CHAPTER 6. MANAGING AND ADMINISTERING (THROUGHPUTS-PROCESSES)
6.3 Planning
Planning is a powerful tool that has to be used carefully. Indeed, how many strategic or operational plans have been implemented as planned? Which components of a planning policy should be used2? To be consistent with the approach developed so far in the DSMPHDS MPHMA, the planning policy and methodology implemented is related to the configuration school approach. In the following section we will present the systemic planning policy and methodology retained for the implementation of the DSMPHDS MPHMA, and later we will present the DSMPHDS Performance Standards Control System.
6.3.1 Implementing a systemic operational planning policy
Once the minimum health and related managerial and administrative activities along with their needed resources have been identified and once an adapted organisation (see Chapter 7) and updated functioning processes have been defined, a relevant implementation mechanism needs to be established. A planning mechanism has to be elaborated, and should be based on the following guidelines:
• A planning mechanism that would link together all the system’s sub-systems: the delivery of health activities, the resources, the various managerial and administrative activities and the organisational capacity of the health system. Furthermore, it is a bottom up policy in which all tiers are involved.
2
For example, we could name the Design, Planning, Positioning, Entrepreneurial, Cognitive, Learning, Power, Cultural, Environment or Configuration planning schools
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• This planning methodology must be inc luded in a planning policy, which incorporates monitoring, supervision and evaluation procedures. Indeed, the lack of success generally encountered in implementing plans is related to the absence of monitoring, supervision and evaluation operational objectives built into the plan itself.
• It also needs a formal organisational service/unit, the planning services, whose mandate is to co-ordinate the implementation of the planning policy.
• The planning chart is based on four general objectives linking all the services together to the specific implementers of the objectives and related budget (resources). It consists of the following related objectives: improving organisation and management, administrative services, planning, and programme delivery (see Table 6.2).
• The supervision procedure includes a schedule in which each facility is supervised on a quarterly basis by the Municipal Offices of Health senior staff: the director, the administrative services co-ordinator, the accountant, the maintenance team leader, the programme co-ordinators, and the curative, preventive, CBHC-IEC, pharmacist and laboratory co-ordinators. It also includes “check lists” related to the DSMPHDS Performance Standards Indicators (PSI) (see below).
• The monitoring procedure is also built into the plan of operations itself. Indeed, each tier (Dispensary, Health Centre, Hospital, MMOH, CMOH) and their related services (planning, programmes, administration) are supposed to hold fortnightly Health Management Team (HMT) meetings. The agenda of these meetings is based on a follow up of the respective tier and services plan of operations.
• As far as evaluation is concerned, the policy is based on quarterly and mid term evaluation and directly linked to the DSMPHDS performance standards indicators
• The DSMPHDS planning methodology should be as comprehensive as possible and integrate the objectives, activities and resources of the major stakeholders.
122 Table 6.2. The DSMPHDS Planning Chart.
TIME FRAME BUDGET
OBJECTIVES J F M A M J J A S O N D BUDGET PER FUNDING SOURCE TOTAL BUDGET
IMPLEM - ENTERS
EVALUATION INDICATORS
1.0 General Objective
Related to the improvement of the structural and functional components of the system (R/CMOH, MMOH, HF)
1.1- Operational Objectives, etc.
2.0 General Objective
Related to the improvement of
service administration
2.1- Operational objectives, etc.
3.0 General Objective
Related to the improvement of
service planning
3.1- Operational Objectives, etc.
4.0 General Objective
Related to the improvement of
service delivery
4.1- Promotive services
4.1.1- Operational objectives, etc
4.2- Preventive services
4.2.1- Operational objectives, etc
4.3- Curative services
4.3.1- Operational objectives, etc
4.4- Rehabilitative Services 4.4.1- Operational objectives, etc
5.0 General Objective
123 6.3.2 Performance Standards Indicators
Ultimately, the purpose of the health system is to provide high quality care to patients suffering from diseases (or prevent disease) that have been chosen as priorities. However, quality has many dimensions. For the patient to receive the right kind of health care a number of different preconditions must exist. Quality from the health provision standpoint has been argued to consist of structural, technical, socio-cultural and process aspects (Wyss, Schopper et al. 2001). In addition, there are other aspects, which are necessary for the support and co-ordination of the health care quality aspects. Therefore, quality needs a broad definition, one that is holistic and has a systemic focus.
Definition of quality of care: Quality of care is “a set of managerial, administrative, technical and interpersonal practices that contribute to the promotion of community health by transforming social relationships which ensure better health conditions in acceptable and achievable standards within the local and social context of the country” (Quoted in Cloutier 2001). For each of these, the aspects for performance monitoring is described in turn below: - Managerial practices refer to a set of prerequisites such as the organisation (structural)
and functioning processes, decision-making, flow of information, planning, monitoring and supervision. It is also related to the incentive system, for personnel to perform to the best of their ability, under the constraints faced.
- Administrative practices include provision of adequate human, material and financial resources for better health delivery services. It focuses more on the mechanisms and administrative routine of policy implementation, monitoring and control.
- Technical practices refer to health care providers’ clinical and technical competence. - Interpersonal practices refer to the expectations and subjective experiences of the
patients, and difficulties encountered, when interrelating with a health care practitioner. - Contribution to the promotion of community health by transforming social relationships refers to the conceptualisation of health promotion in the way that it reaches the community and individuals. In the conventional practitioner-patient relationship, the practitioner exercises control over the patient; also, there are larger political, social and historical influences on the patient that (s)he is hardly aware of.
- Better health conditions in acceptable and achievable standards within the local and social context of the country refers to the means for implementing and respecting minimum standards of health delivery in accordance with the capability of the country.
Therefore, quality of care needs to be looked at holistically, and from the viewpoint of the form and functioning of the health system in Dar es Salaam, in order to ensure all relevant
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aspects are taken into account in designing an optimal quality improvement methodology. These elements are covered in the following sections.
1. Organisational performance standards
Objective:
• To design and put in place the DSMPHDS (updated) health sector reform organisational chart.
Performance standards:
• All technical and administrative decisions are taken at their level of implementation.
• Health Boards at all levels (facilities, district offices) approve the plan of operations, budget, and evaluation.
• The population receives 24 hour first line services 7 days a week from the three designated strategically situated dispensaries in each municipality.
• All private health facilities, on a municipal basis, are supervised as planned.
• The DSMPHDS holds its Steering Committee bi-annually.
Data sources and collection:
• These indicators can all be sufficiently monitored by the City Medical Office receiving complete minutes of the relevant meetings, and feedback from the MMOH.
2. Management performance standards
Objective:
• To implement fully the DSMPHDS Planning Policy.
Performance standards:
• All the tiers of the health system produce an annual integrated plan of operations, taking into account instructions from the utilisation of the basket funds and the various national programmes (guidelines)
• All tiers of the health system produce quarterly evaluation reports
• All tiers of the health system are supervised by the MMOH on a quarterly basis
• The three Municipal Medical Offices of Health are supervised by the CMOH on a monthly basis
• All tiers of the health system use the HMIS information for planning, management and administration (where relevant).
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Data sources and collection:
• Routine management systems.
3. Administrative performance standards
Objective:
• The MMOHs plan human, material and financial resources in a consistent manner and feed into the MPHMA, with supervision on norms and procedures from the CMOH.
Performance standards:
Human resources
• All health facilities are staffed appropriately – that is, they have their minimum staff quota (for the level of the health system), and additional staff is allocated on the basis of patient attendance rates.
• Those in management positions (facility in-charge, service and programme coordinators) are trained in health management.
• Those in administrative positions are trained in resource administration.
• Clinical staff are trained and upgraded in the use of standard treatment guidelines (STG).
• Staff are evaluated for performance and disciplinary measures are taken where necessary.
• New staff are informed of the DSMPHDS orientation policy.
Material resources
• All under-served areas are covered with health facilities.
• All facilities are equipped with infrastructures, plants and vehicles according to the defined standards in the Master Plan.
• All facilities, services and units are equipped with administrative resources.
• Those in administrative positions are trained in resource administration.
• All infrastructures, plants, vehicles, non-medical and medical equipment is maintained and/or rehabilitated.
• The waste administration policy is implemented in all tiers.
126 Financial administration
• All tiers produce an annual integrated budget and auditing.
• All tiers produce a quarterly integrated budget evaluation.
• All tiers produce an integrated monthly comparison budget.
• All tiers implement the DSMPHDS’s cost recovery policy.
• All tiers implement the DSMPHDS’s user charges exemption policy.
Data sources and collection:
• Finance department and planning department.
• Boards and management committee.
• Cost sharing records.
4. Health care activity performance standards
Objective:
• To implement the DSMPHDS Minimum Package of Health Services (curative, preventive and promotive).
Performance standards:
Curative activities
• All tiers are implementing the Minimum Package of curative health services, with focus on: history taking, physical investigation, investigation services, and the delivery of treatment (using STGs).
Preventive activities
• All tiers are implementing the Minimum Package of preventive health services, with focus on: MCH first-line services, and maintaining a high EPI coverage.
127 Promotive activities
• Community based and community involvement activities are carried out at local dispensaries and in the community with the support of health boards.
• Information, Education and Communication activities are carried at dispensary and community bases.
• School health activities are carried out in each school per tier.
• Environmental and transmissible diseases are targeted, with a focus on malaria and cholera.
Outcomes:
• Coverage rates, treatment rates, cure rates and changes in health status
Data sources and collection:
•
Recording of services provided (HMIS).•
Checklists•
IEC Service Quality Assessment for Health Care Providers.•
IEC Service Quality Checklist for Supervisors.•
Supervisory Quality Checklist on Client Satisfaction.6.3
General management
General management refers to the mission, mandates and main functions of the various tiers and in-charges (see Tables 7.2 and 7.3).
a) At the R/CMOH level, general management refers to the various functions related to the harmonization of the DSMPHDS between the various municipalities and to their implementation of GoT (MoH/RLG) policies, norms and procedures.
b) At the MMOH level, general management refers to the various functions related to the coordination, monitoring and supervision of the health facilities and to their implementation of GoT policies, norms and procedures.
c) At the health facility level, general management refers to the implementation or delivery of health services and to the implementation of GoT policies, norms and procedures.
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6.4
Conclusion
Since 1994/5, in the framework of GoT policies and procedures, the DSMPHDS developed specific ways of administering and managing its own system. The implementers, be it at regional, district (municipal) or facility levels, must adapt the government policies and procedures to their local conditions. Indeed, the health status of the population, the environment and the health system capacity varies from one region to another. One has to develop a suitable health delivery system for each locality.
Also, the environment changes over time: the environment and health system of 1995 is not the one of 2003. Henceforth, the DSMPHDS administrative and management activities described previously and this second version of the MPHMA have been harmonized with the current health sector SWAp and Rlocal Government Reforms currently implemented nationwide.
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CHAPTER 7.
THE
DSMPHDS
STRUCTURAL
AND
FUNCTIONAL
ORGANISATION
(FEEDBACK)
CHAPTER 7 AIMS
• Present the range of structural and functional components of the DSMPHDS organisation
• The mission, mandates and functions of the various tiers
• The decentralisation and decision making processes
• Organisational charts per tier
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7.1
Introduction
The Dar es Salaam Public Health Delivery System (DSMPHDS) - from local, operational and systemic points of view - reviewed the Dar es Salaam Health System, to examine the impact of health sector reform (HSR) and Regional/Local Government (RLG) Reform (HSR) on its organisation and functioning processes. A restructuring of the system was proposed by the DSMPHDS taking into consideration the general elements and determinants of the DSM health environment and its’ nature as a divisionalised/professional bureaucracy. The proposals also took into consideration the Minimum Package of Health and related Management and Activities (MPHMA) that had been defined for the system, that is: the services to deliver (outputs), the human, material and financial resources (inputs), and the management and administrates processes (throughputs). The following organisational charts are part of the health organisation feedback system. It stipulates who has the authority to do what, how she/he should do it, and what qualifications she/he should have.
7.1.1 Professional bureaucracy in a “divisionalised” form
The organisational updating took into consideration the nature of health organisations. A hybrid form or structural organisation was elaborated for DSM in which it is seen as a mix of a ‘divisionalised and a professional bureaucracy’. ‘Professional’ for the health facilities because health organisations need well educated staff to carry out complex tasks. And ‘bureaucratic’ because, once acquired the prerequisite knowledge after years of learning, what it is all about is to administer the pre-defined treatments to the identified diseases. The DSMPHDS also has bodies that are not delivering direct health services to the population but are rather co-ordinating, monitoring and supervising the health delivery facilities: these are City/Region and Municipal Medical Offices of Health. They are seen as divisionalised bureaucracies because they have to co-ordinate different health organisations (dispensaries, health centres, hospitals, which are public, private, parastatal and missionary) situated in different localities that all together have different socio-economic status.
These definitions were chosen from local and operational points of view; they involved the major stakeholders, and were made suitable for the DSM specific environment that we will present in the next section.
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Figure 7.1 summarises the general DSMPHDS implementation methodology and strategy, which was based on health sector reform, Rlocal government reform, the Dar es Salaam population health status, the Dar es Salaam environment, and the private health service.
Figure 7.1. The influences on the DSMPHDS Strategy
7.1.2 The organisational vision
The restructuring was not only a matter of replacing one organisation with another, or changing a few of the functioning processes. It was a matter of implementing a new organisational and managerial philosophy that would embody the vision expressed in the Regional/Local Government and Ministry of Health reforms. In this organisational vision, the focus is on the population (see inner circle of Figure 7.2). Indeed, the population is the primary justification for the health system, for which the health system is built and operated. The first and second circles in Figure 7.2 represent the first line (dispensaries and health centres) and second line (hospitals) services. The third circle represent the DSM Region/City
Health Sector Reforms
Regional /Local Government Reforms
DSM Health Status & Environment.
Private Health System.
-Decentralisation to Districts/ municipalities -Community Involvement. Health Boards &Cost Sharing
-Intergration
of National Programs
-Public Private mix.
Decentralisation of the DSM City into 3 Municipalities with Direct authority on the Municipal Medical Offices of
Health
-Complexity, Density, Heterogeneity of Urban settings.
-3 Million people with large socio
-economic
inequalities.
-Poor environment: water,sanitation,housing. -Public system: 65 HF;3 Municipals offices of Health. 1 Region. -Transmissible diseases (Malaria, TB, AIDS) and emerging HBP & Diabetes.
More than 350 “modern” private Facilities.More than 2500 “traditional” private
practioners .
STRATEGY:
From a Local, operational and systemic point of view, Focusing on the development of DSMPHDS Managerial and Organisational capacity
-Linking together the delivery of services, the resources, the processes and the organisational capacity; -Setting of a political and administrative decentralised
organisation implementing the HSR & RLG reforms vision.
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in which major stakeholders - the third line/national referral national hospitals - are part of the DSM environment. Figure 7.2 includes the administrative and political authorities involved at their on level (DSM, Municipality and Health Facilities) of responsibility, as well as the decentralisation of the system. The Health Boards demonstrate the importance of the population involvement and are a guarantee of better transparency and democracy for the DSMPHDS.
Figure 7.2. Organisational and managerial philosophy of the DSMPHDS
Key to Figure 7.2: GoT: Government of Tanzania; MoH: Ministry of health; RLG: Regional/Local Government; DSMHBA: Dar es Salaam Health Board Association; HB: Health Board; I/c: health facilities in-charge; RC/MoH: Regional/City Medical Office of Health; MMOH: Municipal Office of health
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7.1.3 The logical structure underlying the new organisation
The new organisation is based on an underlying logical structure, which has political, organisational, managerial, administrative and technical aspects.
Technical: The health services to be delivered (the outputs of the system) were defined through a Minimum Package of Health and related Management Activities (MPHMA). The national/vertical programmes were integrated in the organisation through the Programme Service Units’ Preventive, Promotive and Curative sub-units (see Chapter 4).
Administrative: The necessary human, material, and financial and information resources (inputs) were identified, together with the identification and implementation of adapted procedures (see Chapters 3 and 5).
Managerial: The processes (throughputs) of the system were identified. Co-ordination and decision-making mechanisms were put in place. A systemic planning methodology was elaborated, linking together the capacity of the organisation, its resources, its processes and its delivery of services. The planning cycle, with its monitoring, supervision and evaluation components, was built into the plan of operations to secure implementation of the plan. A Standard Performance Control System was also elaborated (see Chapter 6).
Organisational: The structural components of a Health Delivery System (feedback) were identified for the specific environment of Dar es Salaam. The referral system was defined and new organisational charts were elaborated. Each tier was given an Administrative Services Unit. The Municipal (district) Medical Offices of Health were structured into Administrative, Planning and Programmes Services. The chart for each tier included its mission, mandates and functions, along with the job descriptions of major cadre positions. The process of defining the structures included the integration of “vertical” programmes that already existed in each tier. Provisions for the supervision of private health facilities were given appropriate weight.
Political: Straightforward mechanisms were put in place to ensure the decentralisation of decision-making processes, both for the staff and for the general population. Health Management Teams were formally put into place in districts and health facilities. Decision making processes were also decentralised further within the districts and hospitals, to the level of their services. Finally, Health Boards were put in place in all districts and health facilities. A DSM Health Board Association was created in December 1999.
135 7.1.4 Integration of all aspects
Through a systemic approach, the equilibrium was found between these various logics. Indeed, all theses sub-systems have to be seen in relation to each other. The functioning of