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Management in Health

Module 01Part 1: Introduction and Strategic Planningand Strategic Management World Bank Institute

Presentation Script

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Management in Health Module 01: Introduction and Strategic Planning and Strategic Management - Part 1 Presentation Script

Welcome Welcome to the course on health management. The course is intended to provide useful information and management tools for people working in sub‐national health units – the health department of a city or town, for example, or the district or regional health office. Other professionals in the health sector (whether managers or not) are also likely to benefit from the course and find it useful. This first module begins with a very brief introduction to the overall course, and then discusses strategic management and planning.

Objectives This first module begins with a very brief introduction to the overall course, and then discusses strategic management and planning. By the end of this module you will be familiar with the topics of the other modules of the course and how they fit together. We begin this module with the role of government in the health sector and why it needs to intervene. We then introduce strategic planning and strategic management as approaches for the public health sector to define and achieve goals. We explain two tools to help with strategic planning, and also discuss the purpose and value of monitoring and evaluation.

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Course Modules The course has six modules, each looking at a basic management function, from the perspective of a sub‐national health system. It aims to provide valuable material and practical tips and tools for strengthening your managerial skills. We greatly value your candid and detailed feedback in order to improve the modules and ensure they meet the needs of health managers and others working in health systems. As noted, this first module covers Strategic Planning and Strategic Management. Module 2 on Organizational Behavior provides tools and tips for managing people. The Financial Management module (number 3) concentrates on managing money, discussing sources of financing, and budgeting skills. The Information Systems module (number 4) describes the importance of information for managers, outlines a systematic approach to developing information systems, and provides examples of how modern technology can improve the efficiency and usefulness of information systems. In Module 5 on Communications you will learn how to communicate more clearly and effectively, and build skills in listening and delivering your message. The sixth module is on change management. People often resist change, but there are ways to help make people more open and accepting, and willing to embrace new and potentially better ways of delivering health care. If done well, change management can greatly improve the acceptability of health sector reforms, and hence their success or failure.

Strategic Planning and Management – Module Agenda

The main topic of this module is strategic planning and strategic management ‐‐ key functions of a health manager in the public sector. But first, we will consider the special roles that the public sector must take on because they are important for society but will not be done by the private sector. Then we

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will introduce strategic management and planning. As health personnel, we all want our work to make a real difference in the well‐being of our clients; additionally, the funders and voters to whom we are accountable increasingly demand better results. Achieving results requires efficient public management.

Public agencies need to develop a capacity for strategic management, which is the management process that integrates all major activities, functions and resources, and directs them toward achieving organizational goals. Strategic management implies and requires that there is a strategy. So the third topic in this module is to discuss strategic planning, which is the process of developing a strategy. A good strategy is one that enables a manager and his or her team to work efficiently towards the important goals they have set, to monitor progress, and if progress lags, to recognize this quickly, and take action to get back on track. We note the importance and value of monitoring and evaluation, and explain the difference between them, before ending the module with a quick recap. We would like to note that this course is not prescriptive and does not advocate any particular management model. The authors understand that local context varies around the world; the goal of this course is to give you tools that will improve your management skills and allow you to manage more effectively and strategically.

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The Role of Governments In your country, what are the relative sizes of the private and public sectors in health? The percentage of all health services provided by the public sector, and financed from the public purse, vary considerably across countries, and the balance that is “right” or “best” is hotly debated in some countries. Much of the debate rests on ideology rather than evidence, and we need not take up the controversy here. But it is generally agreed that because private sector entities must make profits in order to stay in business, there are some services they will not provide. Market failures create crucial, special roles for the public sector to fill. Governments are especially needed to address externalities, provide public goods, and to reduce inequity and poverty. We will take a minute to explain each of these roles in the slides that follow. Of course, the non‐profit sector – including NGOs and faith‐based organizations – can, and in many countries do – help fill these roles. (We should also mention a fourth very important government responsibility, which obviously is not within the scope of this course – we rely on governments to provide a framework for economic growth and stability, and for law and order. And of course you will be able to think of many other important roles that governments fill.)

Why Governments Need to Intervene: Externalities

An externality is a side effect or consequence of an action that affects a “third party” (not directly involved in the action). These external consequences can be positive or negative. For example, immunization’s positive externality is that it also protects people not immunized by lowering overall disease incidence. Good nutrition in a pregnant woman has the positive externality of a healthier baby. Cigarette secondhand smoke is a negative externality for people who breathe in the smoke particles, as are other kinds of pollution. These examples mostly concern individual behaviors. But large externalities

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also can arise from organizations’ decisions and actions. For example, a hospital (or other organization) might save costs by disposing of untreated waste, but the resulting pollution would have high costs for society. The pursuit of profits can have strong negative externalities. An example would be very high prices for patented anti‐retroviral drugs to treat HIV, putting them out of reach for most people living with HIV. Typically, externalities are not taken into account in decisions, so private costs and benefits (the costs and benefits for the person or organization taking the decision) can be very different from social costs and benefits (the total costs and benefits of the action to all those affected), and lead to undesirable, suboptimal outcomes for society. When governments step in to increase activities with strong positive externalities – like immunization, and decrease activities with negative externalities – like smoking, society is better off.

Why Governments Need to Intervene – Provide Public Goods

Public goods are things that can be used by one person without reducing the amount available for others, and which, once provided, are difficult to exclude people from using. A classic example of a public good is clean air. My breathing does not reduce the amount of air left for everyone else to breathe (unless we are in a very confined space). And it would be very hard to exclude some people from breathing the air, or charge them for doing so. So the private sector would have no incentive to invest in clean air, because they would not receive any return on their investment. (You will notice the link between this public good and the concept of externalities – many public goods have positive externalities.) Public health information is another example of a public good – once we have invested in research, produced information, and put it into the public domain using mass media, although its easy to think of ways to charge for access to information through some media, one person getting and using the information does not “use up” any of it.

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Why Governments Need to Intervene – Reduce Poverty, Impure Equity

Most people consider that the public sector is responsible for social justice, by striving for fair opportunities and treatment for all. Some regard health care as a human right to which all are entitled, at least to the extent that it is affordable by society. Without government intervention, only the wealthy are likely to be able to pay for quality health care. Furthermore, illness is one of the main factors causing or worsening poverty. And poor people generally have poorer health status and greater health care needs. This makes government intervention to ensure access to at least basic health care important. Obviously, people have very different health care needs, which leads to a useful distinction between equality and equity. Equal treatment implies the same for everyone. Equity involves fairness and value judgments, and takes account of differing needs and circumstances. One criteria for equity in health is that people with similar levels of need should have similar health care, and those with greater needs should get more care.

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Governments Help Ensure Health Care for the Poor Of course, public resources are limited relative to all the competing priority needs. So the public sector may choose to target public resources to the poor who are seldom covered by health insurance and are least able to afford health care. Private‐for‐profit providers have little incentive to establish health facilities in areas where poor people live. The Government can intervene by providing health services directly, contracting private providers to provide them, or structuring subsidized insurance or other financing schemes. Subsidized voucher programs have proved popular and effective in some countries. In these programs, people pay affordable small amounts for a voucher which entitles them to specific services such as pre‐ and post‐natal care and attended delivery. They present the voucher at the provider of their choice, who is reimbursed at an agreed rate. This enables services and beneficiaries to be targeted well. Without good targeting, it is often the case that higher income people are more likely to use services, and the benefits of public funding can thus go disproportionately to the wealthy. In order to participate in the program, providers must meet quality standards and be approved, which gives them an incentive to improve their services. Higher quality services benefit all patients, whether covered by the program or not. Please refer to the list of resources for the url for an 8 minute “you tube” video describing the safe motherhood voucher program in Kenya – one example of a targeted, subsidized program to ensure priority health services for poor women and their infants.

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Strategic Planning and Management But how does a city or district or provincial health authority decide that its going to design and implement a special targeted program, or define and tackle some other priority, and then go about doing it successfully? Ideas, decisions, commitment and action can come about in all sorts of ways. One systematic way is through strategic planning and management, in which managers analyze data and set priorities and targets – creating a vision for the future, and then figure out how to realize that vision, developing plans and procedures, and following through by “managing for results” to ensure that the targets are met. Strategic planning is the first part of strategic management. But plans are only the beginning – they must be implemented. Strategic management ensures that the resources and processes are aligned to enable plans to be carried out successfully. It also entails monitoring progress and costs, making changes and improvements as needed and evaluating outcomes. Sometimes people use the terms strategic management and strategic planning as if they are the same thing, but we prefer definitions of strategic management that encompass strategic planning, as well as the decisions and day‐to‐day operational management of people, resources and processes through which plans are implemented, monitored, reviewed, and adjusted.

One Model of Strategic Management

There are many different models of strategic management, but the basic elements are common. This diagram is taken from a Handbook on Strategic Management for Senior Leaders written for the US Navy. As you can see, Strategic Planning is a core part of strategic management. This model also includes pre‐planning, implementation, resource allocation and measurement and evaluation. Pre‐Planning” could include analytic work to compile data needed for planning, or efforts to ensure that key stakeholders support the

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work to develop a strategic plan. For example, you may want to develop a strategic plan to tackle the three main causes of premature mortality in your region, or to improve the health indicators which are worst in your area relative to the rest of the country, or the health indicators with the greatest disparities between low and high income groups. A pre‐planning step would be to compile the data on the health challenge, ways that others have tacked it, and suggestions from providers and patients. Before beginning work on a plan, there needs to be clarity on the plan purpose and scope. Once the strategic plan is completed, it needs to be communicated (which this model calls “deployment”) and then carried out. Implementation involves resourcing the plan, putting it into action, and managing those actions. Strategic management also includes measurement and evaluation of the results ‐‐ tracking implementation actions, collecting and analyzing data on progress and impact, and communicating those results to all stakeholders. Of course resources need to be allocated, managed and monitored for all these aspects.

Strategic Planning

Lets look a little more closely at strategic planning and strategies. Strategic planning has been defined as a disciplined effort to take fundamental decisions and actions that shape and guide what an organization is, what it does, and why it does it. Strategic planning is a "big picture" approach that:

• identifies and responds to the fundamental issues facing an organization;

• takes account of external trends and forces that are likely to affect the organization and its mission;

• attempts to be politically realistic by taking into account the concerns and preferences of internal and external stakeholders;

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• relies heavily on the active involvement of senior‐level managers and sometimes elected officials, assisted by staff where needed;

• is action oriented, stressing the importance of developing action plans for implementing strategies; and

• focuses on actions and results. A major danger – and a common problem ‐‐ is spending a lot of scarce time and resources on strategic planning but then not actually implementing the strategy. Some strategies are completely unrealistic, or cannot be funded. Sometimes so much time is spent developing a strategy that there is hardly even time, energy and resources to do routine things, let alone to implement the strategy. So remember that above all, strategic planning is action‐oriented.

1. Analyze Evidence

A key early step in strategic planning is to analyze the relevant data and evidence. So, for example, in developing an HIV strategy, it is essential to understand who is being newly infected and the transmission mechanisms for new infections. If most new infections are among injecting drug users or sex workers (or both), then prevention and outreach efforts must target and work with those populations and their sex partners. If, on the other hand, most new infections are occurring among couples in which one person is HIV‐positive, then a very different prevention approach and focus is needed. The strategic plan should state clearly and concisely the main data on which strategic decisions rest.

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2. Define the Vision ‐ Set Objectives, Targets

The Abiye Safe Motherhood program was sparked by data. The newly elected governor of Ondo state in Nigeria learned that Ondo’s maternal mortality rate was among the worst in the country, despite the fact that this lush, oil‐rich state produces more professors per capita than any other state! He decided to make preventing maternal and child deaths a priority, and to try and ensure that no more women would die as a result of childbirth. This illustrates a key part of strategic planning – to define the vision or overall goal, and the specific objectives or targets that will help make the vision a reality. When the governor of Ondo talks about this program, he describes the vision as being that no more women should die as a result of pregnancy and childbirth. As you can see in this slide, the vision statement of the new maternity hospital that was build in the state as part of the program is couched as a concrete, time‐bound, quantified objective of achieving Millennium Development Goals 4 and 5.

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3. Select Actions ‐ Prioritize, Choose and Cost Once visions and overall goals are defined, strategic planning must decide how to set about achieving them. In Ondo, the strategic planning identified four delays implicated in most maternal deaths – delay in deciding to seek care, delay in reaching a facility, delay in being seen once at the facility, and delay in being referred when needed. Then the strategic planning came up with ways to tackle all the delays, including trying some innovations. For example, to deal with the delay in seeking care, community meetings informed people about the services available and importance of using them, and all pregnant women were registered. Then trained ‘Health Rangers’ were each assigned 25 pregnant women, whom they visit in their homes each week, giving advice on nutrition and malaria prevention, and checking for danger signs of possible complications. A little training and practice overcame initial reluctance to ride motorbikes. Another innovation is to lend each registered pregnant women a cell phone with toll‐free access to ‘Health Rangers’, and health facilities. Health facilities were renovated and some new ones built to fill large gaps in coverage, including a tertiary care maternity hospital. Vehicles were bought to ensure good transport to facilities and for referral. To improve availability of supplies in all facilities, “supply packs" were developed for normal, complicated and C‐section deliveries – which cut pilfering of supplies from the average very high level of 20‐30%. To cope with shortages of doctors, "task shifting and sharing" assigned many new tasks to nurses, such as all post‐operative care for C‐sections, and all discharges, leaving doctors free to operate all day. Patients are discharged quickly, freeing beds and reducing wait times. And the state found the resources to provide maternal care free.

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