Professional Documents
Culture Documents
Prabesh Ghimire
Health Systems Management 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
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.
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.
v. 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.
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.
- 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.
Comparison of different health care system/ nature of different health care systems
Definition of Role of the Budget
Model Funding Strengths Weakness
Health Care State Control
Weak (except Consumerism,
Private and Provider-
for specific For profit high costs,
Free Market Health care state/ friendly,
groups); insurers fragmentation,
(US, South Africa, as a federal professional,
providers are and unequal
Switzerland etc.) commodity government autonomy,
mainly private government access and
financing flexibility
entrepreneurs uninsured
Health care
as
Welfare State Strong: Equal access
guaranteed, Bureaucracy,
(Germany, controls and Ministry of to
state- Taxation underfunding,
Netherlands, finances health comprehensive
supported rigidness
Japan, UK) facilities services
consumer
service
Socialist State Health Care Very strong;
Full and equal
(communist as state owns facilities Bureaucratism,
Government access, low
countries; former provided pays State/party rigidness,
funding costs, full
Eastern Europe, public providers corruption
coverage
Cuba) service directly
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.
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
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.
- DPHO puts forward health projects from both government and non-government
sectors with priority in the thematic committee.
XI Integrated Plan - This meeting is organized to revise, amend and prioritize the projects recommended
Formulation by thematic committee through proper analysis of their interrelations and
Meeting complementarities.
XII DDC Meeting - 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
XIII DDC Council - DDC council approves the projects endorsed by integrated plan formulation
committee.
- DPHO chief is involved to provide necessary justifications for the project, if necessary
XIV Implementation - 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.
The Logical Framework Approach (LFA) is an analytical process and set of tools used to support
objectives-oriented project planning and management.
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.
2. Planning Stage
i. 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 projects hierarchy of objectives
o How the projects achievements will be monitored and evaluated (indicators and sources of
verification)
o The project environment and key factors critical to the projects success (assumptions)
- The log frame also provides the basis on which resource requirements (inputs) and costs (budget)
are determined
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.
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.
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 Activities
Awareness/ Forming Making each members of the team aware of the goals and objectives.
and his/her roles and responsibilities
Conflict-resolution Managing and resolving conflicts at work
Cooperation Involving all members in decision-making
Productivity Working on each others problems and focusing on productivity
Separation Recognizing contributions and achievements
- 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.
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.
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.
v. Interpersonal skills
- Negotiators with patience and the ability to persuade others without using manipulation can maintain
a positive atmosphere during a difficult negotiation.
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.
ii. 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
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. Delegating task
vi. Avoiding over-commitments: Learning to say no to unnecessary tasks.
vii. Discouraging unnecessary interruptions: e.g. unnecessary telephone calls, meetings, visitors, etc.
viii. 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.
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 individuals 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
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.
Delegation of Authority
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.
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
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
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.
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.
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
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
Leprosy Control Division and Communication Center
- 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.
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:
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.
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.
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.
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 citizens 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 peoples participation in extending health services.
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.
Vision: All Nepali citizens have the physical, mental, social and emotional health to lead productive and
quality lives.
Mission: Ensure citizens 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.
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
Sector-Wide Approach
- 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.
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
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 theyre 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.
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 peoples 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 long-
term focus,
- Senge advocates the use of system maps that shows how systems connect.
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.
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. Leader as designer:
- In essence, the leaders 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.
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 organizations 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 organizations 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.
3 Involvement of people - People at all level are the essence of an organization and their full
involvement enables their abilities to be used for the organizations
benefit.
4 Process approach - A desired result is achieved more efficiently when activities and related
resources are managed as a process.
5 System approach to - Identifying, understanding and managing a system of interrelated
management processes as a system contributes to the organizations effectiveness
and efficiency in achieving its objectives
6 Continuous - Continuous improvement of the organizations overall performance
improvement should be a permanent objective of the organization
7 Evidence based - Effective decisions are based on the analysis of data and information.
decision making
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.
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
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
- Planning - Procurement
- Organizing - Development
- Staffing - Compensation
- Directing - Maintenance and motivation
- Controlling - Integration
- The member states including Nepal are recommended to develop priority actions for HRH
strengthening with a focus on rural retention and transformative education.
v. Economic Conditions
- One of the biggest influences is the shape of the current economy.
- Staff salaries alone consume 60-80% of the governments 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.
- 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.
v. HRH Production
- Nearly 200 training institutions are providing proficiency certificate level training courses for health
workers.
- Nepals 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.
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.
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.
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.
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.
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:
Figure: Interrelationship among planning, production and utilization (management) cycle in HRD
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.
iii.
Seniority;
iv.Experience of service in geographical region;
v. Work performance evaluation; and
vi.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.
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.
Dimensions of Quality
i. Technical Competence
ii. Access to Services
iii. Effectiveness
iv. Interpersonal Relations
v. Efficiency
vi. Continuity
vii. Safety
viii. Amenities
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.
- 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
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
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.
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:
- 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.
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
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.
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.
- 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.
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
- 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.
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.
ii. 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 government-
appointed 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.
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