(2009)
WHO, (2016) Global Strategy on Human Resources for Health: Workforce 2030, Gene-
va
WPRO/RTC Health Workforce Planning Workbook (2001) and spread sheet[Link]
[Link]/[Link] book(.
html)
 AMREF HEALTH AFRICA HEADQUARTERS
PO Box 27691-00506, Nairobi, Tel: +254 20 6993000
Fax: +254 20 6009518 E-mail: info@[Link]
Website: [Link]