Health Systems Management

MPH Ist Year

Health Systems Management

Prabesh Ghimire


MPH 1st Year

Table of Contents UNIT 3: CONCEPT OF HEALTH SYSTEMS MANAGEMENT..................................................................... 4 Introduction to health care system ............................................................................................................ 4 Health care systems and its relationship with nature of state ................................................................... 6 Health Planning ......................................................................................................................................... 8 Participatory Approach/ Decentralized Planning Process ...................................................................... 11 Logical Framework Analysis ................................................................................................................... 13 National Development Periodic Plan ...................................................................................................... 15 UNIT 4: INTRODUCTION TO PERSONAL AND INTERPERSONAL SKILLS ........................................... 16 Team Work and Team Development ...................................................................................................... 16 Decision Making and Problem Solving ................................................................................................... 17 Leadership............................................................................................................................................... 18 Negotiation Skills ..................................................................................................................................... 18 Time Management .................................................................................................................................. 19 Stress Management ................................................................................................................................ 20 Delegation of Authority ............................................................................................................................ 22 Conflict Management .............................................................................................................................. 22 UNIT 5: STRUCTURE AND FUNCTION OF HEALTH SYSTEM ............................................................... 24 Factors affecting the health system of a country .................................................................................... 24 Critical Appraisal of the MOHP Organizational Structure ....................................................................... 24 District Health System ............................................................................................................................. 28 Critical Review of National Health Policy-2014 ....................................................................................... 30 Nepal Health Sector Programme (NHSP- III) ......................................................................................... 31 Sector-Wide Approach ............................................................................................................................ 33 Assessing and Managing Organizational Change .................................................................................. 33 Concept of Learning Organization .......................................................................................................... 35 Total Quality Management in Health Care .............................................................................................. 36 SWOT Analysis ....................................................................................................................................... 37 Performance Management in Organization ............................................................................................ 38 UNIT 6: HUMAN RESOURCE MANAGEMENT ......................................................................................... 40 Human Resource Management .............................................................................................................. 40 Evolution of Human Resource Management .......................................................................................... 40 External Influences on HRM ................................................................................................................... 41 Current Situation of HRH in Nepal .......................................................................................................... 42 Issues in HRH Development ................................................................................................................... 43

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HRH Planning and Projection ................................................................................................................. 44 Interrelationship among planning, production and utilization (management) in HRH Development ...... 47 Importance of Career Development and Quality Assurance .................................................................. 48 Quality Assurance in Health Care ........................................................................................................... 50 Situation of HRH in Various Plans of Nepal ............................................................................................ 50 Introduction to Human Resource Information System (HURIS) ............................................................. 52 UNIT 7: INFORMATION MANAGEMENT SYSTEM AND THEIR USE ...................................................... 53 Information Management System in Nepal ............................................................................................. 53 Health Management Information System................................................................................................ 55 Logistics Management Information System ............................................................................................ 57 Logistics Management ............................................................................................................................ 58 Logistics Management System of Nepal............................................................................................. 59 Logistics Management Cycle .................................................................................................................. 60

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UNIT 3: CONCEPT OF HEALTH SYSTEMS MANAGEMENT Introduction to health care system Concept of Health Care System WHO has defined a health system as "all organizations, people and actions whose primary intent is to promote, restore or maintain health". This includes efforts to influence determinants of health as well as more direct health improving activities. A health system is more than the pyramid of public owned facilities that deliver personal health services. It includes, for example, mother caring for a sick child at home, private providers; traditional practitioners; health insurance organizations; BCC programmes, occupational health and safety legislation. Aims/ Goals of Health System: Four major goals of health system are i. Health - Improving population health is the overarching goal of health system. - Health status should be measured over the entire population and across different socioeconomic groups. - The safety of populations must be protected from existing health risks and emerging health risks. - There should be preparations for resilience to future but still unknown health risks. - Health systems should strive for equity in health. Inequitable disparities in health are to be minimized. ii. -

Social and financial risk protection in health An ideal health system will provide social and financial risk protection in health and be fairly financed. All health systems must be financed, and there must be adequate funding in the system to provide essential services.

iii. Responsiveness and people centredness - Responsive and people-centredness represent the concept that the health system provides services in the manner that people want or desire and engages people as active partners. - Responsive health systems maximize people's autonomy and control, allowing them to make choices, placing them at the centre of the health care system. iv. Improved efficiency - Improved efficiency is also a desired outcome of a health system. - People and populations have legitimate expectation of receiving the maximum health gain for the money they and their society invest in health. - There are large variations in health care costs across the world, even among countries with similar socioeconomic status and similar health outcomes. Part of the cariation can be attributed to the efficiency of health systems. Functions of Health System i. Stewardship (oversight) ii. Financing (collecting, pooling and purchasing) iii. Creating Resources (Investment and training) iv. Delivering services (provision)

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Components/ Building Blocks of Health Care System There are six building blocks of a health care system as proposed by WHO i. Service Delivery - In any health system, good health services are those which deliver effective, safe, quality personal and non-personal health interventions to those who need them, when and where needed, with minimum waste of resources. - The service delivery building block is concerned with how inputs and services are organized and managed, to ensure access, quality, safety and continuity of care across health conditions, across different locations and over time. ii. -

Health Workforce A country's health workforce consists broadly of health service providers and health management and support workers, both at public and private sectors. In any health system, a well-performing health workforce is one which is competent, responsive, efficient and productive to achieve the best health outcomes possible, given available resources and circumstances.

iii. Information - A well-functioning health information system is one that ensures the production, analysis, dissemination and use of reliable and timely information by decision makers at different levels of the health system. - It involves three domains of health information; on health determinants, on health systems performance and on health status. iv. Medical Products, Vaccines and Technologies - 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. v. -

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Financing 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. Health financing systems that achieve universal coverage in this way also encourage the provision and use of an effective and efficient mix of personal and non-personal services.

vi. Leadership and Governance - The leadership and governance of health systems, also called stewardship, is arguably the most complex but critical building block of any health system. - This involves overseeing and guiding the whole health systems, private as well as public, in order to protect the public interest. - Leadership and governance involves ensuring strategic policy framework exists and are combined with effective oversight, coalition-building, the provision of appropriate regulation and incentives, attention to system-design and accountability.

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Health care systems and its relationship with nature of state i. -

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Free Market/ Privatized/ Consumer Sovereignty Model Free market approach to health system is an economic strategy that essentially allows supply and demand to drive fees and prices for goods and services, all with least state intervention. Providers are allowed to charge whatever the market will bear for services. The free market model applies when the state undertakes a policy of non-interventionism and restricts its interference in health care matters to the bare essentials, leaving the rest to private funding and corporate provision (e,g, health maintenance organizations, or HMOs). Within the free market, health care delivery systems rely on four major sources of payment: public programs, government-owned health care systems, third party insurance reimbursement through either state employer-sponsored or private insurance, and private pay, individuals who are billed directly for their service usage. The basic assumption of this approach is that funding and provision of care is best left to market forces. These types are most clearly represented by the United States, Australia, but many systems predominantly contain some elements of this type.

Advantages: - Advocates of free-market healthcare contend that systems like single-payer healthcare and publicly funded healthcare result in higher costs, inefficiency, longer waiting times for care, denial of care to some, and overall mismanagement. Disadvantages: - Healthcare as an unregulated commodity invokes market failures not present with government regulation. - Individuals with pre-existing conditions would in some cases not be able to afford healthcare. - Hospitals providing unreimbursed charity care might face bankruptcy. - Selling health care as a commodity leads to both unfair and inefficient systems with poorer individuals being unable to afford preventive care. ii. -

Welfare State The second basic type of health system with state involvement is the welfare state model. A welfare state is a concept of government in which the state plays a key role in the protection and promotion of the social and economic well-being of its citizens. Although there is significant variation as to organization, this type is based on the concept of social solidarity and characterized effectively by a universal insurance coverage generally within the framework of social security.

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Health Systems Management -

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As a rule, this compulsory health insurance is funded by a combination of employer and individual contributions through non-profit insurance funds, often regulated and subsidized by the state. The welfare state involves a transfer of funds from the state, to the services provided (e.g. health care), as well as directly to individual (benefits). The provisions of services tend to be private, often on a fee for service basis, although there may be some public ownership of factors of production and delivery. Consumer pays according to the capacity to pay and not according to what he/she consumes. Germany, Japan and the Netherlands are viewed as examples of this type. Some Nordic countries such as Iceland, Sweden, Norway, Denmark etc. employ a system known as Nordic welfare state Model. Compared to other welfare state models, the Nordic model is characterized by universalism, which means that entitlements to social benefits are based on residence instead of specific need, employment relationship, or other conditions. Furthermore, the Nordic model favours extensive public participation in various areas of economic and social life to promote equality of the highest standard whereas other models are satisfied with covering basic needs. In Nordic model of health care, there is widespread public ownership or control of the delivery of health care services. Furthermore, these health care services focus on achieving geographical and social equity.

iii. Socialist Model - The third, most centralized systems model, the soviet socialist model was invented by Shemasko and dates from 1920. - It is characterized by a strong position of the state, guaranteeing full and free access to health care for everyone. - This is realized by the state ownership of health care facilities, by funding from the state budget (taxes), and by geographical distribution and provision of services throughout the country. - Health services are fully hierarchically organized. They are provided by state employees, planned by hierarchical provision, and organized as hierarchy of hospitals, with outpatient clinics (polyclinics) as lowest levels of entrance. - Among the nations that, until recently had a health care system based on the Socialist model were Russia, Belarus and some of the countries in Central and Eastern Europe. - Many former socialist states are in a process of transition toward a social insurance based system. - The Chinese health care system created in 1949, was also a typical example of now largely extinct twentieth century communist societies. By the early 1980s the Chinese government virtually dismantled it. Its way of financing was dramatically changed by reducing government's investments, the imposition of price regulation, and the decentralization and under-financing of its public health system. China now has a private health care system.

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Comparison of different health care system/ nature of different health care systems Model

Free Market (US, South Africa, Switzerland etc.)

Welfare State (Germany, Netherlands, Japan, UK) Socialist State (communist countries; former Eastern Europe, Cuba)

Definition of Health Care Health care as a commodity Health care as guaranteed, statesupported consumer service Health Care as state provided public service

Role of the State Weak (except for specific groups); providers are mainly private entrepreneurs

Funding

Budget Control

Strengths

Weakness

Private and state/ federal government financing

For profit insurers and government

Providerfriendly, professional, autonomy, flexibility

Consumerism, high costs, fragmentation, unequal access and uninsured

Strong: controls and finances facilities

Taxation

Ministry of health

Equal access to comprehensive services

Bureaucracy, underfunding, rigidness

Very strong; owns facilities pays providers directly

Government funding

State/party

Full and equal access, low costs, full coverage

Bureaucratism, rigidness, corruption

Health Planning The orderly process of defining health problems, identifying unmet needs and surveying the resources to meet them, establishing priority goals that are realistic and feasible, and projecting administrative action, concerned not only with the adequacy, efficacy and efficiency of health services but also with those factors of ecology and of social and individual behaviour that affect the health of the individual and the community. Health planning is the identification and elaboration (within existing resources) of means and methods for providing in the future, effective health care relevant to identified health needs for a defined population. Rationale - To effectively plan delivery of effective health services to the population within provided resources. - To translate new policy statement into operational plan. - To address the emergence of new problems Types of planning Based on the managerial hierarchy, planning can be classified into three main types i. Strategic planning (grand planning) - It is long term planning for five years or more. - It is done by top management (e.g. MoH, DoHS). - It provides long-term direction and scope to the organization. - E.g. second long term health plan. ii. -

Tactical planning It is middle term planning from one to five years. It is done by middle management for divisional or departmental activities (e.g. regional health organizations).

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Operational planning It is short term planning generally, annual, quarterly or monthly. It is the action plan for each functional unit (HP, SHP, PHCCs). It is prepared by lower management.

Process of health program planning i. Review of national policy and guidelines - It is the overall process of familiarization with government directives and conditions that must be followed in preparation of health plans. - The overall goals, objectives and guidelines set out by national health policies, long-term, periodic and annual plans need to be reviewed. ii. -

Analysis of present status of the programme After reviewing national goals and objectives, it is necessary to observe a three year national, regional and district level trends of major indicators of health programme.

iii. Situation analysis - Situation analysis is the process of analyzing and interpreting all information available from various sources of information on current situation of health programmes in a particular area. - Following things should be taken into consideration in analyzing the situation of the health programme. • Time/ seasonal variation • Place/ institution wise distribution • Community/ group-wise distribution • Resources (human, finance, logistics & physical resources) • Organizational condition • Strengths, weakness, problems & constraints. iv. Identification of problems - Based on situation analysis, it is possible to identify major health problems, their weaknesses, problems & constraints. - This helps in determining which program is to be planned. v. -

Prioritization of problems We cannot solve all the problems at a time because of limited resources. Hence, the problems that are more important are selected for the programme. Following things should be taken into consideration in prioritizing health problems. • Targeted towards population • National priority • Availability of resources • Community participation • Magnitude (DALYs burden) • Budget feasibility

vi. Setting plan objectives, targets and effective strategies - This step defines what the program wants to achieve within the planned period of time, in the light of earlier identified health need priorities. - Various strategies to achieve the proposed plan are identified and listed out.

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vii. Costing, determination of resource and budget requirements - Resource requirements and costs of implementing health sector plan are assessed. - The specific purpose is to identify the extent to which existing resources could cover planned intervention packages, and to identify and quantify the need for additional resources and budget. viii. Developing the plan of operation and log frame - A log frame is the summary of the implementation plan specifying main objectives, expected results and activities. How health planning is linked to management planning? - Health planning efforts are disease specific; that is they are categorical approaches directed towards specific health problems. - Health planning are designed to o Enhance quality of care and reduce health care gaps o Provide or control access to care - These health planning efforts are not strategic management. Health planning is the implementation of health policy and affects a variety of health care organizations and society as a whole. In contrast, management planning is organization specific. - Management planning is often anchored in a single organization or group of organizations aiming to maximize gains from the invested resources. - Health Planning is different from management in reasons that o Some strategic alternatives available to management planning may not be realistic for many health planning. o Health care organizations have unique cultures that influence the style of and participation in strategic planning. o Health care plans have always been subject to considerable outside control which may not be true for specific management plans. o Society and its value place special demands on health care plans. However, management planning, especially when customized to health care, does seem to provide the necessary processes for health care organizations to cope with vast changes that have been occurring. Over time, management planning approaches increasingly have been modified to fit the unique aspects of health care organizations. Health planning is linked to management planning in fact that the tools used for planning in health sector are predominantly derived from management planning; for instance Gantt Chart, Log frame, PERT network analysis, SWOT analysis, etc.

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Participatory Approach/ Decentralized Planning Process Steps of Participatory Planning of Nepal with reference to health sector planning: Steps I

Theme Budget Ceiling and Guidelines

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Revision of Budget Ceiling and Guidelines (District)

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Pre-Planning Workshop

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VDC/ Municipality Meeting Selection of Projects from settlement level

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Ward Assembly

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VDC/ Municipality Meeting

Activities The National Planning Commission provides the budget ceiling and guidelines for the upcoming fiscal year to the DDC. MOH provides the guidelines and budget ceiling to DDC for implementation of local level plan and programs conducted through District Development Fund and Municipal Development Fund. MOH provides to MOFALD, the list of prioritized health indicators and list of programs to be supported by local bodies. The District Development Committee prepares an estimate of the following resources: o Own source revenue and resources of the district o Block grant from the government of Nepal o Resources from the line ministries o Grants and other forms of support from other organizations For estimating budget ceiling; reviewing the guideline; and estimating resources, DDC conducts stakeholder analysis: where District Public Health Chief is involved. Budget Ceilings and Guidelines for VDCs, Municipalities, D(P)HO and hospitals taking considerations health priorities, gender equality and social inclusion issues. DDC organizes pre-planning workshop to disseminate information on ceiling and guidelines. The approved ceilings are provided to VDC, municipalities, D(P)HO and hospital mentioning the priority health programs. The Municipalities organizes discussion with different stakeholders for estimating budget for different sectors including health for the coming fiscal year. -

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VDC/ Municipal Council Meeting

Ilaka Level Planning Workshop Thematic Committee Meeting

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Workshop at settlement level is organized in association with FCHVs, Ward Citizen Forum, Community organizations, user groups, NGOs and local inhabitants Felt needs are discussed and proposals of the project are identified prioritizing local (health) needs. In a ward assembly, Ward committed in coordination with ward citizen, compile and prioritize the proposed projects. HFOMCs will ensure if the proposed health projects are prioritized and included. The proposals for the projects collected from the ward level are further discussed/ analyzed at the VDC/municipality through thematic committee meetings and integrated plan formulation committee meeting. HF Incharge ensures if proposed priority health programs are included and provides necessary justifications. The municipal/VDC councils will prepare three separate lists of projects and submit to DDC Projects which will be financed by own source/budget Projects which need partial support from the DDC – sent to DDC Projects which are recommended for total support from DDC- sent to DDC In this meeting workshop, the projects mentioned in the periodic and annual plans are reviewed and prioritized for Ilaka. HF Incharge and representatives from D(P)HO are involved in the meeting and provides justifications to prioritize relevant projects in health sector. The proposed projects are adjusted by Ilaka level under different themes. Health projects are discussed under Social Development Committee and DPHO provides necessary technical assistance.

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Health Systems Management XI

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Integrated Plan Formulation Meeting DDC Meeting

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DDC Council

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Implementation

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DPHO puts forward health projects from both government and non-government sectors with priority in the thematic committee. This meeting is organized to revise, amend and prioritize the projects recommended by thematic committee through proper analysis of their interrelations and complementarities. DDC meeting is organized to discuss the preparations for the DDC council and review projects endorsed by the Integrated Plan Formulation Committee. Public health inspector is involved to ensure if health related programs to be implemented by DDC are included in the project DDC council approves the projects endorsed by integrated plan formulation committee. DPHO chief is involved to provide necessary justifications for the project, if necessary DDC conducts documentation of the projects approved by the council to National Planning Commision, MOFALD and other sectoral ministries including MOH. DPHO sends the annual program including health to RHD which is then compiled and sent to MOHP and DOHS.

Salient Features of Participatory Planning Process - Different interest groups including women and marginalized groups are involved in the local planning process where local needs are reconciled with national priorities. - It is a bottom up and decentralized planning process with extensive local participation. - Many committees such as integrated plan formulation committee are created to ensure citizen’s control in formulating, implementing and monitoring the local plans that potentially affect them.

Figure: Participatory planning process of Nepal

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Logical Framework Analysis The Logical Framework Approach (LFA) is an analytical process and set of tools used to support objectives-oriented project planning and management. The LFA helps to - Analyze an existing situation, including the identification of stakeholders’ needs and the definition of related objectives; - Establish a causal link between inputs, activities, results, purpose and overall objective (vertical logic); - Define the assumptions on which the project logic builds; - Identify the potential risks for achieving objectives and purpose; - Establish a system for monitoring and evaluating project performance; - Establish a communication and learning process among the stakeholders, i.e. clients/ beneficiaries, planners, decision-makers and implementers. Process of LFA Planning The LFA planning is composed of two stages: 1. Analysis stage and 2. Planning Stage 1. Analysis Stage i. Stakeholder Analysis - The stakeholder analysis is done to explicitly understand and recognize the concerns, capacities, interests and needs of different groups in the process of problem identification, objective setting and strategy selection. - The key questions asked in stakeholder analysis are o Whose problem or opportunities are we analyzing o Who will benefit or loose-out from a proposed intervention? - Stakeholder analysis matrix and SWOT analysis are widely used. ii. -

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Problem Analysis Problem analysis identifies the negative aspects of an existing situation and established the cause and effect relationships between the identified problems. Problem analysis is the most critical stage of project planning, as it guides all subsequent analysis and decision making on priorities. Problem analysis are done through participatory brainstorming exercises with stakeholders where root causes are identified and arranged in a problem tree by establishing cause-effect relationships.

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iii. Analysis of Objectives - In this stage negative situations of the problem tree are converted into solutions and expressed as positive achievements (objectives). - The objectives are presented in a diagram (objective tree) showing a means to ends hierarchy. iv. Analysis of strategies/ alternatives - The purpose of this analysis is to identify possible alternative options/strategies, to assess the feasibility of these options and agree upon one project strategy. - Out of the possible strategies of interventions shown by objective tree, the most pertinent and feasible one is selected on the basis of a number of criteria, including relevance, likelihood of success, resource availability, etc. 2. i. -

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Planning Stage Preparing Log Frame Matrix The results of analysis stage are presented and further analyzed in the Log frame matrix. The log-frame consists of a matrix with four columns and four (or more) rows, summarizing the key elements of a project, namely o The project’s hierarchy of objectives o How the project’s achievements will be monitored and evaluated (indicators and sources of verification) o The project environment and key factors critical to the project’s success (assumptions) The log frame also provides the basis on which resource requirements (inputs) and costs (budget) are determined

Components of Log frame Matrix a. First Column: Intervention Logic - The intervention logic should identify what the project intends to do and show a causal relationship between the different levels of objectives. - It includes: o Overall Objective: It is the higher-order objective that is to be achieved through the proposed project. o Purpose: It should describe the intended effects of the project, the immediate objective for the direct beneficiaries. o Results/Outputs: The results should be expressed as the targets which the project management must achieve and sustain within the life of the project. o Activities: Activities should define how the team will carry out the project. It provides an indicative list of activities that must be implemented to accomplish each result.

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b. Second Column: Objectively Verifiable Indicators - The objectively indicators should describe the project’s objectives in operationally measurable terms, specify the performance standard to be reached in order to achieve the goal, the purpose and the outputs. - Therefore OVIs should be specified in terms of quantity, time, target group and place. c. -

Third Column: Source of Verification The source of verification, also called means of verification should be specified at the time of formulation of indicators. The source of verification should specify what sources of information should be made available, from where and how regularly.

d. Fourth Column: Assumptions - Assumptions are external factors that have the potential to influence the success of a project, but lie outside the direct control of project managers. - Most of the assumptions are identified during the analysis phase highlighting number of issues that will impact on project’s environment. National Development Periodic Plan The major highlights of 13th periodic plan (2013/14-2015/16) are: Objective: - To ensure that all citizens have equitable access to basic and good quality health services Strategies i. Improve access to and the quality of free and basic health services. ii. Include preventive, curative, promotional and rehabilitative health services among primary health services. iii. Manage human resources, physical infrastructure, institutional capacity development, and the supply of medicine and equipment effectively and appropriately given the level of health institution in question. iv. Expand treatment services for communicable and non-communicable diseases. v. Enhance collaboration among government, private, and development partner agencies in improving health services, and vi. Improve the nutritional status of vulnerable citizens by implementing multi-sectoral nutrition programmes. Operating Policies - A campaign to expand free basic health services will be expanded in all regions and at all levels. - Incentives will be provided to women to access prenatal and postnatal health services by expanding free and safe delivery services. - Outreach health services such as mobile camps with special services, outreach clinics, and telemedicine will be made effective. - Health service delivery will be made effective by developing the capacities of health staff and institutions. - A safe motherhood programme including safe abortion service will be made accessible. - Preventive health services will be strengthened in collaboration with the non-government sector.

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Addressing gender-based violence will be mainstreamed in health programs. The management of the human resources, physical facilities, medicine, and equipment required by the health sector will be made effective. To enhance the accountability of the health sector to the public, participatory planning, social auditing, and public hearings will be made effective. Nutrition rehabilitation centers will be established and nutrition services in central and zonal hospitals will be expanded to improve child and maternal health.

UNIT 4: INTRODUCTION TO PERSONAL AND INTERPERSONAL SKILLS Team Work and Team Development A team is a group of people who are united to achieve a common goal that is too large in scope to be achieved by a single individual- or at least not efficiently achieved. A team can be classified into three types Team Type Description Creative Designs something new Problem-solving Figures out causes of a problem and identifies solutions Tactical Executes plans to produce something Teamwork Teamwork is an action of team members. Actions labeled as teamwork include: - Providing assistance to each other. - Sharing expertise with others - Providing positive, constructive feedback to others in an effort to improve processes or outcomes. - Working toward solutions that entire group or team can support rather than focusing on solution that offer the greatest personal benefit. Team Development Stage of Team Development Awareness/ Forming Conflict-resolution Cooperation Productivity Separation

Activities Making each members of the team aware of the goals and objectives. and his/her roles and responsibilities Managing and resolving conflicts at work Involving all members in decision-making Working on each other’s problems and focusing on productivity Recognizing contributions and achievements

There are three main components in any team development i. Goal: - Result-oriented tasks or content aspect (e.g. team goals and objectives). - These are usually developed through interaction with team members; ii. -

Methodology: Process aspect, which includes the team's interactions and how members work together (e.g. leadership, team roles, etc.) Teams, especially technical teams, frequently struggle more with process issues than with task issues;

iii. Resources: - Time, budget, computer facility, educational tools and administrative support.

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Decision Making and Problem Solving -

Managers are constantly called upon to make decisions in order to solve problems. Decision making and problem solving are ongoing processes of evaluating situations or problems, considering alternatives, making choices and following them up with the necessary actions.

The decision making and problem solving process involves the following steps i. Defining the problem - The decision-making process begins when a manager identifies the real problem. - The accurate definition of the problem affects all the steps that follow; if the problem is inaccurately defined, every step in the decision making process will be based on an incorrect starting point. - One way that a manager can help determine the true problem in a situation is by identifying the problem separately from its symptoms. ii. -

Developing possible alternatives A successful problem solving requires thorough examination of the problems. Thus, a manager should think through and investigate several alternative solutions to a single problem before making any decisions. One of the best methods for developing alternatives is through brainstorming, where a group works together to generate alternative solutions. However, several other ways can also be used to develop solutions such as nominal group technique and Delphi technique.

iii. Analyzing the alternatives - The purpose of this step is to decide the relative merits of each alternative. - Managers must identify the advantages and disadvantages of each alternative solution before making a final decision. Evaluating the alternatives can be done in numerous ways. Some of the possibilities include: o Determining the pros and cons of each alternative. o Performing a cost-benefit analysis for each alternative o Using ranking technique - Regardless of the method used, a manager needs to evaluate each alternative in terms of its feasibility, effectiveness and consequences. iv. v. -

Selecting the best alternatives After analyzing all possible alternatives, a manager selects the best one. Sometimes the selection process can be fairly straight forward with most pros and fewest cons. When the best alternative may not be obvious, a manager must decide one which is most feasible and effective and incurs low cost. Implementing the decision to solve the problem Manager must thoughtfully devise programs, procedures, rules, or poliices to help employees in implementing the problem-solving process.

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Leadership Leadership is a process or ability to influence the behaviour of others, to motivate and mobilize others to work together and achieve a common goal. It is a way of focusing and motivating a group of people to enable them to achieve their own aims and develop themselves. Styles of leadership in an organization i. Directive style of leadership - In this type of leadership, the leader defines the roles of group and directs them what task to do and how, when, and where to do it. - The leader alone initiates problem- solving and decision-making. - Solutions and decisions are announced; communication is largely one-way, and the leader closely supervises implementation of health program. ii. -

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Coaching style of leadership In this style, the leader still provides a great deal of direction and leads with his or her ideas, but the leader also attempts to hear the group member’s feelings about decisions as well as their ideas and suggestions. While two-way communication and support are increased, control over decision-making remains with the leader.

iii. Supportive style of leadership - In such leadership, the focus of control for day-to-day decision-making and problem-solving shifts from the leader to the group members. - The leader’s role is to provide recognition and to listen actively and facilitate problem-solving and decision-making on the part of the group members - This is appropriate where the members have the ability and knowledge to do the assigned tasks. iv. Delegating style of leadership - The delegating leader discusses the problems with members of the group until a joint agreement is achieved on the problem and ways to resolve it. - Thereafter, the decision-making process is delegated totally. - The group then has significant control on deciding how tasks are to be accomplished.

Negotiation Skills -

Negotiation is a process of conferring to arrive at an agreement between different parties, each with their own interests and preferences. It is a process of communicating back and forth, for the purpose of reaching a joint agreement about differing needs or ideas. Negotiation is an invaluable skill for a health manager. Not only they negotiate agreements with vendors, but also effectively negotiate with stakeholders, service providers and clients.

Some of the most significant skills for successful negotiation are i. Active listening and focused speaking - Misunderstandings can occur if the negotiator does not state his proposal/ points clearly. - During a bargaining meeting, an effective negotiator must have the skills to state his desired outcome as well as his reasoning.

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Collaboration and teamwork Negotiation is not necessarily a one side against another arrangement. Effective managers must have the skills to work together as a team and foster a collaborative atmosphere during negotiations.

iii. Problem solving - Individuals with negotiation skills have the ability to seek a variety of solutions to problems. - Instead of focusing on his ultimate goal for the negotiation, the individual with skills can focus on solving the problem, which may be a breakdown in communication, to benefit both sides of the issue. iv. Decision making ability - Leaders with negotiation skills have the ability to act decisively during a negotiation. - It may be necessary during a bargaining arrangement to agree to a compromise quickly to end a stalemate. - A manager can use BATNA (Best Alternative to Negotiated Agreement) as a standard for accepting or rejecting negotiated terms and providing quick decisions. - If the proposed agreement is better than BATNA, then a manager may accept the proposal, otherwise reject it. v. -

Interpersonal skills Negotiators with patience and the ability to persuade others without using manipulation can maintain a positive atmosphere during a difficult negotiation.

vi. Ethics and reliability - Both sides in a negotiation must trust that the other party will follow through on promises and agreements. - A negotiator must have the skills to execute on his promises after bargaining ends. Time Management Time management is the process as well as skill of managing oneself in relation to time. It is a process of setting priorities and taking charge of the situation and time uitilization. Importance of time management for managers i. Time management is of paramount importance to health managers during emergency management and outbreak response. ii. Proper time management help managers get more organized help them achieve their goals and objectives within the shortest possible time. iii. Proper time management facilities managers to multi-tasking. iv. Better time management helps managers in better planning and eventually better forecasting. v. Managers who accomplish tasks on time are less prone to organizational stress and conflicts. vi. Time management helps manager prioritize tasks and activities in health care organizations. Causes of poor time management i. Poor planning – Absence of plan of action is likely to trigger off a false start, resulting in unproductive time utilization on the critical path of the task being undertaken. Consequently managers might not find enough time for completing the task.

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Lack of prioritization- As a result of the inability to distinguish between the urgent, the important and the unnecessary tasks, unimportant tasks are likely to get done first at the cost of urgent and important tasks.

iii. Procrastination: Putting off tasks for later may cause tasks to pile up and can force managers to run into a time crunch later. It is generally triggered by the fear of failure/ success, perfectionism, wanting to do it all or incorrect priorities. iv. Interruptions- Interruption and distractions such as unnecessary visitors, telephones, e-mails, unscheduled meetings and poor communications. v. -

Other causes Ineffective delegation/ not delegating tasks to subordinates Poor networking Confused authority Personal disorganization Bad attitude

Techniques of effective time management by managers i. Using activity time log: Keeping a time log is very effective way to help managers manage their time better. ii.

Goal setting: Helps managers in monitoring the day to day activities and ensures the activities are progressing timely and in the right direction.

iii. Defining priorities: Helps managers spend more time on the activities and tasks that are important and valuable. iv. Scheduling activities: Preparing a weekly and daily schedule of prioritized tasks helps to stay on track and get prepared for obstacles. v. vi. vii. viii.

Delegating task Avoiding over-commitments: Learning to say no to unnecessary tasks. Discouraging unnecessary interruptions: e.g. unnecessary telephone calls, meetings, visitors, etc. Avoiding paperwork as far as possible

Stress Management Stress is an inevitable result of work and personal life. Managers must learn how to create healthy stress for employees to facilitate performance and well-being without distress. Causes of stress in the organization 1. Individual factors i. Inner conflicts: Non-specific fears, anxiety and guilt feelings ii. Perceptual influences: Individuals perceiving work conditions as threatening iii. Home-work interface: conflicting demands of work and home

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2. Organizational Factors i. Culture: lack of communication, fears about job security, culture of blame, expectation of prolonged work by employee. ii. Task demands: Design of individual’s job, working conditions, and the physical work layout. iii. Control: Lack of control over work iv. Role conflicts v. Inter-personal factors: Poor relationships, abrasive personalities, bullying, sexual harassment and leadership styles vi. Support system: Lack of support from managers and co-workers, lack of recognition Effects of stress i. Individual effects - Psychological distress - Medical problems - Behavioural problems ii. -

Organizational effects Participation problems Performance decrements Compensation awards

Techniques of Stress Management Stress management techniques should be directed at both individual and organizational levels. 1. Individual level i. Time management: Activity logging, prioritizing activities, scheduling, developing action plans. ii. Non-competitive physical exercises: aerobic, walking, jogging, cycling, etc. iii. Relaxation and biofeedback: meditation, hypnosis and biofeedback iv. Development of social support system: committing time to family and friends v. Adjustment of perceptions 2. Organizational level i. Job redesigning: Redesigning jobs to give employees more responsibility, more meaning work, more autonomy, and increased feedback can reduce stress. ii. Goal setting: Goal-setting helps to increase task motivation, while reduces the degree of role conflict and ambiguity to which people at work are subjected. iii. Role negotiation: Role negotiation helps to clarify and resolve role confusion and conflicts. iv. Organizational communication: Increasing formal organizational communication with employees reduces uncertainty by lessening role ambiguity and role conflict. v. Social support system in the workplace: Team building is one way to develop supportive social relationship in the workplace and reduce organizational stress. vi. Organizational culture can help employees manage stress by strengthening coping skills and providing shared values and beliefs.

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Delegation of Authority -

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Delegation of authority is essential to the effective operation of a health care organization. Delegation means conferring authority from one executive or organizational unit to a subordinate for the purpose of carrying out a particular assignment or assignments. Although the executive gives up some control over work performance, delegation of authority does not mean surrender of authority. An administrator delegating authority always retains overall authority for assigned tasks given to a subordinate. A chain of authority is established following the formal organizational structure. Authority is delegated only to the extent required to perform an assigned task in a satisfactory manner. Delegation may be downward, upward or lateral.

Process of delegation The process of delegation consists of three aspects i. Assignment of duties - The administrator or department head is the one who decides how the work is to be divided among the subordinates. - By reviewing his or her own functions and duties, he/she will be able to determine the functions to be delegated. - Three groups of functions the administrator or department head may wish to review are: routine functions that are time consuming, functions requiring a certain degree of skill, and functions that cannot be delegated and must be performed by the administrator. ii. -

Granting of authority The second part in the process of delegation of authority is the granting of authority to make decisions, use resources and take action to perform the allocated duties. Duties are assigned and authority is delegated to positions within the facility. Once the duty of function is delegated, commensurate to perform the duty is granted. The scope of authority is limited to the duty to be performed. The authority should be granted in writing, if feasible. Charts, manuals and job descriptions will be a valuable assistance in determining the scope of authority.

iii. Unity of command - This concept states that the delegation of authority and issuance of orders or commands comes only from a single supervisor to a single subordinate, and each subordinate report only to one supervisor. Conflict Management Conflict is the expression of disagreement over something important. Conflict occurs when individuals or groups have competing interests and ideas. Conflict can be productive when it - Focuses on strategic or tactical concepts or ideas, not personality. - Provides an atmosphere in which individual feel free to express dissenting opinion - Can lead to more creative solutions. Conflict is unproductive when it - Is characterized by frequent, repetitive arguments that are not resolved. - Leaves people angrier and more frustrated. - Replaces real issues with jokes, sarcasm, denial, blame

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Causes of conflict i. Jurisdictional ambiguities: Unclear organizational policies, job boundaries and task responsibilities ii. Personality clashes: Differences in personality, attitudes, values, beliefs and experiences. iii. Power and status differences: Influence of power over another iv. Goal difference: Pursuing different goals in the organization v. Communication differences: Differences in speaking, communicating styles, faulty communications, etc. vi. Gender and cross-cultural differences: (between service providers and clients/ or between staffs) vii. Structural factors: Differences in resources, authority or organizational priorities. viii. Conflicting interests: ix. Performance expectations x. Unresolved prior conflicts Techniques of conflict management i. Avoiding - In this technique, manager prefers to stay out of conflicts, ignore disagreement, or remain neutral. - Avoiding might be appropriate when the issue is perceived by the manager to be trivial. - It might also be an appropriate approach to use when there is no chance of winning or when disruption would be very costly. - However, avoidance might be frustrating to others and there is usually a residue of feelings and relations that can impact future conflicts. ii. -

Forcing This is also known as win-lose approach. A manager seeks to reach his/her preferred outcomes at the expense of other individuals. This approach may be appropriate when quick action is needed, such as during emergencies and outbreaks. It can also be used to confront unnecessary actions. Forcing may result in fear, lack of respect and hatred towards manager.

iii. Accommodating - A manager using this style subjugates his/her own goals, objectives and desired outcomes to allow other individuals to achieve their goals and outcomes. - This technique is appropriate when manager realize that he/she is in the wrong or when an issue is more important to one side than the other. - This style is important for preserving future relations between the parties. iv. Collaborating - This is also known as win-win approach. - Both conflicting parties creatively work towards achieving goals and desired outcomes of all parties involved. - This technique is appropriate when the concerns are complex and creative ideas are required. - The process of collaborating mandates sincere efforts by al parties and it may require a lot of time to reach a consensus. v. -

Compromising Compromising can also be referred to as bargaining or trading. It is based on give and take and typically involves a series of negotiations and concessions This technique can be used when the goals of both conflicting parties are of equal importance, when both sides have equal power, or when it is necessary to find a temporary, timely solution.

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UNIT 5: STRUCTURE AND FUNCTION OF HEALTH SYSTEM Factors affecting the health system of a country Discuss the internal and external factors influencing health care system in a country i. -

External Factors Global priorities and health agendas: SDG, ICPD, Alma-Ata Declaration, Health in all policies, etc. Globalization and trade liberalization Conventions and declarations Regional Commitments Demographic factors: Population including proportion of marginalized and disadvantaged groups Social Factors: Poverty, health profile of a country Economic Factors: Sources of finance, budget allocation to health sector Influence of global actors: funding agencies, business houses, WTO, World Bank, WHO, etc. Technological Advancements Professional Regulation

ii. -

Internal Factors Nature of the state Health policy and strategy: e.g Universal health coverage in Nepal is guided by it new health policy. Policies and regulations: National Heath policy, Health Service Act, Health Sector Strategy, etc. Health care financing mechanism in a country:  Out of pocket financing  Community based financing  Social health security programme Availability of infrastructures HRH demographics: availability and distribution of HRH of various levels and skill-mix.

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Critical Appraisal of the MOHP Organizational Structure The Ministry of Health is one of the leading government ministries charged with the overall role to improve the health of the people. This ministry is primarily responsible to make necessary arrangements and formulate policies for effective delivery of curative services, disease prevention, health promotion activities and establishment and regulation of overall health care system. The organization of Ministry of Health is a complex structure comprising of several divisions, departments, centers, foundations, councils, hospitals, health directorates, and offices Key characteristics of organizational structure of MOH - MOH currently consists of five divisions and twenty sections within its ministry. Three of the divisions are headed by human resources from health sector. • Personal Administration Division • Policy planning & International Cooperation Division • Curative Service Division • Human Resource & Financial Management Division • Public Health Administration, Monitoring & Evaluation Division - The structure also includes three separate departments with specific roles and functions. • Department of Ayurveda • Department of Drug Administration • Department of Health Services

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The Department of Health Services operates its activities through its seven divisions and five centers. Divisions Centers • Child Health Division • National Health Training Center • Family Health Division • National Tuberculosis Center • Epidemiology and Disease Control Division • National Public Health Laboratory • Primary Health Care Revitalization Division • National Center for AIDS and STI Control • Logistic Management Division • National Health Education, Information • Management Division and Communication Center • Leprosy Control Division -

The Ministry of Health extends its preventive, promotive and curative health services from central to grass-root levels through more than 4521 governmental health facilities and hospitals. Six central, three regional, three sub-regional and 10 zonal hospitals including all district hospitals are included in the organizational structure. Another important feature in the organizational structure is the presence of District (Public) Health Offices covering all 75 districts with more than 4000 peripheral health facilities responsible for conducting public health activities up to the grassroot level.

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Strengths in the organogram - The organization of MOH is comprehensive involving different functional structures from central to peripheral levels (division, departments, centers, councils, foundations, hospitals, health offices and health centers. - The organizational structure makes provisions for at least one health facility in each VDC/ municipality. Weaknesses in the organogram Some of the weaknesses of current organogram of MOH are listed as follows: - The placement of health institution is based on political division and not population based. - Relation between central, regional, zonal and district hospitals is not clearly defined. - Similar roles given to different divisions and sections, those are likely to result in role conflicts. - No clear hierarchical relationships exist in the organizational structure (especially at the central level). Hierarchy between Divisions of MOH and its departments are not clear.

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Figure: Organogram of Ministry of Health showing central to peripheral structures ©Prabesh Ghimire

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District Health System A district health system includes the interrelated elements in the district that contribute to health in homes, educational institutions, workplaces, public places and communities, as well as in the physical and psychosocial environment. The following are some of the components of a district health system: - district health office; - district hospital or hospitals; - health centers; - community, neighborhoods and households; - Private health sector, NGOs and mission health services. Organization Structure of DPHO The organizational structure of District Public Health Office is shown in the figure below:

Figure: Organogram of DPHO Functions of DPHO The functions of District Public Health Office are as follows: i. Planning - Prepare the structure of district level health development plan. - Prepare detailed work plan and work calendar PHCs & HPs and technicians of DPHO. - Collection of information within the district and identify district health and identify district level health indicators. ii. -

Family Planning Programme Make arrangements to provide long acting and permanent services through clinics or camps. Make arrangements to provide FP consultancy services through health institutions, PHC-ORC and health workers.

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iii. Safe Motherhood - Ensure the provision of safe motherhood services including aama program by grass-root level health institutions. iv. Immunization - Ensure the quality and coverage immunization services. - Make arrangements for regular supply of vaccines and management of cold chain. v. -

Nutrition Programme Conduct survey in nutrition Make arrangements for growth monitoring Make arrangements for supply of vitamin-A, iron tablets and iodized salt. Make arrangement for management of SAM cases by establishing OTC and stabilization centers.

vi. Child Health Programme - Make arrangements for implementation of CB-IMNCI activities at community level vii. Disease control (Diarrhoea, ARI, Malaria,/ Kala-azar, TB, Leprosy and HIV/AIDS) - Make arrangements for prevention and treatment of diseases by various health institutions in the district. - Make arrangement s for collection of sample. - Make arrangements for promotion of condom use. viii. -

Other Functions Epidemic control and emergency preparedness and response activities Conduct health education programmes. FCHV programme. Monitoring and supervision of all health programs in the district. Conduct regular administrative works of DPHO. Coordination with private institutions, NGOs and CSOs.

Problems and issues in district health system of Nepal The problems and issues of health service management at the district and grass-root level in Nepal are as follows: i. Problems and issues in provision of preventive and community health services - The numbers and location of community level facilities (HPs, and PHCCs) are based on administrative areas, which do not adequately reflect needs. - There is a lack of effective supervision and monitoring mechanisms especially at grass-root level facilities. ii. -

Problems and issues in provision of curative services The resources available to district hospitals often bear no relation to the size of the facility, service population (clinical, technical and administrative staff): medical supplies, equipment and facilities.. There are extensive staff vacancies in hospitals.

iv. Problems and issues in inter and intra sectoral coordination - There is no effective mechanism to assure coordination at district and grass-root levels. - The existing formal coordination committees (e.g. RHCC, DHGSTF, HFOMC, etc.) are not functional in several districts and grass-root levels.

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v. -

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Problems and issues in management and organization There is limited continuity in the planning process from one year to the next. The District Development Committee’s approved plans are not accepted in their original form by higher authorities at the center.

vi. Problems in logistics management - Stock outs and overstocks exist due to inadequate procurement planning, lack of an inventory control system and insufficient resources to satisfy demand. - Storage space and conditions are not always managed due to a lack of resources, use of rented facilities and lack of supervision. vii. Problems in health facility maintenance and development - Most of the health posts are located in sites much smaller than required for their proper functioning. - Except for newly built facilities many of the existing health facilities lack basic amenities such as water supply and latrines. viii. Problems in information management - Reporting is often delayed and incomplete. - Data is often non-reliable and inconsistent. Opportunities - Health sector strategy (2015-20) aims towards strengthening district health governance and ensuring universal health coverage. - Many external assistances in post-earthquake scenario with opportunities for strengthening district health system by addressing resource constraints. - Evidence based decentralized planning has been a recent focus of ministry of health. Critical Review of National Health Policy-2014 National Health Policy 2071 is a replacement of the previous policy to address current and newly emerging health challenges through mechanism of universal health coverage and accountable health system. Vision: All Nepali citizens have the physical, mental, social and emotional health to lead productive and quality lives. Mission: Ensure citizen’s fundamental rights to stay healthy by utilizing available resources optimally and fostering strategic cooperation between service providers, service users and other stakeholders. Goal: To ensure health for all citizens as a fundamental human right by increasing access to quality health services through a provision of just and accountable health system. Objectives: - To provide free basic health services - To establish an effective and accountable health system - To promote people’s participation in extending health services.

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Policies The National Health Policy includes 14 policies covering broad range of health service provisions. The major provisions in the policy include: - Universal health coverage and provision of basic health services at free of cost. - Development and management of HRH - Development of ayurvedic and alternative medicine - Promoting information, education and communication - Promotion of nutritional activities to prevent malnutrition - Strengthening health professional councils - Focusing on good governance - Mainstreaming health in every policy of the state - Rolling out nationwide insurance plan - Promoting public private partnership - Improving financing in health sector Strengths - Recognizes health services as a fundamental right of citizens by providing basic health services free of cost. - Focuses poor, marginalized and vulnerable communities of both rural and urban areas based on equality and social justice through universal health coverage. - Availability of doctor, nurse and health technicians in each VDC and midwife in each ward. - Aims to establish at least one health institution in each village within 30 minutes distance. One PHCC for every 20 thousand population and one 25-bedded hospital for every one hundred thousand population. - Provisions for one doctor along with 23 health workers for every 10 thousand population. Weaknesses - Gender issues in health are not adequately addressed by this policy. - This policy is silent regarding the emerging double burden of diseases. - The policy seems over-ambitious regarding distribution of health workers (e.g. one doctor/VDC) and health institutions with no particular road map and resources to achieving them.

Nepal Health Sector Programme (NHSP- III) Vision: All Nepali citizens have the physical, mental, social and emotional health to lead productive and quality lives. Mission: Ensure citizen’s fundamental rights to stay healthy by utilizing available resources optimally and fostering strategic cooperation between service providers, service users and other stakeholders. Strategic Priorities: i. Equity in health systems ii. Quality health services for all iii. Health systems reforms iv. Multi-sectoral collaboration Goal: The goal of NHSP III is improved health status of all people through accountable and equitable health service delivery system.

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Outcomes: 1. Outcome 1: Strengthened health systems: HRH, Infrastructure, Procurement and Supply chain management 2. Outcome 2: Improved quality of care at point-of-delivery 3. Outcome 3: Equitable utilization of health care services 4. Outcome 4: Strengthened decentralized planning and budgeting 5. Outcome 5: Improved sector management and governance 6. Outcome 6: Improved sustainability of health sector financing 7. Outcome 7: Improved healthy lifestyles and environment 8. Outcome 8: Strengthened management of public health emergencies 9. Outcome 9: Improved availability and use of evidence in decision-making processes at all levels Basic health package: 1. Community level preventive, promotive and rehabilitative health services including follow up care. 2. Consultation services at general outpatient services (<50 bedded hospital) and counseling (ANC, PNC, secual health, HIV, mental, adolescent, FP, GBV, oral hygiene, preconception). 3. VPD: National immunization program, measles diagnosis and treatment 4. HIV/AIDS: rapid testing, treatment and follow up services 5. TB: sputum diagnosis, treatment, follow up services 6. Malaria: diagnosis and treatment 7. Dengue: symptomatic case management 8. Neglected tropical diseases: diagnosis and treatment of Kala-azar and lymphatic filariasis. Deworming. 9. STIs: syndromic diagnosis and treatment 10. Diabetes: screening and treatment 11. Cardiovascular diseases: screening and treatment 12. Cancer: screening for breast and cervical cancer, cyrotherapy 13. Oral: check up, toothache management, oral thrush management 14. Ear: hearing test, acute otitis media 15. Eye: vit-A supplementation, refraction error 16. Reproductive health: ANC, delivery, PNC, PMTCT, PAC, etc. 17. RH Morbidity: UV prolapsed ring pessary management 18. Newborn care: Resuscitation, management of neonatal conditions 19. Child: IMNCI, growth monitoring 20. Family planning 21. Nutrition: Iron/Folic acid, Vit-A supplementation 22. Others: GBV, geriatric, injuries, diagnostic services

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Sector-Wide Approach -

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The Sector Wide Approach (SWAp) is a method of working between government and external development partners. The Sector Wide Approach (SWAp) came into effect in Nepal 2004. The defining characteristics of a SWAp are o All significant funding for the sector supports a single sector policy and expenditure programme, under Government leadership. o Adopts common approaches across the sector o Progresses towards relying on Government procedures to disburse and account for all funds. Donors in development partners must take collective action for sectoral achievements. As a result of SWAp, some donors will be obliged to give up the right to select which project they finance in exchange for influence in the development of strategy and resource allocation.

Importance of SWAp - Increased health sector coordination, stronger national leadership and ownership. - Reduced duplication of resources, lower transaction costs, improved aid effectiveness and health sector allocative efficiency. - SWAp has been an integral part of the poverty reduction strategy and health sector reform and has gained a wider attention from donor agencies as well as aid recipients. Critics - Recipient government and donors only fund activities in the national health sector plan but does not contribute in the development of whole health system. Assessing and Managing Organizational Change Organizational change refers to a modification or transformation of the organization's structure, processes, goods or services. Flexibility requires that organizations be open to change in all areas, including the structure of the organization itself. Factors affecting organizational change i. External Factors - Technological change and innovation - Globalization - Social and political changes: new legal provisions - Workforce diversity

ii. -

Internal Factors Changes in managerial personnel Declining effectiveness Change in work climate Deficiencies in the existing system Crisis: strikes, walkouts Employees expectations

Assessing organizational change - The basis for assessing organizational change must be to compare prior states with later states. To understand the states of an organization, one must compare it with other organizations. - To understand the causes of change, potential causal factors and their links to different outcomes must be explored.

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Seashore suggests that assessment of organizational change requires: - An assessment of considerable scope, cost and intrusion - A very hospitable research site (which must be developed through preparatory work) - The collection and synthesis of diverse kinds of data from diverse sources - The use of longitudinal measures and comparison units. Lawler et al. proposed a global map to be used for the identification of the key determinants of organizational change. This model suggests six broad classes of variables for assessing organizational effectiveness: i. Effectiveness outcomes: productive output rate, quality, cost of service, or cost, timeliness and quality in service organizations. ii. Individual and group behaviour: individual effort, problem solving methods, supervisory teamwork, inter-group conflict, resolution. iii. Individual and group attitudes and beliefs: shared beliefs and social norms, job satisfaction iv. Individual and group characteristics v. Work characteristics, technology and organizational structure vi. External environment Managing Organizational Change According to John Kotter, managing change involves following processes: i. Creating urgency - Identifying potential threats and developing scenarios showing what could happen in the future. - Examining opportunities that should be or could be exploited. - Starting honest discussions and giving dynamic and convincing reasons to get people develop a sense of urgency around the need for change. ii. -

Forming a powerful coalition Asking for commitments from leaders and key stakeholders in the organization. Team building with mix of people from different departments and levels.

iii. Creating a vision for change - Determining the vision that is central to the change. - Creating a strategy to execute that vision. iv. Communicating vision Communicating vision to all relevant groups. - Addressing people’s concerns and anxieties. v. -

Removing obstacles Identifying change leaders whose main roles are to deliver the change. Looking at the organizational structure, job descriptions, and performance and compensation systems to ensure they’re in line with the vision. - Identify people who are resisting the change and addressing them through communication, negotiation, empathy and support. vi. Creating short-term wins - Creating short-term projects that can be implemented without help from any strong critics of the change. - Choosing achievable targets, with little room for failure.

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Building on the change Reviewing the projects and analyzing what went right and what needs improving. Setting goals to continue building on the momentum that has been achieved. Focusing on continuous improvement.

Concept of Learning Organization According to Peter Senge, learning organizations are organizations where people continually expand their capacity to create the results they truly desire, where new and expensive patterns of thinking are nurtured, where collective aspiration is set free, and where people are continually learning to see the whole together. - The basic rationale for such organizations is that in situations of rapid change only those that are flexible, adaptive and productive will excel. - For this to happen, organizations need to discover how to tap people’s commitment and capacity to learn at all levels. According to Senge, the learning organization depends upon the mastery of five dimensions: i. System thinking - It refers to the notion of treating the organization as a complex system composed of smaller systems. - Some of the key elements here are recognizing the complexity of the organization and having a longterm focus, - Senge advocates the use of system maps that shows how systems connect. ii. -

Personal mastery This is a process where an individual strives to enhance his vision and focus his energy, and to be in a constant state of learning. It goes beyond competency and skills, although it involves them.

iii. Mental models - These are deeply ingrained assumptions, generalizations, or even pictures and images that influence how we understand the world and how we take action. - If organizations are to develop a capacity to work with mental models then it will be necessary for people to learn new skills and develop new orientations. iv. Building shared vision - A shared vision gives employees energy and focus. - Striving to accomplish a shared vision will encourage people to take risks, experiment and become committed to a long-term view of the organization and its environment. v. -

Team learning Team learning is important because modern organizations operate on the basis of teamwork, which means that organizations cannot learn if team members do not come together and learn. It is a process of developing the ability to create desired results; to have a goal in mind and work together to attain it.

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Leadership in learning organization (What kind of leader can effectively lead a learning organization?) Senge defined three leadership roles that would create and lead a learning organization. i. -

ii. -

Leader as designer: In essence, the leader’s task is designing learning processes. These processes enable people throughout the organization to deal productively with the critical issues they face, and develop their mastery in the learning disciplines. Crucial design work for leaders of learning organizations concerns the following: o Creating a common vision with shared values and purpose. o Determining the policies, strategies and structures that translate guiding ideas into business decisions. o Creating effective learning processes which allow for continuous improvement of the policies, strategies and structures. Leader as teacher The leader as teacher involves helping individuals in the organization to be aware of their mental models and the assumptions on which these are based. This allows people to continually change their view of such reality that they can see beyond merely superficially issues and discern the underlying causes of problems.

iii. Leader as steward - The concerns of the leader as steward involve stewardship for all the people in the organization that he directs. - It also involves stewardship for the purpose and core values on which the organization is based. - A leader in a learning organization actively seeks to change how the competitive environment works to create a more successful organization with more satisfied workers that would be achieved in a traditional organization. Total Quality Management in Health Care Total Quality Management is defined as a management philosophy concerned with people and work processes that focuses on customer satisfaction and improved organizational performance. In TQM, systems are established to prevent health and administrative problems, increase client satisfaction, continuously improve the organization’s processes, and provide better health care services. The following fundamental beliefs form the basis of the TQM approach: - TQM is appositive strategy for growth and should be integrated into the organization’s strategic plan. - TQM management must be committed to and actively involved in the TQM process. - TQM is a process, not a program. - Quality improvement process must be applied to all levels of the organization. Principles of Total Quality Management Principles Description 1 Client centered - Health care organizations should understand current and future client organization needs. - They should meet the client requirements and strive to exceed client expectations. 2 Leadership - Leaders should create and maintain the internal environment in which people become fully involved in achieving the organization’s objectives.

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3

Involvement of people

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4

Process approach

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5

System approach to management

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6

Continuous improvement Evidence based decision making

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7

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People at all level are the essence of an organization and their full involvement enables their abilities to be used for the organization’s benefit. A desired result is achieved more efficiently when activities and related resources are managed as a process. Identifying, understanding and managing a system of interrelated processes as a system contributes to the organization’s effectiveness and efficiency in achieving its objectives Continuous improvement of the organization’s overall performance should be a permanent objective of the organization Effective decisions are based on the analysis of data and information.

Basic Elements of TQM i. Client Focus: All strategic decisions health care institutions make need to be driven towards client needs. ii. Strategic planning: For TQM, strategic planning needs to anticipate many changes such as client expectations, new opportunities, advanced diagnostic technologies development, evolving client centered system and social expectations. iii. Continuous learning and improvement: The process of continuous improvement and learning must be embedded in the regular cycles of planning, execution and evolution. iv. Teamwork: In TQM, individuals cooperate in team structures such as quality circles, steering committees and self-directed work teams. v. Quality Assurance: Quality assurance activities include quality planning, control, improvement, internal audit and reliability, It also includes quality advice and expertise and training of personnel in quality. Tools for TQM - Team-building and group-integration tools - Specific process/technical tools - Process flow chart - Check sheet and histograms - Pareto analysis - Process control chart - Quality function deployment (QFD) SWOT Analysis This is an outline of strengths, weaknesses, opportunities of, and threats to, the organization. It is usually done at the start of a strategic planning exercise in a group setting, to identify all factors in each area. The factors are usually organized in a table of four quadrants so participants in the planning exercise can visually (and easily) see the context for the planning. i. Strengths: Strengths include factors like staff capabilities, effective management processes, competitive advantage and unique programs or products. ii. Weakness: Weaknesses include factors like gaps in staff skills, financial problems and inadequate information systems. iii. Opportunities: Opportunities include factors like global influences, new policy developments, partnerships and research. iv. Threats: Threats include factors like market demand, loss of key staff and political effects.

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Performance Management in Organization A performance management is a continuous process of identifying, measuring and developing the performance of individuals and teams and aligning performance with the strategic goals of the organization. (Aguinis, 2005) Objectives of Performance management - To enable the employees towards achievement of superior standards of work performance. - To help the employees in identifying the knowledge and skills required for performing the job efficiently as this would drive their focus towards performing the right task in the right way. - Boosting the performance of the employees by encouraging employee empowerment, motivation and implementation of an effective reward mechanism. - Promoting a two way system of communication between the supervisors and the employees for clarifying expectations about the roles and accountabilities, communicating the functional and organizational goals, providing a regular and a transparent feedback for improving employee performance and continuous coaching. - Identifying the barriers to effective performance and resolving those barriers through constant monitoring, coaching and development interventions. Components of performance management system An effective performance management system includes the following components: 1. Performance Planning: - Performance planning is the first crucial component of any performance management process which forms the basis of performance appraisals. - Performance planning is jointly done by the supervisor and employee in the beginning of a performance session. - During this period, both mutually decide upon the targets and the key performance areas which can be performed over a year. 2. Performance Appraisal and Reviewing: - The appraisals are normally performed twice in a year in an organization in the form of mid-term reviews and annual reviews which is held in the end of the financial year. - In this process, progress towards meeting expectations are measured, reported, discussed and documented by both supervisor and the employee. - The entire process of review seeks an active participation of both the employee and the supervisor for analyzing the causes of loopholes in the performance and how it can be overcome. 3. Feedback on the Performance followed by personal counseling and performance facilitation: - Feedback and counseling is given a lot of importance in the performance management process. - This is the stage in which the employee acquires awareness from the supervisor about the areas of improvements and also information on whether the employee is contributing to the expected levels of performance or not. - The employee receives an open and a very transparent feedback and along with this the training and development needs of the employee is also identified. - The appraiser adopts all the possible steps to ensure that the employee meets the expected outcomes for an organization.

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4. Rewarding good performance: - This is a very vital component as it will determine the work motivation of an employee. - During this stage, an employee is recognized for good performance and is rewarded. 5. Performance Improvement Plans: - In this stage, fresh set of goals are established for an employee and new deadline is provided for accomplishing those objectives. - The employee is clearly communicated about the areas in which he/she is expected to improve and a stipulated deadline is also assigned within which the employee must show this improvement. - This plan is jointly developed by the supervisor and an employee is mutually approved.

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UNIT 6: HUMAN RESOURCE MANAGEMENT Human Resource Management Human Resource Management in the context of health “refers to functions involved in planning, organizing and supporting the professional development of the health workforce within a health system, both at the strategic and policy levels. - Martineau, Martinez According to Management Sciences for Health (MSH), - Good human resource management (HRM) is essential to retaining staff and maintaining a high overall level of performance within a health organization. Effective HRM is one of the key building blocks of a comprehensive HRH strategy. - A responsive human resource management system can help ensure that staff know what they are supposed to do, get timely feedback, feel valued and respected, and have opportunities to learn and grow on the job. - Fragmented, politicized human resource management systems and lack of human resource managers are two common barriers to effective HRM. Functions of HRM HRM functions are carried out to fulfill the goals and objectives of the organization. There are two sets of functions of HRM, namely managerial functions and operative functions. i. Managerial Functions ii. Operative Functions - Procurement - Planning - Development - Organizing - Compensation - Staffing - Maintenance and motivation - Directing - Integration - Controlling

According to Mc Kinnies (2012), there are five broad functions of HRM: i. Resourcing: Activities include HR planning, talent management, succession planning and ending the employment contract (including managing retirement and redundancy). ii. Performance: Managing individual and team performance and the contribution of workers to the achievement of organizational goals, for example, through goal-setting and appraisals. iii. Reward system: Designing and implementing reward systems covering individual and collective, financial and non-financial rewards, including pay structures, parks and pensions. iv. Learning and Development: Identifying individual, team and organizational development requirements and designing, implementing and evaluating training and development interventions. v. Employment relations: Managing employees, communication, handling union management relations, managing employee welfare and handling employee grievance and discipline. Evolution of Human Resource Management i. -

Period before industrial revolution The number of specialized crafts was limited and was limited and was usually carried out within a village or community with apprentices assisting the master craftsmen. Communication channel was limited.

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Period of industrial revolution (1750 to 1850) Industrial revolution marked the conversion of economy from agriculture based to industry based. A department was set up to look into wages, welfare and other related issues. This led to emergence of personnel management with the major task as worker’s wages & salaries, and worker’s record maintenance. An important event in industrial revolution was growth of Labour Union in 1790.

iii. Post Industrial Revolution - The term Human resource management saw a major evolution after 1850. - Various studies were released and many experiments were conducted during the period which gave HRM altogether a new meaning and importance. - A brief overview of major theories released during this period is presented below: • Fredrick W. Taylor gave principle of scientific management: This led to the evolution of scientific human resource management approach which was involved in worker’s training, maintaining wage uniformity and focusing on attaining better productivity. • Hawthorne studies were conducted by Elton May & Fritz Roethlisberger (1927 to 1940): The observations and findings of Hawthorne experiment shifted the focus of human resource from increasing worker’s productivity to increasing worker’s efficiency through greater work satisfaction. • McGregor’s Theory X and Theory Y (1960) and Maslow’s Hierarchy of needs (1954): These theories led to the transition from the administrative and passive personnel management approach to dynamic human resource management approach which considered workers as a valuable resource. • As a result of these principles, human resource management became increasingly line management function. • Human resource management is assuming a more critical role today. Its major accomplishment is aligning individual goals and objectives with corporate goals and objectives. External Influences on HRM i. -

Global Priorities and Health Agendas Global priorities determine the overall HRH policy directions to meet the standards and goals. Some of the examples include o Sustainable Development Goals o Global Strategy on HRH Workforce and o The Kampala Declaration and Agenda for Global Action Health Worker for All and All for Health Workers, 2-7 March 2008

ii. -

Government Policy and regulations These types of regulations influence every process of the human resource management, including hiring, training, compensation, termination, etc. With the introduction of new workplace compliance standards, human resource department is constantly under pressure to stay within the law. o National Health Policy 2014 o Nepal Health Sector Strategy 2015-2020 o National HRH Strategic Plan

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iii. Regional commitments - In 2014, member statesof WHO South-East Asia Reion agreed to the “Decade for Stregthening Human Resources for Health in SEA Region 2015-2024”.

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The member states including Nepal are recommended to develop priority actions for HRH strengthening with a focus on rural retention and transformative education.

iv. National Contexts - Mathema Report 2015 and subsequent cabinet decisions for improving medical education are likely to influence HRH planning and production in health sector. - Government decisions such as guideline for mobilization of Scholarship doctor and health personnel2071. v. -

Economic Conditions One of the biggest influences is the shape of the current economy. Staff salaries alone consume 60-80% of the government’s recurrent health budget in most countries. Health staff affordable in any country depends not on the need for their services but on the resources available to support them.

vi. Technological advancements - This is considered an external influence because when new technologies are introduced, the HR department can start looking at how to downsize and look for ways to save money. vii. Workforce demographics - As an older generation retires and a new generation enters the workforce, the human resource department must look for ways to attract this new set of candidates. Current Situation of HRH in Nepal -

In the health sector, the government of Nepal has 417 sanctioned post titles and 31 occupation groups. Majority of the public health workforce is governed by the Health Service Act, 1977/98; while significant number of administrative and management staffs who are deployed to the public health sector are governed by the Civil Service Act, 1993.

An HRH assessment report of 2013 and other national data shows the following situation of HRH in Nepal i. Stock of HRH - Among the technical cadres, paramedical health workers are the largest group in the public health sector. - Public health workers comprise of only about 1% of the total health workforce. - Doctors make up about 12% of the private health sector workforce and 5% of the public health workforce and 8% of the total. - More than 80% pharmacists, 75% dentists and 60% doctors are working in the private sector. - Doctors and nurses have increased to greater proportion in 2015 as compared to 2012. ii. -

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Health Worker Population Ratio Nepal is found to have 0.17 doctors per 1000 population and 0.50 nurses per 1000 population. This represents 0.67 doctors and nurses per 1000 population, which is significantly less than WHO recommendation of 2.3 doctors, nurses and midwives per 1000 population. There are only 1 public health workers for every 100,000 population.

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iii. Regional distribution of HRH - The public health workforce is quite well distributed across the five development regions in relation to the population distribution. However, there are no specific data to get a clear picture of distribution within each region. - For the private sector HRH, the eastern, western and far-western regions have relatively fewer health workers in relation to their population. iv. Ecological distribution of HRH - The terai region has only about 36% of health workers when it accounts for 50% of the country’s population. v. -

HRH Production Nearly 200 training institutions are providing proficiency certificate level training courses for health workers. Nepal’s health training institutions are producing a large number of health workers annually with approximately 10,000 graduating each year. Between 2009 and 2011, over 32,000 health workers were produced. Over 7,000 doctors graduated from 2009 to 2011. Over 600 public health professionals are graduated each year.

Issues in HRH Development i. -

Centralized Process HRH planning is a centralized process focused on the public sector with minimal input from lower levels and consequently limited sensitivity to local needs. HRH planning is not linked to overall health planning framework.

ii. -

Inappropriate determination HRH requirements are determined by staffing norms and numbers of sanctioned posts. Neither approach accurately reflects actual need.

iii. Mismatch between need and supply - The supply of the health personnel does not correspond to need. - There is a persistent mismatch between the skills personnel have taught and those required for the positions they fill. iv. Lack of coordination - There is lack of effective coordination, consultation and collaboration among the numerous committees and individuals ministries, organizations and agencies involved in planning, production & use of HRH i.e. between MOH, national planning commission, ministry of education, universities, private sectors etc. v. -

Unplanned growth of educational institutions There is unplanned/uncoordinated growth of public and private medical schools and the establishment of new degree or training programmes within existing institutions. The new medical schools, new degree and training programmers often are established without consideration of the health sectors HRH requirements.

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vi. Policy change - Frequent policy changes affecting health personnel are introduced without assessing their impact on HRH planning and development. vii. Impotency of HURIC - HURIC data is not effectively linked to planning of health personnel. HRH Planning and Projection HRH planning as a systematic analysis of HRH needs in order to ensure that correct number of employees with the necessary skills is available when they are required. The purpose of workforce planning projections is to • Contribute to evidence-based, rationalized decisions in the formulation of national HRH policies and strategies. • Rationalize policy options based on a (financially) feasible picture of the future in which the expected supply of HRH matches the requirements for staff within the overall health service plans. • Identify short and longer term actions for achieving long-term objectives. Factors affecting HRH Projections (Uncertainties) - Change in national situation: Demographic changes, epidemiological shifts, economic change, etc. - The capacity of government for implementing the proposed interventions (both current and projected) - Conflicting priorities of different stakeholders. - Leadership turnover - Actions of stakeholders that can impact on health systems development. Supply Projection Supply usually refers to the availability and characteristics of HRH at a given time, or at a future time according to specified assumptions about production, losses and use. To assess and plan whether the future levels of HRH will be adequate to achieve future health objectives; some projections of future supply of HRH are estimated. Methods of supply projection i. Trend Projection - It is a method of forecasting future HRH supply assuming past trends and ratio in HRH movement are stable. - It is one of the simplest methods of forecasting future HRH supply. - This method involves analyzing trends from past historical data. ii. -

In and Out Method This method is based on projection of available stock of HRH and inflow and out-flows of HRH by various means.

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iii. Cohort Method - In this method, the approximate percentage of each cohort of graduates who will remain in active workforce over time is estimated. - An observed or assumed cohort retention rates are used to project numbers of each cohort of graduates who will be active in future years. - For example: 98% remain active 5 years after graduation, 96% remain active 10 years after graduation, 92% remain active 15 years after graduation. Factors affecting HRH supply - Health workers supply o HRH production/ training capacity o Human capital stock o Other resources o Global, regional, local exit and entry forces, labour market conditions - Health workers attrition/ loss o Death, out-migration o Career change Demand Projection There are four different methods of estimating demand for HRH planning i. Workforce to population ratio method - In this method, desirable ratio is established on the basis of current situations, international comparisons, recommended standards, extrapolation of past trends, etc. - The ratio is then applied to future estimates of population size to derive future HRH demand.

ii. -

Service demand method This method determines what number and kind of health services (effective demand for services) people will actually use at the anticipated monetary and other cost of providing these services. These service demands are converted into manpower demand generally by use of empirical staffing and productivity standards.

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iii. Service Target Method - This method involves the setting of targets for the production and delivery of specified health services and then conversion of those targets into manpower requirements by means of staffing and productivity standards. - The health service targets are specified by panel of experts, taking into account priorities, health wants and technical, administrative and financial feasibility of providing health services.

iv. Health Needs Method - The health needs method uses the biological needs of the community to estimate demand for HRH. - The community’s health needs are identified and quantified using judgments on desirable standards (norms) of good health care.

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Factors affecting HRH Demand - Demand for health services o Population demographic characteristics: population size, age structure o Epidemiological factors: disease patterns o Socio-economic factors: income, education o Behavioural factors: utilization patterns - Health service policy and resources o Technology and service provision patterns o Finance/ budgets Factors influencing choice of method - Magnitude of system and HRH changes sought - Nature and urgency of the HR problem  Projections for less than 10 years permit only minor changes in the health system, supply or deployment.  Projections for more than 20 years allow significant changes in the type of health system, personnel numbers and ratios. - Number of cadres to be projected - Data availability, especially on staffing patterns, costs, productivity, and on geographical and functional distribution. - Passive or active government health policies - Level of precision sought Interrelationship Development

among

planning,

production

and

utilization

(management)

in

HRH

Planning, production and utilization are interrelated processes in Human Resource Development. - HRH planning provides the basis for the production or training of health personnel in various schools or programmes. For example: Plan of MOHP and National planning Commission to increase the production of HRH in particular category triggers IOM, CTEVT and/or other universities to train more personnel in that particular category. - The graduates thus developed are then utilized and managed into the process of various health services. - For example: The graduates from the respective institutes get utilized and managed into health services within the government (DPHO/ MOHP) or non-government sectors. - Experience in HRH management (utilization) provides feedback on the basis of which production, planning and management can be appropriately adjusted. - Planning furthermore may reach on manpower training and management (utilization) if problems are identified. The interrelationship among planning, production and utilization (management) cycle in Human Resource Development can be illustrated in the diagram as follows:

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Figure: Interrelationship among planning, production and utilization (management) cycle in HRD

Importance of Career Development and Quality Assurance Career development is the continuous process of managing progression of HRH in learning and work. The quality of this process significantly determines the quality and performance of HRH. Importance of career development i. Attracting skilled HRH: Career prospects and learning opportunities are influencing factors when potential HRH are choosing between two jobs. ii. Job Satisfaction: HRH who participate in required training courses and development activities during work time have higher job satisfaction and organizational commitment. iii. Retaining HRH/ reducing attrition: Career development opportunities help to retain HRH and thus prevents turnover. iv. Service improvements and quality: The concerned departments and offices can also increase service productivity and quality by investing in their HRH via career development. Provisions for career development and capacity building of HRH in Nepal - The formal provisions covering career development opportunities, including postgraduate study, inservice training and national or international study tours, are given by the Health Service Act. - The Act dictates a range of criteria according to which such opportunities are to be made available to health workers, including: i. Relevance of the training to the employee’s work; ii. Marks in educational qualifications;

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iii. iv. v. vi.

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Seniority; Experience of service in geographical region; Work performance evaluation; and Age (in cases of training that culminates in an educational degree, candidates must be under the age of 45). Leave is available for up to four to six years for participation in the study or training programmes.

Provisions for quality assurance of HRH in Nepal - The GON has established various professional councils for the quality assurance in HRH production. These include: i. Nepal Medical Council ii. Nepal Nursing Council iii. Nepal Health Professional Council iv. Nepal Pharmacy Council - These councils are guided by respective acts and are responsible for the quality assurance in the following ways: o Determining the qualification for accreditation of health professionals o Conducting licensing examination for newly produced health professionals. o Providing recognition to training institutions for providing formal medical education and training. o Formulating code of conduct for maintaining professional ethics in health practice. Professional bodies/ Scope Roles in quality assurance councils Nepal Health Professional Public health Examination of application and registration of Council professionals and health professionals with required minimum Mid-level health qualifications, Revocation of certificate of workers frauds, Recognition to educational qualification Nepal Medical (NMC)

Council

Medical doctors

Nepal (NNC)

Council

Nurses and ANMs

Nursing

Nepal Pharmacy Council (NPC)

Pharmacists

Council for Technical Education and Vocational Training (CTEVT)

Basic and MidLevel Paraprofessionals

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Formal permission, , regular supervision of medical colleges, quality standardization, examination and certification of medical doctors, etc. Formal permission, standardization of quality, quality control, certification and accreditation of nurses. Standardization of pharmacy colleges, monitoring and supervision, quality control, certification and accreditation of pharmacy professionals. Examination, Certification and accreditation

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Quality Assurance in Health Care Quality Assurance is a continuous process which includes series of activities for improving and maintaining optimum level of quality of health care services that includes mainly; setting standards and protocols, communicating standards, developing indicators, monitoring compliance with standard and solving problems by team approach. Tenets of quality assurance - Quality Assurance is oriented toward meeting the needs and expectations of the patient and the community. - Quality assurance focuses on systems and processes. - Quality assurance uses data to analyze service delivery processes. - Quality assurance encourages a team approach to problem solving and quality improvement. Dimensions of Quality i. Technical Competence ii. Access to Services iii. Effectiveness iv. Interpersonal Relations v. Efficiency vi. Continuity vii. Safety viii. Amenities Quality Assurance cycle and health services delivery in Nepal: i. Planning for Quality ii. Setting/ Reviewing Standards iii. Communicating Standards iv. Monitoring the Use of Standards v. Identifying and Prioritizing Problems vi. Defining the Problem vii. Choosing a Team viii. Analyzing and Studying the Problem to Identify the Root Cause ix. Developing Solutions and Actions for Quality Improvement x. Implementing and Evaluating Quality Improvement Efforts Situation of HRH in Various Plans of Nepal The situation and provisions for HRH in major planning document of Nepal are: i. Health Service Act (1994) - The health service act (1997) makes provision for the management of health workers employed by the MOHP and provides guidance on the recruitment, deployment, promotion, and discipline of health workers. ii. -

National HRH Strategic Plan In 2011, Ministry of Health and Population developed the 2011-2015 HRH Strategic Plan.

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This plan aimed to ensure equitable distribution of appropriately skilled human resources for health (HRH) to support the achievement of health outcomes in Nepal and in particular for the implementation of the Nepal Health Sector Programme. HRH Strategic Plan (2011-2015) contained a range of strategies and activities to achieve this aim and the following planned outputs: o Appropriate supply of health workers for labour market needs; o Equitable distribution of health workers; o Improved health worker performance; and o Effective and coordinated human resource planning, management and development across the health sector

iii. Second Long-Term Health Plan (1997-2017) - The Second Long-Term Health Plan planned the following activities regarding HRH: o Decentralization of HRH planning within the national guidelines of the “HRH Master Plan” o Conducting periodic assessment of the need to supply of health personnel in coordination with relevant sectors, ministries, organizations and professional bodies. o Production of HRH based on projected needs rather than capacity of training institutions. - Provision of subsidies in pre-service education to candidates from remote areas and to promote gender equity. iv. Thirteenth Periodic Plan - The thirteenth periodic plan of Nepal places management of human resource as one of the major strategies. v. -

NHSP I (2004-2010) The Nepal Health Sector Programme 2004-2010 implemented following major intervention to address HRH challenge: o Two-year bond for medical graduates who studied MBBS under government scholarship to service in public peripheral facilities. o Policy and long-term plan on SBA o Incentive packages to retain doctors, nurses and technicians

vi. NHSP-III Strategic Plan (2015-20) - The NHSP-III strategic plan has defined nine outcomes for the health sector of which strengthening HRH is one among the first outcomes. - There are two outputs concerning HRH for achieving the outcome of strengthening HRH. o Output 1a.1: Improved staff availability at all levels with focus on rural retention and enrollment o Output 1a.2: Improved human resource education and competencies

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Introduction to Human Resource Information System (HURIS) HURIS is a computer-based system used to acquire, store, manipulate, analyze, retrieve, and distribute pertinent information regarding human resources for health. HURDIS can also be defined as a systematic procedure for collecting, storing, maintaining, retrieving, and validating data needed by MOH about its human resources, personnel activities, and organization unit characteristics. Status of HURIS - HURIS was developed by DOHS in 1994 with the support of GTZ. - Since 2004, the system is in operation at the Health Sector Human Resource Information Centre (HURIC), MOH. - HURIS, which is located in the MOH, was upgraded to enable districts to enter data by remote data capture using the internet. - This is a very widely used standard, international database, which is particularly suited to a huge HR database for a large number of employees. - The database includes all employees of the MOH. It does not include healthcare staff working in army, police and civil service hospitals, or those employed in the private sector. - HURIS is networked to the District Health Office, where trained operators are expected to keep it the HR date up-to-date. The database holds an extensive amount of information including: - Personal details - Education and training - Posts - Institutions, locations and resources (numbers of beds) Importance of HURIS in Nepal - HURIS as a whole mainly improves information sharing and communication between the MOHP and DOHS and its subordinate bodies. - The Human Resource Development Information System reduces cost and time spent on manual data consolidation regarding HRH information. - The system hopes to give the Human Resource Information Centre (HURIC) of MOHP more strategic role, as the information taken from HURIS can be the basis for employee training schemes and work efficiency projects. - The basic advantage of a HURIS is to not only computerize HRH records and databases but to maintain an up to date account of the decisions that have been made or that need to be made as a part of an HRH management plan. - HURIS in Nepal being an IT enabled system, data entry, update and retrieval are all significantly faster. Redundant data can be easily replaced. - A computerized system can greatly reduce fragmentation and duplication of data. All data can be stored in a single system to enable retrieval of complete picture of each HRH. Moreover, depending on the requirement, reports can be generated in different ways that provide an accurate picture. Verification of data and error rectification are also relatively easy in computerized systems. - The skill mix and distribution of HRH at different regions, districts and health institutions can be determined based on the HRH information available through HURIS.

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UNIT 7: INFORMATION MANAGEMENT SYSTEM AND THEIR USE Information Management System in Nepal Health information is an integral part of a national health system. It is a basic tool of management and key improvement for the improvement of health status in the country. The primary objective of information system is to provide reliable, relevant, up to date, adequate, timely and reasonably complete information for health managers at community, health facility, district and national levels. Some of the existing management information systems in health sector of Nepal are: i. -

Health Management Information System (LMIS) HMIS has been implemented since 1994 with the support of EDPs. The current HMIS manages information on all health services mainly delivered through government’s health facilities.

ii. -

Human Resource Management Information System (HuRDIS) This information system started in 1994 with the support of GIZ. HuRDIS is designed to provide information on HR situation of each health facility including public, private and NGO sector in the country. Currently, official records of employees of MOHP are only maintained in this system.

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iii. Logistics Management Information System (LMIS) - This system is designed to receive timely information (quarterly reports) from all health facilities on supply, consumption and stock level of selected essential drugs and commodities. - Information generated from this system is used for procurement and distribution planning. - A web based LMIS upto the district level is in operation since 2008. iv. Financial Management Information System - Financial management information system is designed to provide timely financial information. - Trimesterly (4 monthly) budget disbursement and expenditure records are maintained at district/ region and national level in more than 300 cost centers in the country. - Disbursement and expenditure reporting is channelized through cost centers to district treasury and to the Account Comptroller General’s Office. - Cost centre also send the financial reports to the respective Regional Directorate and Departments. - Financial information is available by budget heading and cost centers. - However, dissemination of financial information is limited. - The Health Economic and Financing Unit (HEFU) in MOHP has access to electronic data of 64 districts through ACGO. v. -

Training Information Management System NHTC is trying to update the training information into electronically prepared data bank (Training Information Management System). All the training information taken from different training site under national health training are being updated and made available to each participant.

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NHTC has now plan to upgrade the training management system at central level and link with regional health training centers and other clinical training sites into TMIS software. NHTC is also preparing trainers roaster on different discipline and training types.

vi. Drug Information Network - Drug Information Network was established in 1991 under DDA to develop and disseminate information on proper use of drugs, possible adverse reaction, contraindication, toxicity, drug standards and efficacy, precaution and proper storage and handling, targeting to health care professionals in the public and private sector and consumers. - Further it provides information related to products, name of manufacturing company, retail and wholesalers, and professionals registered in Nepal. vii. -

Other Information Systems Health Infrastructure Information System (HIIS) Insurance Management Reporting System (IMIS) Ayurveda Reporting System (ARS)

Problems and constraints in health information system - Significant gaps exist in information including but not limited to health status, management support services, quality of health services for all public, private and NGO sectors. - In some areas, data are collected excessively but not analyzed, used and disseminated. - Data is often not reliable and consistent. - Reporting is often delayed and incomplete. - Information/ evidence based decision making is not yet a culture adopted in the health sector. - There is a lack of skill among the health personnel to collect and use information systems. Health Sector Information System in Nepal As outlined in the health sector information strategy, the health sector information system will operate in the following way: i. Information Generation - Routine health service data will be collected at each service level and processed and use by all health personnel. - Administrative and financial data will be collected, processed and utilized by account and administrative staff as prescribed. ii. -

Information processing District Health Information Bank will serve as a center for all health and management data from health facilities located in the district, regardless of their levels. District health information bank will function as a single repository in which data will be analyzed and fed back to the facilities. MOPH, Departments and RHDs will receive reports from DHIB. A National Health Information Center will provide managerial and technical leadership for development of health sector information system.

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Figure: Health Sector Information System Health Management Information System HMIS is a system that disintegrates data collection, processing, reporting and use of the information necessary for improving health service effectiveness and efficiency through better management at all levels of health services. - WHO, 2000 - The current HMIS uses 50 forms for recording and reporting with 290 indicators being regularly monitored Key Features of HMIS - Addresses the needs of Nepal Health Sector Program, policy and programmes. - Enables selected indicators to be disaggregated by caste/ ethnicity - Enables health facility level data reporting - Integrates vertical reporting systems: EOC, Aama, CB-NCP, TB, HIV, etc. - Enables electronic data entry at district and hospital level and web-based reporting to central level. - Ensures all public and non-public facilities report to HMIS.

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Relevance of HMIS i. Relevance at central level - It supports annual planning and program implementation. - It helps assessing (evaluating) progress towards goals and targets. - It helps to monitor the achievement, coverage, continuity and quality of health services. - It links data/ information to MOHP, all departments, divisions/centers on time. ii. -

Relevance at District level It helps to identify the health problems and to solve them. It assists in assessing the coverage of different district health services. It assists in planning, monitoring and evaluation of logistics distribution. It helps in implementing social security programmes with special emphasis on free health services.

iii. -

Relevance at Grass-root level To evaluate the continuity of services to be taken by different patients. To find out the percentage of people utilizing the health services from the target population. To prepare monthly and quarterly work activities. To review the work progress.

Mechanisms to maintain the quality of HMIS i. Data Verification and follow- up meeting. ii. Feedback System (Manual & IT enabled) iii. Supervision/Monitoring iii. Training iv. Involvement of Beneficiaries /Civil Society- Annual reports Challenges and Weakness of HMIS - Due to various reasons, there is irregular, incomplete and inconsistent reporting. - The service data of private and non-government sectors are not adequately covered. - HMIS has been used merely for collection and reporting of data to higher level without proper utilization of available data. - There are large discrepancies between data reported to HMIS and recorded in registers in the health facilities. - There is a weaker practice of evidence based planning, monitoring and evaluation. - Disaggregation of data is not done to identify health needs of specific groups. - Reliance on non-technical staffs for data entries with greater likelihood of errors.

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Logistics Management Information System A logistics management information system (LMIS) is the system of records and reports that is used to collect, organize, and present logistics (drugs, vaccines and other health commodities) data gathered across all levels of the system. - LMIS was developed in 1994 and expanded nationwide in 1997. - It is designed to receive timely information (quarterly reports) from HFs on supply, consumption and stock of selected essential drugs and commodities. - Information generated from this system is used for procurement and distribution planning. - A web-based LMIS up to DPHO is in operation since 2008. - LMIS is monitored effectively by LMIS unit at LMD. - This system tracks more than 206 items at District level. Importance of LMIS - It monitors the national pipeline and stock level of key health commodities. - It maintains quality of drugs and commodities. - It estimates annual requirements of program commodities including contraceptives, vaccines and essential drugs.

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It helps to make demand and ensure supply of drugs, vaccines, contraceptives, and essential medical supplies at all levels. It helps in determining the stock level and additional stock for health facilities and hence manages logistics supply. Ensures year round availability of drugs and commodities.

Strengths of LMIS - A nationwide LMIS producing reliable logistics data for decision making at all levels. - Improvement in storage practices, thus reducing the waste and expiry of commodities. - LMIS made possible and successful introduction of the pull system for essential drugs. Problems and constraints of LMIS - Web-based LMIS and inventory management system are not updated regularly.

Logistics Management Logistics management is an integrating function, which coordinates and optimizes all logistics activities, as well as integrates logistics activities with other functions including marketing, sales manufacturing, finance, and information technology. - Council of Supply Chain Management Professionals (CSCMP),2011 Necessity of logistics management Logistics management is necessary to benefit public health programs in many important ways as follows: i. Logistics management increases program impact - If a logistics system provides a reliable supply of commodities, more people are likely to use health services. - Customers feel more confident about the health program when they have a constant supply of commodities. It motivates them to seek and use services.

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Logistics management enhances quality of care Well-supplied health programs can provide superior service, while poorly supplied programs cannot. Likewise, well-supplied health workers can use their training and expertise fully, directly improving the quality of care for clients. An effective logistics system helps provide adequate, appropriate supplies to health providers, increasing their professional satisfaction, motivation, and morale.

iii. Logistics management improves cost efficiency and effectiveness - An effective supply chain contributes to improved cost effectiveness in all parts of a program, and it can stretch limited resources. - Strengthening and maintaining the logistics system is an investment that pays off in three ways. • It reduces losses due to overstock, waste, expiry, damage, pilferage, and inefficiency; • It protects other major program investments; and • It maximizes the potential for cost recovery. Logistics Management System of Nepal -

Prior to 2003, the Ministry of Health relied entirely on a ‘Push System’ to allocate health commodities based on historical consumption patterns and equitable rationing of national drug stocks. Logistics Management Information System of Nepal is currently based on hybrid push and pull system.

Push System of Logistics Management - A push system is a supply based approach in which logistics are supplied to lower based on decisions from higher levels. - Push system exists from central (Logistic Management Division & Central Medical Store) and regional level (regional medical stores) to district levels. Pull System of logistic management A pull system of logistic management is a demand based approach for ensuring the reliable availability of health commodities at all service delivery points within a health system. Pull system exists below district level. Half the annual estimated consumption of a health facility is dispatched directly to the facility. The remaining half is stored at district level for demand-based supply The supply of health commodities to health facilities are made based on demands from peripheral health facilities. - Regional medical store maintains buffer stocks of key essential drugs to supply district stores as per need. Merits and Demerits of pull system Merits Demerits D(P)HO - Pull system brings improvement in over and under - Repeated packaging and supply stock situations of commodities may incur - Ensures year round availability of drugs and greater costs. commodities Peripheral - Helps to emergency order of essential drugs. - There may be problem in supply Facilities - Facilitates availability of health commodities round if particular drugs are demanded the year. by many health facilities at the - Field level health personnel are empowered same time because of decentralized logistics decision making

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Figure: Logistic Management System of Nepal Logistics Management Cycle A logistics management includes a number of activities that support the six rights. Over the years, a model has been developed to illustrate the relationship between the activities in a logistics system; called the logistics management cycle. Major activities in the logistics Management Cycle: i. Serving customers - Everyone who works in logistics management must remember that they select, procure, store, or distribute commodities to meet customer needs. - Storekeepers provide customer service when they issue logistics to the health facility, and the central medical stores provide customer service when they issue commodities to the region and district ii. -

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Selection In any health logistics system, health programs must select drugs and commodities. Selection of products is made on the basis of national list of essential medicines. In a health logistics system, a national formulary and therapeutics committee, pharmaceutical board, board of physicians, or other governmentappointed group may be responsible for product selection.

iii. Quantification - After logistics have been selected, the required quantity and cost of each item must be determined.

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iv. Procurement - Procurement of health logistics is the responsibility of procurement unit at LMD. - After a supply plan has been developed as part of the quantification process, quantities of logistic items must be procured. - Health systems or programs can procure from international, regional, or local sources of supply; or they can use a procurement agent for this logistics activity v. -

Inventory management: storage and distribution After the logistic items have been procured and received by the health system or program, it must be transported to the service delivery level where the client will receive the products. LMD is responsible for the distribution of medicines from its central and regional stores to the district stores. DPHO is responsible for sub-district level distribution and storage.

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Health Systems Management

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