Health policy and Managemenkgjajhfguiyejkdjuy luht.pptx

Health policy and Management Yalemwork Kerie ( MPH ), PH Department Arsi University, 2024. 1

COURSE CONTENTS 1. Introduction Definitions of Management, health and public health Meaning and scope of health service management 2 . Management Theories • Introduction • Classical management theory • The behavioral school • The quantitative school • Other approaches to management theory 2

Cont. 3 . Development and Organization of the health system Global typologies for health systems Development and organization of the health system in Ethiopia (indigenous/modern, public/private) Approaches in organization and delivery during various periods (modern health services, basic health services, PHC, SWAP); Initiatives in health development (including MDGs, PASDEP) Policies, strategies and programs during various periods 3

Cont. 4 . Management and leadership in the health sector Health management with focus to the Ethiopian health system (planning, organizing, implementation, monitoring and evaluation) Concepts and applications of leadership in the health sector 5. Resource Management (human, finance, time and material Human Resource Management Human Resource Planning Recruitment and selection Orientation and Socialization Supervision Performance appraisal Promotion, transfer and supervision 4

Cont. Theories of motivation • Content theories of motivation • EGG theories • Two factor theories • Process of theories of motivation • Implication for health managers ➢ Managing other resources • Managing materials/ Equipment • Managing drugs • Managing finance/money • Managing time • Managing space 5

Cont. 6. Health services coverage, utilization and quality The concept of coverage and patterns of health care utilization (including organization and use of the referral system) Quality of health care 6

Cont. 7. Health Economics and Health Care financing Application of economics to the health sector Demand and supply in the health sector Issues of equity in the health sector Methods of economic evaluation and costing of health care programs Principles and types of healthcare financing Healthcare financing in Ethiopia 7

Cont. 8. Health management information system (HMIS) Principles and components of HIS/HMIS Ethical and legal issues in HMIS Application of IT in the analysis and management of health systems Ethiopian HMIS 8

Cont. 9. Managing a health team • Structure and functions • Staffing patterns • Controlling and assessing the work • Health information in the management process ➢ Public Health Laws/ National health legislations 9

Teaching methodology Lecture Discussion Individual reading Student presentation Assessment Group/individual assignments Tests/ quizes Final Exam 10

References 1.Management Sciences for Health (MSH). Managers who lead. MSH, 2005. 2.Wagstaff A, Van Doorslaer E. Equity in the finance and delivery of health care. 1995. 3.Shaw RP, Griffin CC.Financing health care in Sub-Saharan Africa through user fees and insurance.The World Bank, 1995. 4.Drumond MF, Stoddart CL, Torrance GW. Methods for the economic evaluation of health care programs. 1993: 39 - 54. 5.Jira C. Health planning for health science students. Carter Center; 2003. 6.Jira C, Feleke A, Mitike G. Health services management for health science students. Carter Center; 2003. 11

Reference cont. 7.Berhane Y, Haile Mariam D, Kloos H. The epidemiology and ecology of health and disease in Ethiopia. Addis Ababa; Shama Books, 2006. 8.Haile Mariam D. Exploring Alternatives for Financing Health Care In Ethiopia: An Introductory Review Article.Ethiop J Health Dev2001;15(3):153-163. 9.Pankhurst R. An introduction to medical history of Ethiopia, with a postscript by AsratWoldeyes . Trenton, New Jersey; 1990. 10.Walt G, Vaughan P. An Introduction to the Primary Health Care Approach in Developing Countries: A Review with Selected Annotated References. Ross Institute of Tropical Hygiene: London School of Hygiene and Tropical Medicine; 1981 12

Introduction to Health service management Learning objectives At the end of this session, you will be able to; Define management, health and public health Know the meaning and scope of health service management List the concept and principles of management Explain management and environment Mentions the types, skills and roles of managers State the main functions of management 13

Rationale for the course 14

This course is designed to equip medical students with the knowledge , skills, and attitude needed to lead and manage health service and organizations. 15

Definitions Management is defined in several ways - Getting things done through people. - The efficient use of resources. - Getting people to work harmoniously together and to make efficient use of resources in order to achieve objectives. 16

Cont. It is the process of reaching organizational goals by working with and through people and other organizational resources . The process of directing, coordinating , and influencing the operations of an organization so as to obtain desired results and enhance total performance . 17

Cont. Management is the process of Planning, Organizing, Leading, and c ontrolling the efforts of organizational members and of using all other organizational resources to achieve stated organizational goals . HSM- the b ranch of management that is concerned with planning, organizing, staffing, directing/leading, controlling and coordinating the delivery of health care service within a health facility. 18

Cont . Health management: the application of management principles for health care. Health policy: decisions, plans and actions that are undertaken to achieve specific health care goals within a society. It outlines priorities and the expected roles of different groups; and it builds consensus and informs people (WHO). 19

Cont. Which definition do you prefer and why do you like it? Write your own definition of management that applies to your situation. 20

Cont. The definition of management is based on two principles: 1.Commitment to achievement, and 2. The importance of people and other resources. This means that people are the most important resource for getting things done. 21

Administration and Management The term "Management" and "Administration" are used interchangeably in government and business organizations. Administration - Means overall determination of polices and major objectives. Functionally: It is the laying down of the general purpose of the organization. The framing of its major polices. The formulation of general plan of procedure. Approval of specific major projects that fall within the general programme . 22

Cont. Management :is essentially an executive function, the active direction of human effort . It is the work that a manager seeks to get results through other people. 23

Definition of health and public health Health Health is a very abstract concept to conceptualize and measure and it is too difficult to put in words. It is a broad concept and its definition also differs among social classes, cultures, religion and ethnic groups. Generally, there are two opposing models concerning the definition of health: 24

Cont. I . Negative (narrow) model II. Positive (broad) model I. Negative (narrow) model This model views health as: Absence of diseases or disability or infirmity Physical and physiological capabilities to perform routine tasks. 25

Cont . According to this definition, Individual is health if all the body parts; cells, tissues, organs, organ systems are functioning well. Doctors tend to go along with this idea and are intense on active intervention with drugs or surgery rather than educational intervention to change behavior Despite its narrowness, it is a widely held view among lay man by equating health with the absence of diseases. Disease “A” + Medical treatment = health 26

Cont . II. Positive (broad) model The positive model - sees health as a broader and more holistic concept. Probably the most widely known of such models is that of the constitution of World Health Organization (1948), which defines health, as: “ A state of complete physical, mental, and social well-being not merely the absence of disease or infirmity.” This classic definition is important, as it identifies the vital components of health. 27

Cont . To more fully understand the meaning of health, it is important to understand each components of health: 1. Physical health It is the absence of diseases or disability on the body parts. It is the biological integrity and the physiological well functioning of the human body. It is the ability to perform routine tasks without any physical restriction. 28

Cont . 2. Mental health Termed as psychological health and it is subjective sense of well being . It has two major components: A. Cognitive component Is the ability of an individual to learning, perceiving, thinking clearly. E.g. A person is said to be mentally retarded if he cannot learn something new at a pace in which an ordinary person learns. 29

Cont . B. Emotional component Is the ability of expressing emotions (e.g. fear, happiness, and to be angry) in an “appropriate” way. Also means maintaining one’s own integrity in the presence of stressful situations (tensions, depression and anxiety). E.g. if somebody gets into coma during an examination. 30

Cont. 3. Social health Is the ability to make and maintai n “acceptable” and “proper” interaction and communication with other people and the social environment; satisfying interpersonal relationship and role fulfillment. For example, to mourn when close family member dies, to celebrate festivals, to create and maintain friendship etc. 31

Cont. The absence of health is denoted by such terms as disease, illness and sickness, which usually mean the same thing though social scientists give them different meaning to each. Disease is the existence of some pathology or abnormality of the body, which is capable of detection using, accepted investigation methods. 32

Cont. Illness is the subjective state of a person who feels aware of not being well. Sickness is a state of social dysfunction: a role that an individual assumes when ill. 33

Public health Definition Public health is defined as the science and art of preventing diseases, prolonging life, promoting health and efficiencies through organized community effort. It is concerned with the health of the whole population and the prevention of disease from which it suffers. 34

Concept and principles of management In the process of fulfilling his/her managerial duties the manager would apply the following concepts and principles. Concepts 1 Effectiveness Effectiveness is the degree to which a stated objective is being achieved . It is the ability to choose the appropriate objectives and achieve them. Is the measure of how well an organization or person is meeting his/her goals. It is something that management tries to improve . 35

Cont . 2. Efficiency is defined as the ability to accomplish something with the least amount of wasted time, money, and effort or competency in performance. It is concerned with the balanced use of resources ( money, material , human resource, time and information ) Is the measure of how well an organization is using its resources to achieve its goals. 36

Cont. 3. Economy of scarce r esources Some, and often many, resources are scarce and costly thus we have to economize. 4. Work relations Work activities should be designed and structured so as to support each other towards the achievement of objectives. 37

Cont. 5. Information Management needs information if it is to make the right decision for action. At the same time, information can easily handicap management , if it is not the right kind at the right time and in the right hands. 38

P rinciples of management 1.Management by Objective: Management sees that objectives are specified and then if they are achieved. The objective should state: What is to be accomplished How much of it Where it is to be done When it is to be completed. 39

Cont. Therefore, a clear statement of objectives makes it possible to evaluate how effective one is in approaching and reaching the objectives 40

Cont. 2.Learning from experiences: -Analysis of the results between the objectives and achievements made. For better performance there should be feedback to learn from the experience gained. 41

Cont. 3.Division of labor: - Management attempt to bring about balance of work among the different people concerned . 4.Substitution of resources: often when the resources that are normally used to provide services become scares or too expensive , different resources may be used to provide the intended results . 42

Cont. 5.Convergence of work Working relations should contribute to the success of each activity and so to general effectiveness. These working relations of activities are:- -the logical relations with each other -time relations or sequence -functional and structural-working relations between people 43

Cont. 6.Functions determine structures When the work is defined i.e. the function and duties of the individual members of the team are clearly defined and known to all. The exact nature of authority will be clearly delineated on the structure. 44

Cont. 7.Delegation : takes place when some body’s authority is lent, to enable that person to take responsibility when the occasion arises . Delegation is the assignment of authority to another person to carry out specific activities . It is the process of distributing and entrusting work to another person, and therefore one of the core concepts of management leadership. 8.Management by Exception: do not be overloaded with the routine, unnecessary information and be selective . Make big decisions first. Priority in decisions. 45

Cont. 9.Shortest Decision Path: decision must be made as closely as possible in time and place to the object of decisions and to those affected by it. This principle deals with issue -Who should make which decision? -When and where? 46

Management and Environment Health service organizations exist in the larger environment they are not isolated. They are affected by the external environment and vice versa. Management performs all the functions of management in interaction with its environment. 47

Cont. External environment is an open system perspective. Managers cannot perform their tasks well unless they have understanding of, and responsive to, the many elements of the external environment – economic, technological , social, political , and ethical factors that affect their areas of operations . 48

Components of the e xternal Environment 1. Political : policy, political institution/ organization , Government officials/ institutions . 2. Economic and Business Communities: suppliers , clients, farmers, merchants, 3. Social: community, leaders, others . 4. Technology: medical equipment, 5. National and International Issues. This interaction relationship between managerial functions and the environment occur because organizations are following an open system. 49

Types, skills and roles of managers Types of Managers Top/Senior/General Manager: H ave authority over and are responsible for entire organizations. They establish, operating policies and guide the organization’s interaction with its environment. they make decisions affecting the entirety of the organization. They don’t direct day to day activities They set goals and strategic plans Conceptual and human skills are very reliable but less need for technical skills 50

Cont. 2. Middle-level Manager: responsible for smaller segments of the organization and reporting to senior managers . Or They are responsible for caring out the goals setting by top managers. They supervise first level of managers They can motivate and assist first level managers They may also communicate upwards by offering suggestions and feedback to top managers. 51

Cont. 3. Supervisory/First-level Manager: They are the “first” or lowest level of managers in the organizational hierarchy. They are responsible for daily management of health activities in the health unit/community. Have authority over and are responsible for overseeing specific work and a particular group of workers. Report to middle-level managers, Do not supervise other managers. 52

MANAGERIAL SKILLS Effective managers utilize three distinct types of skills 1. Technical Skills T.S . of managers are their abilities to use the methods, processes, and techniques of managing . The understanding of technical element of activities in general and proficiency in specific kind of technical activity . Ability to perform a specific work. Eg . Designing a computerized staff monitoring tool. 53

Cont. 2.Human/Interpersonal Skills This is the ability to work with others and win cooperation from the health team, other sectors and the community These are abilities of managers to get along well with other people, to understand them, and to motivate them in the work place. 54

Cont. 3 . Conceptual Skills The ability to visualize the organization as the whole and its relationship with the community and other sectors. Critically analyze and solve complex problems. Eg . Finding the best way to provide a certain service. This skills permit managers to understand how the various factors in particular situations fit together and interact with one another. 55

Cont. Not all managers use these skills to the same degree or in the same mix . The extent to which each management skill is used varies with the manager’s position in the organizational hierarchy; degree of authority, scope of responsibility; and number, type, and skills of subordinates. 56

Managerial Roles Henery Mintzberg isolated ten roles he believes are common to all managers. These roles have been grouped into three major categories : Interpersonal Roles ( 3) Informational Roles ( 3) Decisional Roles (4) 57

Interpersonal Roles They involves directing, supporting and supervising your team and work together with people from other agencies. They provide information 58

Cont. Interpersonal Roles 1. Figurehead: As a symbol of legal authority, performing certain ceremonial duties, e.g. signing documents & receiving visitors, making speeches at organizational events. 2. Leader (inspiration) : Motivating subordinates to get the job done properly. 3. Liaison: Serving as a link in a horizontal (as well as vertical) chain of communication . Have internal and external contact 59

Cont. Informational Roles (process information) 4. Nerve Center (monitor): serving as a focal point for non-routine information; receiving all types of information. 5 . Disseminator: Transmitting selected information to subordinates. 6. Spokes person: Transmitting selected information to outsiders. 60

Cont. Decisional Roles (use information) 7. Entrepreneur: Designing and imitating changes within the organization . Seek and identify opportunities to promote improvement and needed changes. 8. Disturbance Handler: Taking corrective action in non-routine situations. 9. Resource Allocator: Deciding exactly who should get what resources. 10. Negotiator: Participating in negotiating sessions with other parties (e.g. unions) to make sure the organization’s interests are adequately represented. 61

The need for managers in health care Health care is an expensive industry that ranges from preventive care, to emergency services, to follow up and rehabilitation. Heath care organizations are complex and dynamics The nature of organizations requires that managers provide leadership, supervision and coordination of an employs. HSM can be observed as getting people both health and non health workers work together harmoniously to make effective use of resources to deliver health service effectively to the community they serve. 62

Qualities of good manager Knows when, where, what and how to act, i.e. good manager is flexible, kind and patient. Knows the importance of accountability i.e. must be able to account for whatever she/he has use or done. Should be transparent Should be able to consult because he is not working in isolation Should be polite and able to share knowledge with others But management incurs some problems; 63

Cont . Biasness Lack of knowledge and skills Inadequate resources Environmental hazards Lack of cooperation Poor communication Competition in management Beauracracy 64

Main functions of management Function is defined as a broad area of responsibility composed of many activities aimed at achieving a predetermined objectives. Management is universal and necessary function . 65

Cont. - It is essential for all kinds of organizations. This is because every organization requires:- -The making of decisions - The coordinating of activities -The handling of people and - Evaluating the performance directed toward its objectives. 66

Cont. Functions of management are put in different ways by different experts/scholars; (2, 3, 4, 5, 6, 8 functions). Two continuous functions of management are:- 1.Communication 2.Decision- Making The 3 management functions ; Planning , Implementation, Evaluation (PIE) The Four Functions of Management Planning , organizing, influencing and controlling. 67

Cont. The 5 functions of management. Planning Organizing Staffing Directing Controlling 68

Planning The main objective of this section is to acquire planning skill so as to plan and prepare health action plan for health service system Why we plan? Because the supply of material, financial and human resources are limited. A carefully developed plan is the best way to guarantee that these limited resources are allocated, properly used , and accounted for during the prescribed time frame. 69

Plan cont. We plan because planning is the cornerstone of managing and leading teams to achieve results. One of the major reasons, managers’ need to plan is in order to cope with an uncertain environment . Three types of uncertainty 1. State uncertainty ("What will happen?") 2.Effect uncertainty (" What will happen to our organization?") 3. Response uncertainty ("What will be the outcome of our decisions?"). 70

Plan cont. It is a specific action proposed to help the organization achieve its objectives . To Plan is to propose a forward program for guiding the future affairs of an organization. It functions like a blueprint: it defines the steps and decision points required to achieve a desired result or a large goal . 71

Plan cont. C haracteristics/elements of a good plan Successful implementation starts with a Good Plan. There are elements that will make a plan more likely to be successfully implemented. 72

Cont. OBJECTIVITY: Planning should be based on objective thinking . It should be factual, logical, and realistic. It focuses on the organizational goals . 73

Cont. FUTURITY Must foresee with reasonable accuracy the nature of future events affecting the firm. Designing the future means making the right decisions today with a vision of tomorrow . FLEXIBILITY It must adjust smoothly and quickly to changing conditions without seriously loosing their effectiveness. 74

Cont . STABILITY In most of the time, it should be stable. is related with flexibility. CLARITY It has to be clear for every member/stakeholder. 75

Cont. SIMPLICITY understandable by every member /stakeholder . It should be simple, not ambiguous . DYNAMIC: It is not a dogma. CONTINOUS process. 76

C lassifying plans Plans may be classified on different basis or dimensions . The important ones are: Time Dimension Repetitiveness Scope/Breadth Dimension 1. Time Dimension (Duration of plans) a. Long-Range Plan: ranges from five years and more. b. Short-Range Plan: covers a period of one year or less. c. Medium-Range Plan: lasts from 1 -5 years . 77

Cont. 2 . Repetitivenes s- How general/specific A. Single-use plans : are predetermined courses of action developed for unique , non-recurrent situations. E.g. programs, Budgets. B. Standing Plans : are predetermined courses of action developed for repetitive situations. E.g. Rules, Policies, Procedures. 78

cont. 3.Scope/Breadth (Level of Plans):Where it is formulated in the organization A. Strategic Planning /Top Management Planning - Primarily concerned with solving long-term problems associated with external environmental influences. B. Tactical/Operational Planning - is concerned with the efficient, day to-day use of resources allocated to a department manager’s are responsible. - is narrower, short-term planning. 79

Cont. N.B. The appropriate type and timing of the plan depend on the organization’s needs. 80

Planning Definition Planning is deciding in advance what to do , how to do it , when to do it , who is to do it . It bridges the gap between where we are and where we want to go. It is the process of establishing goals and a suitable course of actions to achieve the goals . Planning is the foundation of organizing, influencing and controlling. 81

Cont. Required to make decision on; What should be done ? How it should be done? Who will be responsible? Where the action is to be taken? Why is it done? 82

Purpose/importance of planning To provide direction To reduce/offset uncertainty or change To minimize waste or redundancy To set the standards to make control effective To manage by objective To help in coordination To secure economy in operations To increase organizational effectiveness 83

Cont. Health planning Health Planning- is the process of defining community health problems, identifying needs and resources, establishing priority goals, and setting out the administrative action needed to reach those goals. Planning is a process that sets the base for future action. 84

Cont. The important components of the definitions of planning are concepts of:- Where are we going (objectives) With what (Resources) How (efficient and appropriate implementation) When (future)? 85

Scope of planning What is the target client? Population Institution Programme What the plan intends to address should be clearly defined What is the target geographical region or area? Village/ kebele District/ Zonal Region At what level you are planning has to be clearly defined 86

F eatures of planning A Good Plan Should g ive : Clear vision/mission, goal and objectives A clear picture of the tasks to be accomplished The resources needed to accomplish the task in terms of human, material, financial and time resources (4Ms manpower, material, money and movement). 87

Cont. Planning takes place at all levels : Planning takes place at any level in health system Planning takes place continually, it is cyclic/spiral process Planning must be collective undertaking : It requires the participation of:- Professionals (from health and other sectors) Community/Non-Governmental Organizations (NGO) Government/Party 88

Cont. Vision : Describes what an organization desires to achieve in the long-run, generally in a time frame of five to ten years , or sometimes even longer. Focus on tomorrow and what an organization wants to ultimately become. Mission / purpose: Is an action-based statement that declares the purpose of an organization and how they serve their customers. Focus on today and what an organization does to achieve . 89

Types of planning There are two types of planning:- 1.Strategic planning-often referred as allocative planning –Normally five years or more. 2.Tactical/operational planning -may be referred to as activity planning. It covers a short period of time medium term-usually one-year. 90

1. Strategic planning Strategic Planning is the process of determining what an organization intends to be in the future and how it will get there. It is finding the best future for your organization and the best path to reach that destination. Strategic planning is often used in place of long range planning. 91

Strategic planning cont. Focuses on environmental assessment, i.e. an organization must be responsive to a dynamic, and changing environment. Being strategic means Clear about the organization's objectives, Aware of the organization's resources, Responsive to a dynamic environment . Strategic thinking: "Are we doing the right thing?" 1. A definite purpose be in mind 2. Understanding of the environment 3. Creativity in developing effective responses to those forces. 92

Cont. Strategic thinking requires you to ask the following questions before you start planning: What are the needs of the population our organization aims to serve? Is our organization currently meeting these needs? In what ways could our organization meet needs that are not currently being met? 93

Stages of Strategic plan writing 1. Where are we now? SWOT Analysis SWOT (strengths and weakness, opportunities and threats) is a strategic planning tool that matches internal organizational strengths and weakness with external opportunities and threats. By reviewing strengths, weaknesses, opportunities and threats a useful strategy for achieving objectives will become evident. 94

SWOT Analysis Matrix Internal External Positive Strength availability of resources trained human power. Opportunity clear and supportive government polices the presence of a functional health committee in the communities Negative Weakness lack of managerial Talent Outdated facilities Threats adverse cultural believes towards modern medical practice Growing cost of essential drugs. 95

Cont. 2. Where are we going? The Mission begins the answer to the second strategic planning question: where do we want to go? An organization’s mission: - is its purpose, - its reason for being, - provides orientation, consistency, and meaning to the organization’s decisions and activities at all levels. The Mission Statement describes clearly and concisely why the organization exists. It should be re-examined periodically by current staff. 96

Cont. Why does an organization need a Mission? The Mission is what allows members of an organization to clearly understand why they are doing the work. Only when health workers are aware of the organizational mission or ultimate purpose, will they fully understand the meaning and the value of their efforts. 97

Cont . EXERCISE: - Construct the Mission Statement of a hospital. 98

Cont . C onstructing the mission statement To construct or revise a Mission Statement, the Board of Directors and Managers and their Teams must carefully scan the internal and external environments before answering four basic questions: A. What do we do? B. Whom do we serve? C. How do we do it? and D. Why do we do it? Finalize and disseminate the Mission Statement to staff, and board members, those who are served by the organization, and the general public. 99

Cont. A. What do we do? Describe the purpose of the organization: what it does/what it will do. The planning team must clearly identify and define the needs of the populations to be served and specify which of these needs the organization intends to address. E.g. Our mission is to contribute to reducing the number of unwanted pregnancies (the what) by providing uninterrupted access to high-quality, modern methods of contraception, so that men and women of reproductive age can control the number and spacing of pregnancies. 100

Cont . B. Whom do we serve? Define the target population. The Mission Statement should specify which groups within the target population are the organization’s priorities . E.g. Our mission is to contribute to reducing the number of unwanted pregnancies by providing uninterrupted access to high-quality, modern methods of contraception, so that men and women of reproductive age (the who) can control the number and spacing of pregnancies. 101

Cont . C. How do we do it? Describe the means, resources, or strategies by which the organization tends to reach its goals . E.g. Our mission is to contribute to reducing the number of unwanted pregnancies by providing uninterrupted access to high-quality, modern methods of contraception (the how), so that men and women of reproductive age can control the number and spacing of pregnancies. 102

Cont. D. Why do we do it? Explores the basic reasons behind the organization’s decision to do what it does. The answer generally describes a response to a broad social problem. E.g. Our mission is to contribute to reducing the number of unwanted pregnancies by providing uninterrupted access to high-quality, modern methods of contraception , so that men and women of reproductive age can control the number and spacing of pregnancies (the why). 103

Cont. 3. Where are we going? - Create a Vision, It is the moment to dream, to decide, what your organization wants to be in the future, and How it wants to be viewed by the outside world. The vision guides and focuses the organization’s efforts and helps to align, inspire, motivate, and secure the commitment of each working group and individual within the organization. 104

Cont . CREATING A SHARED VISION A vision is more powerful when a large number of people from various organizational levels develop it together than comes from the organization’s upper levels. C onstructing the vision Step 1. Keep the big picture in mind . Refer to your organization’s mission and the population you are supposed to serve so that the vision aligns with the mission . 105

Cont. Step 2. Answer the following questions: What will our organization look like in three to five years? What aspects of mission will we have achieved and in what areas will be excel? What will make us most proud? (e.g. quality of our services, commitment, creativity, financial stability, etc.) What values do we maintain, and how will they be reflected in our services and the way we run our organization? Write down the answers to each of the questions and come to consensus within your team. 106

Cont. Step 3. Look at your organization through the eyes of your target population, beneficiaries, donors, partners, collaborators, competitors, and society in general. For each of these groups, ask: How do we want these groups to see our organization in three to five years? What will they say about our services? What will they say about our staff? What will they say about our standing/status in their communities? Write down the answers to each of the questions and come to consensus within your team. 107

Cont. Step 4. Translate these ideas into a few sentences that describe the desired future in the future in a concrete manner; E.g. “We are widely recognized as the leading provider of easy and uninterrupted access to high-quality, modern methods of contraception. Our services allow thousands of men and women of reproductive age to determine the number and spacing of their pregnancies.” 108

Cont. 4. Where are we going? The answer lies in the objectives – the desired results – that will help to transform your organization’s mission and vision into actionable, measurable . Objectives must be SMART: S = Specific M = Measurable A = Appropriate to the scope of activities R = Realistic within the allotted time T = Time bound, with a specific date of completion . 109

Cont. 5. How will we get there? Define the route by which an organization will achieve its strategic objectives in the medium and long terms . 6. How will we know we are getting there? It is crucial for you as a manager of health program or health service to monitor and measure whether and how well your organization is carrying out its strategies and the extent to which you are achieving your strategic objectives. 110

Structure of the Strategic Plan Introduction: Briefly explain when and how the planning process took place , which concerns or circumstances the plan responded to, who participated , and how the plan will be used. Analysis of the Environment: Summarize the internal Strengths and weakness and external Opportunities and Threats that you identified through the SWOT analysis. The Mission, Vision, and Strategic Objectives: Present the well-written statements of these three critical elements and explain how the mission and the vision led to the strategic objectives. 111

Cont. Strategies: Present the strategies that you propose to use to achieve the results of each strategic objective. Write a brief explanation of why each strategy was chosen. Measuring Implementation: Present the Results Monitoring Chart, write a brief explanation of the choice of indicators, and describe the process and schedule for reviewing the plan. Conclusion : Add any final comments and point out that annual operational plans will be developed on the basis of the strategic plan. 112

Cont . 7. Operationalize the plan When you and your planning team have developed the strategic plan and it has been approved and circulated, your organization will be prepared to produce annual operational plans that will translate strategic objectives and strategies into comprehensive packages of activities. 113

2. Tactical/operational planning Tactical/operational planning is short-range planning that emphasizes the current operations of various parts of the organization. Short-range is defined as a period of time extending only about one year or less into the future. 114

Comparing Strategic and Tactical Planning Strategic Planning usually developed by upper-level manager plans are based primary on a predication of the future strategic plans generally less detailed than tactical plans. long term Tactical/Operational Planning Developed by lower-level manager. plans are based on known circumstances that exist within the organization Short term 115

S teps in health planning In the planning process, there are six steps: 1.Situational analysis 2.Selecting priority problems 3.Setting objectives and targets 4.Identifying potential obstacles and limitations 5.Designing the strategies 6.Writing the plan 116

1.Situational analysis The first stage in the development of a plan, at whatever level, national, district or community, is to improve the understanding of the current situation. The purpose of situational analysis is to provide a broad basis of understanding. This is for two reasons:- It provides a common reference point for the rest of the planning process It allows the selection of priority areas of concern for planning. 117

Content of situational analysis Population characteristics Review area characteristics and infrastructure Analysis health needs Analyze health services Analyze resources Review past implementation experience 118

2.Selecting critical priority problems Sets priorities for the organization, in the light of competing needs and limited resources. Setting priority is, perhaps the most critical and hardest planning stage and yet cannot be avoided. 119

Cont. The selection criteria for priority setting are:- Magnitude of the problem Degree of severity (consequent suffering and disability) Feasibility- in terms of cost effectiveness and social acceptability of intervention. Sustainability in terms of resources and organizational capacity Community concern and Political acceptability with consideration of equity 120

Cont. Ranking which health problems they think were most important. This can be done by using criteria on five point scale 5 points-very high 4 points-high 3 points-moderate 2 points-low 1 point-very low 121

3.Setting objectives and targets If the programme is made to have an objective and target, it must be SMART:- S -Specific M -Measurable A -Achievable R -Realistic T -Time specific/Time framed Eg . By the end of 2024, 90% of eligible people will be vaccinated covid-19 vaccine in Asela town. 122

4. Identifying obstacles and limitations The planner should ask himself/herself about the presence of any situation (obstacle/limitation) that may prevent the achievement of each objective and target. The limitations/obstacles may be: Resources, Environmental obstacles 123

Cont. Ask the question "what is or could be, preventing the achievement of the objectives? Review limitation of resources (people, equipment, information, money and time) Revise obstacles in the geographical, climatic, technical and social environment) Analyze obstacles-to what extent they can be removed, reduced Revise objective accordingly 124

5. Designing the strategies Once objectives and targets are set, the planner assesses the different ways (strategies) for achieving them. The potential strategies often include technology to be applied, procedures to be used and defining the role of communities and other sectors. 125

Cont. For each chosen strategy, the corresponding activities to be undertaken and the resources needed should be detailed, including who will do the activities (job description of all involved personnel) which things would be needed (equipment, materials and money), where the work will be done and the methods of controlling. 126

6. Writing the plan The purposes of writing the plan are:- To request funds or resources from the government or funding agencies For monitoring and evaluating the implementation process by all concerned . 127

Cont. An outline of writing the plan may include Summary -is important because it gives a clear idea of what is going to be done without going through the plan document. A problem statement (explanation of the background, the problem to be dealt with, the reasons for undertaking the plan ) Objectives and targets:- to be clearly stated Strategies and activities (responsibilities should be allocated for each activities ( GANTT CHART) 128

Cont. Resources needed and how they are going to be utilized specify budget required Monitoring and evaluation (periodic and end of programme assessment, how, by whom, when, indicators of effectiveness) Gantt Chart -This is a bar graph with time on horizontal axis and the resources/activities to be scheduled on the vertical axis. 129

Why plans fail? The following are some important reasons why plans are not successful Planning is not integrated into the total management system A lack of understanding of the different steps of the planning process Concerned parties not participated or contributed in the planning process 130

Cont. Management expects that plans will be realized with little effort Too much attempted at once Failing to operate by the plan Inadequate input in planning Unforeseen (unexpected) changes in the environment. 131

2. Organizing It is the function performed after planning. is the process of establishing orderly uses for all resources within the management system. The process of assigning tasks/group tasks in to departments, delegated authority and allocating resources across the organization. Focuses attention on the structure and process of allocating jobs that common objectives can be achieved. 132

Cont. Henri Fayol Guidelines Developed 16 General Guidelines for organizing resources. Father of “Administrative Management Theory ” 1. Judiciously prepare and execute the operating plan. 2. Organize the human and material facets so that they are consistent with objectives , resources and requirements of the concern. 133

Cont. 3.Establish a single competent, energetic guiding authority (formal management). 4. Coordinate all activities and efforts. 5. Formulate clear, distinct and precise decisions . 6. Define duties. 7. Encourage initiatives and responsibilities 8. Arrange for efficient selection so that each department is headed by a competent , energetic manager and all employees are placed where they can render the greatest service. 134

Cont. 9. Offer fair and suitable rewards for services rendered. 10. Make use of sanctions against faults and errors. 11. Maintain discipline. 12. Ensure that individual interests are consistent with the general interest of that organization. 13. Recognize the Unity of Command. 14. Promote both material and human coordination . 15. Institute and effect controls. 16. Avoid unnecessary regulations 135

Cont. The Organizing Process The five main steps of organizing process are: 1. Reflect on plans and objectives. 2. Establish major tasks. 3. Divide major tasks into subtasks. 4. Allocate resources and directives for subtasks . 5. Evaluate the results of implemented organizing strategy. 136

Organization Two/more people who work together in a structured way to achieve a specific goal/set of goals. It is a planned design of a corporate structure showing the relationship between employees and the function each should perform to make the organization work effectively towards its set of objectives . A Good Organization achieves its objectives - in the shortest time, - with the lowest cost, - with the least disruption of its members . 137

Cont . Types of Organizations Many types: manufacturers, associations, political parties, community associations, hospitals, etc. Formal and Informal organizations. 138

Cont. Common Characteristics in organizations: Contain a number of individuals, who interact with one another to try to achieve a set of objectives. Are structured with people interacting together according to a set of rules. Convert resources into some kind of output. 139

Cont. Organizational Structure/Chart Organizations have boundaries, authority, ranks , communication channels, and rewarding systems that enable those working in it to work in harmony. The chart represents channels through which authority, power and responsibilities flow. Authority and power flow down wards and accountability flows up wards. 140

Cont. Advantages of having organizational chart: define broad areas of responsibilities , provide a basis for writing job descriptions , indicate channels of communication , clarify relationships between people, and avoid complications caused by overlapping of functions . 141

Elements of organization structure The most important elements of organization structure are: Division of labour Decentralization Delegation Over all coordination to secure unity Authority and responsibility 142

I. Division of labour Divide operating work into manageable units: The concept of Departmentalization. All organizations regardless of their size/mission divide their overall operations into working groups. This process of grouping specialized activities in a logical manner is called departmentalization. 143

Steps to follow Divide the whole work into individual jobs. Group similar jobs into sections. Combine related sections into divisions. Assemble correlated/functional divisions into departments. Assign heads to each department to supervise and control the various activities of each department. 144

Cont. Reasons and Benefits Take advantage of specialization Facilitate control Aid coordination Secure adequate attention Reduce expenses, etc. 145

II. Decentralization Dividing managerial work among the various executives in order to reduce pressured from the top and secure quick decisions on the spot. under this concept; The top management gives a limited autonomy to some of his/her important executives to make independent decisions on important matters such as, planning, organizing, staffing, directing, and controlling, pertaining to their department. 146

III. Delegation is a matter of entrusting part of your work of operation/management to others. will not be effective unless you express/imply five actions. Assign duty to your subordinates Grant him/her sufficient authority to do the job. Make him/her feel that he/she has obligation. Explain to others that you have delegated work. Give support as needed and follow up the progress of work. 147

IV. Coordination The process of organizing people or groups so that they work together properly and well. It brings activities into proper relation with each other to make certain that every thing that needs to be done is done. Coordination is means of Distributing authority, Providing channels of communication, and Arranging the work so that right things are done, in the right place, at the right time, in the right way, by the right people. 148

Cont. A coordinated activity is orderly, harmonious, efficient, and successful. When an activity is not coordinated, it is liable to fail in its objective: an uncoordinated activity is disorderly, discordant, inefficient and unsuccessful. 149

Techniques of Coordination Simplified organization -Clear-cut organization and procedures that are well-known to all persons concerned will ensure coordination. Harmonized programme and polices Well-designed methods of communication -Good communication brings about coordination and helps members of organization to work together. 150

Cont. Aids voluntary coordination -Each member should be ready and willing to adapt his work to secure unified action Coordination through personal guidance -The supervising executives have a dominant role to play in brining about coordination of the tasks of their subordinates 151

V. Authority and Responsibility One of the purposes of an organization is to show the structure of authority power, accountability, and responsibility in the organization chart. The chart represents channels through which authority, power and responsibility flow. Authority and power flow downwards, through organization structure, from the chief executive to the functional managers to the first line workers. Accountability flows upwards from the first line worker to the departmental manager to the chief executive. 152

Cont. Authority - is the right to do something or to tell someone else what to do. -Right to decide and command subordinates Power - is the ability to do something: In this role as a supervisor a manager’s power may be seen in his ability to causes subordinates to do what he wishes them to do. Rewards are the positive side of power and punishment are the negative side of power. 153

Principles of organization To make coordination effective, 7 well recognized Principles of organization must be applied . Objective - The objective of each group of tasks must contribute to the objectives of the organization as a whole . Definition- Each group of tasks must be clearly defined so that everyone knows exactly what the tasks are . Command- Each group of tasks must have one person in charge, and all concerned must know who this person is. 154

Cont. Responsibility -The person in charge of a team is responsible for the performance of its members. Authority -Each person responsible for a group of tasks must have authority equal to the responsibility. Span of control -refers to the number of individuals a manager supervises. -more individuals= greater the span of management - fewer individuals= smaller the span of management 155

Cont. Also called Span of Authority, Span of Supervision, and Span of Responsibility. The central concern is How many individuals a manager can effectively supervise. Balance - the person in charge or several groups must see that the groups balance. 156

3. Staffing Objectives At the end of this section, you will be able to: List the key elements in staffing. Identify the different steps to follow in getting the necessary manpower to the institution. 157

Cont. Definition The management function that deals with recruitment , selection, placement, orientation and socialization, training and development of organization members Includes the following basic activities: Human Resource Planning Recruitment, selection and socialization Training and development Performance appraisal Promotion, transfers, Demotions and separations 158

Human resource planning Planning for future personnel needs of an organization (includes expansion and development of an organization) Takes into account both internal activities, and f actors in the external environment. Planning procedures Planning for future needs Planning for future balance (number needed versus present) Planning for recruiting 159

Recruitment It is the process of searching for prospective employees and stimulating them to apply for jobs in an organization. The development of a pool of job candidates in accordance with a human resource plan. Recruitment includes : Job description : a written description of a non-management job, covering title, duties, and responsibilities, and including its location on the organization chart. 160

Recruitment cont. Position description : a written description of a management position, covering the title, duties and responsibilities, and including its location on the organizational chart. Hiring specification: It is a list of the characters of an individual who should be hired to perform a specific task/job. A statement of the human qualifications necessary to do the job & contains such as: Written description of the education, Experience Training Skills, etc. 161

Selection It is the process of asserting the qualifications, experience, skill, knowledge, etc. of an applicant with a view to appraising his/her suitability to a job. It is the process of choosing individuals who can successfully perform a job from available candidates It is a crucial process in management and requires constant attention, interest and concern of management. The three sources of information used in selection are application forms , pre-employment interviews and testing . 162

Placement It is the process of assigning the selected candidates with the most suitable job (matching employee specification with job requirements) 163

Orientation or socialization It is a program designed to help employees to fit into the organization smoothly. Types of information provided : General information - routine activities About the organization - history, purpose, operation, values Services / products- expected contribution of the employee to the organization Detailed presentation - policies , rules, benefits, 164

Training and development Training program: to maintain or improve current performance. For managers: conceptual and human skills (future) Developmental program: to develop skills necessary Non-managers : technical skills (current job) Individual-professional development plan: employees set educational and training goals each year. 165

Training Programs Procedures to determine training needs of individuals: Performance appraisal: measure work against the standards Analysis of job requirements: job requirements/available skill Organizational analysis: effectiveness of organization Train those with low performance and high turnover Employee survey: about problems faced and actions needed After assessing needs - plan appropriate training. 166

Approaches to training On-the-job training Job rotation: variety Internship: combined classroom teaching Apprenticeship: training under guidance of skilled co-worker Off-the-job training Vestibule training: training on realistic job setting or equipment 167

Performance appraisal Often difficult Types: informal appraisal and formal systematic appraisal Informal appraisal-Feedback on day-to-day performance (strength/weaknesses) Formal systematic appraisal-A systematic feedback about performance (semi-annually or annually) Purpose : to give feedback, to recognize outstanding performance, locate the need for additional training and identify candidates for promotion. 168

Methods of rating an employee Manager’s rating (commonest) Group of managers rating (second most commonest) Group of peers rating Employees’ rating of bosses combination of methods 169

Promotions, transfers, and separation Promotion: Moving to a higher position and responsibility To recognize outstanding performance Should be fair (merit-based) Discrimination may occur: sex, race, age, and minority. 170

Transfers Shift to other positions For experience To fill vacancies To keep individuals interested in the job Sometimes, for those with in adequate performance Problem: some employees refuse transfers (family problem) 171

Discipline, Demotion and Separation Discipline: when the organization’s policy is violated Steps: Warning Reprimand Probation Suspension Disciplinary transfer Demotion Discharge For poor performance, separation is better than letting the employee stay on the job. 172

4. L eading or Directing Objectives At the end of this section, you will be able to: Define leadership Identify the difference between a leader and a manager 173

Cont. Leadership is a process of directing and influencing the task-related activities of group members. It may also be defined as leadership is the process through which an individual attempts to intentionally influence another individual or a group in order to accomplish a goal. It is one of the most important things managers do. It is the means by which things are accomplished in organizations. 174

Cont. A manager can establish goals, strategies, relate to others, communicate, collect information, make decisions, plan, organize, monitor, and control; but nothing happens without leadership . 175

Cont. The core concepts embedded in leadership are: L eadership is a process. It manifests itself in the doing; it is a performing art. O nly individuals lead. The focus of leadership in a person. T he focus of leadership is other individuals and groups. The follower might be just one other person, a group, members of an organization, or the population of a nation . 176

Cont. It entails influencing. Influence is leadership’s center of gravity and most critical element. Who is influenced ? Followers (individuals and groups). What is influenced ? The cognitive target of influence is their thoughts ; the affective target is their feelings ; and the behavioral target is their actions or deeds . For what purpose are followers influenced? The objective of leadership is good accomplishment. Leadership is instrumental; it is done for a purpose. leadership is intentional; it is not accidental. 177

Characteristics of managers versus leaders Manager Leader Administers Innovates A copy An original maintain develop Focuses on systems & structure Focuses on people Relies on control inspires trust Short- range view Long-range perspective Asks how and when Asks what and why Eye on the bottom line Eye on the horizon Imitates Originates Accepts the status quo Challenges the status quo Classic good soldier Own person Does things right Does the right thing Read about formal and informal leaders 178

5. Controlling It is the measurement and correction of performance in order to ensure those enterprise objectives and the plans devised to attain them are being accomplished. It is the process by which management sees if what did happen was what was supposed to happen. If not needed adjustments are made. Controlling as a management function is closely related to planning, organizing and leading. 179

Cont. Control is not an end in itself rather the primary aim of control is to improve performance by ensuring that resources are more effectively deployed, and that mistakes are rectified. Therefore , an essential part of the control process is taking corrective actions as needed . 180

Pre-requisites of control systems Controls require plans -The clearer, more complete and more integrated plans are, the more effective controls can be . Controls require clear organizational structure -The existences of organizational structure and the clearer, more complete, and more integrated this structure is, the more effective control action can be. 181

Important Components/Functions of a Control Establish Standards of Performance Gather Information and Measurement current Performance. Compare Performance with the Standard Taking corrective Actions/ intervention Rewarding Ensuring that resources are more effectively deployed and mistakes are rectified. 182

1. Establishing Standards - The control process begins when standards are set. - Standards are units of measurement established by management to serve as benchmarks for comparing performance level. 183

2. Measuring Actual Performance Measurement is an ongoing, repetitive process, The frequency of measurement dependent on the type of activity being measured. It involves comparison between what is accomplished and what was intended to be accomplished. 184

3. Comparing Performance Against Standards It is a matter of comparing measured results with established indicators/standards previously set. If performance matches the standards, managers may assume that “every thing is under control”. They should not have to intervene activity in the organization operations. 185

4. Taking Corrective Action This step is necessary if performance falls short of standards and the analysis indicates action is required. The corrective action could involve a change in one/more activities of the organization’s operations. The corrective action must be taken at the appropriate time. 186

Corrective Deviations Correction actions may be done by: Adjustment in the resource allocation. Modification in directing, training, selection, etc. of subordinates. Improvement in supervision, motivation, work environment, etc 4. Reassignment/ clarification of duties. 5. Changing/ altering objectives. 187

Types of Management Control There are two types of controls: 1. Organizational controls E.g. Standards of measurement such as profitability. 2. Operational controls E.g. Meeting quality standards during the production process, ensuring enough supply of raw materials. 188

Cont . Types of operational controls: 1.Predictive controls They anticipate problems before they actually occur. 2.Concurrent controls They help us take timely action before large damage takes place. 3.Historical controls They measure results after the happening of events. 189

Developing /Designing a Control System Managers face a number of challenges in designing control systems that provide accurate feedback in a healthy, economical fashion that is acceptable to organization members. Most of these challenges can be traced back to decisions about what needs to be controlled and how often progress needs to be measured. 190

Cont . Trying to control too many elements of operations too strictly can annoy ( irritates ) and demoralize employees , frustrate their mangers and waste valuable time, energy, and money, managers may focus on easy-to measure factors. Most of these problems can be avoided by an analysis that identifies: key performance areas (KPA) Strategic control pointes. (SCP) 191

Identifying key performance Areas Key performance or key result areas (KRAs) are those aspects of the unit or organization that must , function effectively for the entire unit or organization to succeed. 192

Cont . These areas usually involve major organizational activities or groups of related activities that occur throughout the organization or unit. 193

Identifying strategic Control Points It is also important to determine the critical points in the system where monitoring/information collecting should occur. Once such strategic control points can be located, the amount of information that has to be gathered and evaluated can be reduced considerably. 194

Cont . Managers need some kinds of control : Controls that standardize performance to increase efficiency and to reduce costs. Controls that safe guard organization's assets from theft, waste/misuse. Controls that standardize the product's quality Controls that set limits for delegated authority. 195

Cont . Controls that measure on-the-job performance of all employees in the organization, including periodic performance reviews. Control for planning and programming operations. Controls that allow top management to keep firm's plans and programs in balance. Controls designed to motivate people to contribute their best efforts. 196

Feedback in the Control Process An essential element in the control process is feedback. Characteristics of any feedback system Timely :The information generated by the control process must be feed back in time for remedial action to be taken. Reliable: Precise - should focus on those aspects of performance, which need to be addressed. Right:– recipient 197

Forms of management control The three basic forms of management control; Monitoring Supervision Evaluation 198

1. Monitoring It is the day-to-day watch on, or continuous follow up of, the on going activities. The key question in monitoring is: Are things going all right? It is carried out through observation of materials, discussion with workers, supervisors, review of reports and statistical data. 199

Cont. It is regularly checking to see that program activities are being done as planned. The goals of monitoring are: To identify any problem early, and To solve without delaying the progress of the program. 200

How to monitor a program? Program managers should follow four steps when monitoring an intervention: Establish data sources (in practice, limitations of time and resources may require giving priority to one set of information needs over the other). Collect data on program implementation and outcome. Compare program outcomes with prior or expected outcomes. Assist in making policy and management decisions 201

2. Supervision Supervision is continuous processes to be conduct by the management in line with controlling. Examples of supervision Task oriented : both quantity and quality of the task are taken into consideration. Person oriented: supervision is the control of the workers based on the understanding of their needs, past training and styles of working. 202

3. Evaluation It involves the comparison of the actual performance of the system. Ask “Did we achieve what we set out to do?” and comparing the present situation with the past in order to find out to what extent organizing purposes have been achieved. 203

Cont. The results of evaluation are expected to show: - What a program has been trying to do; - What actually happened; - Where are the differences/gaps between plans and what happened; - The reasons for the difference/gaps, and - What needs to be done about them. 204

Implementation Learning Objectives At the end of this section, you will be able to: Define implementation, Decide on important issues to facilitate implementation, Understand factors that affect implementation and find means of alleviating them. Know that coordination, monitoring, controlling and supervision of works are vital for implementation, 205

Definition Implementation is putting a program into action or doing the work. It is depends on the plan. Once a program has been planned and marketed, it must be implemented. 206

Factors that facilitate Implementation 1.The implementer need 2.Allocating the necessary resources/Inputs 3.Create good relation with the stakeholders at all levels 4.Coordination of the work 5.Communication 6.Monitoring and Supervision 207

Factors affecting Implementation/ Causes of Poor Implementation Poor implementation means delayed or non-implemented or different from that planned. Factors A change in priorities/ polices. Resistance to the changes. Lack of necessary resources. Lack of appropriate organizational structures. Lack of appropriate managerial skills. Unforeseen circumstances, e.g. famine, war, etc. 208

Evaluation Learning objectives At the end of this section, you will be able be; Define evaluation Appreciate the purposes of doing evaluation Know the deference of effectiveness and efficiency Know appraising staff performance 209

Definition It is the methodical process of determining the worth of a system, project, course of action, campaign, etc. It involves the comparison of the actual performance of the system. 210

Cont. It is carried out mainly as a way of looking at program activities, human resources, material resources, information, facts and figures; in order to monitor progress and effectiveness, consider costs and efficiency, show where changes were needed, and help to plan more effectively for the future. Hence, evaluation is a continuous process. 211

Cont. Determining the value or worth of the objects of interest (health programs) against standard of acceptability. Evaluation should plan how results can be used for decision-making. Results are wasted when they are not used. 212

Cont . T he results of evaluation are expected to show: • What a program has been trying to do?; • What actually happened? • Where the differences/gaps between the plan and the actions has happened • The reasons for the difference/gaps, and • What needs to be done 213

Purposes of Evaluation To determine achievements of objectives related to improved health status To improve program implementation To provide accountability to funders, community and other stakeholders To increase community support initiatives To contribute to the scientific basis for community public health intervention To inform policy decisions 214

Deference between Effectiveness and Efficiency Effectiveness Effectiveness is the degree to which a stated objective is being achieved. It is something that management tries to improve. Efficiency It is concerned with the balanced use of resources (money, material, human resource, time, space and information. 215

The Process of Evaluation Steps 1. Deciding when and how to evaluate: Planning 2. Selecting objectives and methods to be used: Planning 3. Carry out the evaluation: Data collection 4. Looking of the results: Data analysis 5. Using the results to improve the program: report and application. 216

Types of evaluation Input evaluation Process e valuation/Program Monitoring Output evaluation Outcome evaluation Impact Evaluation 217

Types of evaluation 218

Health System and Health Policy in Ethiopia Objectives: By the end of this chapter, you should be able to: Understand key Health system and health-system building blocks Describe the health policy principles, priorities and strategies in Ethiopia Discuss on HSDP and Health Sector Transformation Plan (HSTP) Describe PHC 219

Health System is defined as the sum total of all organizations, people, resources and all activities whose primary purpose is to promote health, to restore or maintain health (WHO ). Includes everyone responsible for good health , all branches of government and operates within the public sector, civil society and for-profit entities. 220

Cont. Health systems have three objectives 1 . Improving the health of the population they serve 2. Providing financial protection against the costs of ill-health ( Risk Protection )…sharing risk and providing financial protection => Fairness in financial contribution 3.Responding to people’s expectations(Responsiveness) reflects the importance of respecting people’s dignity, autonomy & the confidentiality of information 221

Cont. A well-functioning health system responds in a balanced way to a population’s needs and expectations by: Improving the health status of individuals, families and communities Defending the population against what threatens its health Protecting people against the financial consequences of ill-health Providing equitable access to people-centered care Making it possible for people to participate in decisions affecting their health and health system. 222

How is the Ethiopian healthcare delivery system organized? The health service system in Ethiopia is federally decentralized. Offices at different levels of the health sector in Ethiopia, from the Federal Ministry of Health (FMOH) to Regional Health Bureaus and Woreda health offices, share decision-making processes, powers, and duties. 223

Cont. The FMOH and the RHBs focus more on policy matters and technical support also responsible for owning , financing and supervising the service delivery of regional hospitals. Woreda health offices focus on managing and coordinating the operation of a district health system that includes a primary hospital, health centers, and health posts under the Woreda’s authority. 224

How is the Ethiopian healthcare system financed? In the Ethiopian health system, some public health services have been provided to all citizens free of charge , regardless of their level of income. Almost all of the curative services are covered by individuals from out-of pocket expenses. 225

Building Blocks of Health System Health systems are composed of the following six building blocks: 1. Leadership and governance procedures and practices, including planning, that produce commitment and accountability. 2. Human resource policies and procedures that produce a supported and motivated work force. 3. Financial management, which is concerned with accounting and budgeting, along with the related reporting and analysis that make it possible to ensure that the organization's resources are used in the service of its mission 226

Cont . 4 . Management of medicines and medical supplies so that the right products are delivered in the right quantities, at the right time, and in the right place, and then used appropriately. 5 . Health information and associated monitoring and evaluation practices that facilitate effective problem solving , informed decision-making , and the formulation of policy based on evidence. 6. Health service delivery that is supported by quality management processes and that addresses the basic health needs of the populations to be served . (Source: WHO, 2007) 227

Health Tier System in Ethiopia Primary health care period (1974 – 1991) 228 the six tiered organization of health services delivery in Ethiopia

Four tier system SWAP- Sector Wide Approach Period (1991-1998) 229

The three tier healthcare delivery system of Ethiopia (since 2010) 230

Cont. Primary Level The “ first” level of contact between the individual and the health system. Essential health care (PHC) is provided. A majority of prevailing health problems can be satisfactorily managed. The closest to the people. Provided by the primary health centers. 231

Cont. Secondary Level More complex problems are dealt with. Comprises curative services . The first referral level. 232

Cont. Tertiary Level Offers super-specialist care. Provided by regional/central level institution. Provide training programs. 233

Common healthcare Delivery gaps in Ethiopia Poor management and governance of service delivery systems Weak referral system Shortage of resources, and inefficient use Poor generation & utilization of health information Poor Recording, Reporting, and documentation Under-use of available services 234

Policy and Health policy A policy is a set of clear statements and decisions defining priorities and main directions for attaining a goal . policy is concerned with what is to be done (content); how to do it ( strategy) . A policy involves agreement or consensus on the following main issues: Goals and objectives to be addressed, Priorities among those objectives and Main directions for achieving them. 235

Health Policy HP can be defined as the “formal written document, decisions, plans, and actions that are undertaken to achieve specific health goals within a society. ” WHO. An explicit health policy can achieve several things: - It defines a vision for the future; - It outlines priorities ; - The expected roles of different groups; & - It builds consensus and informs people. 236

Health Policy cont. It was issued in 1993 The policy formulation has been the result of Critical reviews and scrutiny of the nature, Magnitude and root causes of the usual health problems of the country, and The broader awareness of newly emerging health problems in the country. 237

Cont. The policy emphasizes the importance of achieving access to a basic package of quality primary health care services for all segments of the population In a decentralized way. It states that the health service should include preventive, promotive and rehabilitative components. Gives strong emphasis to the fulfillment of the needs of the less privileged rural population . 238

The Ethiopian health policy Core principles: 1. Democratization and decentralization of the health system. 2. Comprehensive health care ( prevention , promotive and curative) components. 3 . Equitable and acceptable health service system that will reach all segments of the population within the limits of resources. 4. Promoting and strengthening of inter- sectoral activities. 5. National self-reliance in health development by mobilizing and maximally utilizing internal and external resources. 6. Assurance of accessibility of health care for all segments of the population. 239

Cont. 7. Working closely with neighboring countries , regional and international organizations 8. Development of appropriate capacity building based on assessed needs. 9. Payment according to ability with special assistance mechanisms for those who can not afford to pay . 10. Participation of private sector and NGO in health care. 240

Health Policy: Priorities Information, Education and Communication (IEC) 2. The control of communicable diseases , epidemic and disaster related to malnutrition and poor living conditions. 3. Support to the curative and rehabilitative cares. 4. Attention to traditional medicines: Research and gradual integration to modern medicine. 5. Health research on major health problems. 241

Cont. 6. Provision of medicines, medical supplies and equipment . 7. Human resources Development 8. Special attention will be given to the health needs of: Family particularly women and children , Those in the forefront of productivity , Most Neglected regions , Rural area, Urban Poor, pastoralists, and national minorities. Victims of man-made and natural disasters 242

Health Policy: Strategies 1. Democratization within the health system 2. Decentralization 3. Inter- sectoral collaboration 4.Health education 5. Promotive and preventive activities 6. Human resource development 7. Availability of drug supplies and equipment 8. Traditional medicine 9. Health systems research 243

Cont. 10.Family health services 11. Referral system 12. Diagnostic and supportive services 13. Health management information system 14. Health Legislations 15. Systematized and rationalized Health Service Organization 16. Effective and efficient administration and management of the health system 17. Public, private, and international sources for financing Health Services 244

Health Sector Development Program (HSDP) 245

Cont. Following the national health policy in 1993, Ethiopia produced and was implemented a 20-years Health Sector Development Program launched in 1998 The HSDP has been implemented in four phases building on lessons learned from phase to phase. Has three main goals: Building basic infrastructure Provide standard facilities and supplies Develop and deploy appropriate health personnel 246

Cont. It focuses on preventive and promotive aspects of care with: Health Education Reproductive Health Care Immunization Better Nutrition Environmental Health and Sanitation. 247

Phases of HSDP HSDP I-1997/8-2002 HSDP II-2002/3-2006 HSDPIII–July 2006-June 2010 HSDP IV–June 2010-2015 248

Cont. HSDP I (1997/98–2001/02) Covered the first five years (1997/98–2001/02) Prioritized disease prevention Introduced a four-tier system for health service delivery Characterized by a primary health care unit (PHCU), comprising one health center and five satellite health posts; the district hospital, regional hospital and specialized hospital. 249

Cont. HSDP-II (2002/03–2005/06) Introduced the Health Service Extension Program (HSEP ) Innovative health service delivery system It is a community based health care delivery system at kebele and household levels 250

Cont. HSDP III (2006/7-2009/10) Directly aligned with the health-related MDGs Focuses on high-impact health system strengthening interventions needed to accelerate scale-up and increase coverage of key health services for HIV , TB , malaria, as well as maternal and child health. 251

cont . HSDP IV (2010 – 2015) Developed as part of the National Growth and Transformation Plan (GTP) The expression of the renewed commitment to the achievement of MDGs as a top global Policy Gives priority to maternal and child health, nutrition , as well as the prevention and control of major communicable diseases, such as HIV/AIDS. Emphasizes the strengthening of HSEP to improve the quality of PHC, human resource development and health infrastructure . Developed the three tier health delivery system Community empowerment/ownership 252

Reading assignment on HSTP 253

HSTP The Health Sector Transformation Plan (HSTP) is the five-year national health sector strategic plan after successfully concluded the 20 years National HSDP. It has been prepared by conducting in-depth situational assessment and performance evaluation of HSDPs ; considering the global situation and the country’s global commitment; and most importantly, the goals of the national long-term vision and Growth and Transformation Plan (GTP). It covers EFY 2008-2012 ( July 2015 – June 2020 ). 254

Strategic Themes of HSTP Strategic themes are the main focus areas of the sector‘s strategy. Strategic themes are the Sector’s “Pillars of Excellence.” The HSTP Strategic Pillars are: 1. Excellence in health service delivery 2. Excellence in quality improvement and assurance 3. Excellence in leadership and governance 4. Excellence in health system capacity 255

Strategic Theme 1: Excellence in health service delivery This theme refers to the promotion of good health practices at individual, family and community levels and the provision of preventive, curative, rehabilitative and emergency health services. The provision of service delivery should address existing gender, geographic, economic and socio demographic inequities. 256

Cont. Good health service delivery is vital element of any healthcare system and is a fundamental input to improve the health status of the people of Ethiopia. Its attributes include: a) Comprehensiveness b) Accessibility c) Coverage d) Continuity e) Responsiveness f) Coordination 257

Strategic Theme 2: Excellence in quality improvement and assurance This theme refers to managing and improving quality and safety in health services at all levels of the healthcare system. The focus on quality in health systems at this time is due to the clear evidence that quality remains a serious concern . Quality and safety have been recognized as key issues in establishing and delivering accessible, effective and responsive health systems. 258

Cont . Furthermore, this theme will follow a simple ‘map’ of domains where quality interventions could be made (and where current quality problems might be located). 1. Leadership 2. Information 3. Patients and population engagement 4. Regulation and standards 5. Organizational capacity 6. Models of care 259

Strategic Theme 3: Excellence in leadership and governance This theme refers to evidence-based policy formulation and planning ; implementation; effective monitoring and evaluation, motivation and partnerships to achieve results. It incorporates: Equitable and effective resource allocation; Leadership development within the sector and the community Woreda transformation; and Partnership and coordination 260

Strategic Theme 4: Excellence in health system capacity This theme refers to the enhancement of resources for health, which includes human and financial resources , health infrastructure and supplies that are accessible to communities. It also refers to professional development to promote respectful and compassionate care. Health infrastructure includes construction of new facilities, rehabilitation of older ones and equipping these facilities as per national standards . 261

Cont . It emphasizes availability of adequate water and sanitation facilities as well as power and internet connectivity in health facilities. Supply chain is about ensuring commodity security and delivery of safe, effective and affordable essential medicines at all levels. This theme highly encourages use of technologies and innovations. 262

Primary health care Learning objectives At the end of this section, you will be able to; Define PHC and state the historical development of PHC Explain the PHC approach Know PHC as part of socio-economic development See PHC as level of health care Describe PHC principles and strategies Mention essential components of PHC 263

PHC The International Conference on PHC held at Alma-Ata in 1978 defines as: PHC defined as essential health care on practical, scientifically sound, and socially acceptable methods , and technology made universally accessible to individual and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. 264

Cont. Important terms in the definition : Essential health care: Health care provided through PHC is basic , indispensable and vital. Scientifically sound: The strategy we use in implementing PHC should be scientifically explainable and understood. Socially acceptable methods and technology : should be accepted by the local community and to consider the local value, culture and belief. Universally accessible: The PHC approach is to bring health care as close as possible to where people live and work in order to guarantee universal accessibility to the individuals, family and community. 265

Cont. Community involvement: Community can achieve better health status through their own efforts and the health workers role is to help them identify their problems and to point out methods for dealing with the problems. Self-reliance and Self-determination: able to support yourself, being independent understanding your own needs and trying to minimize problems. Knowing when and for what purpose to turn to others for support and cooperation. 266

PHC HISTORICAL DEVELOPMENT The World Health Organization, WHO, established in 1948. Major objective: The attainment by all people of the highest possible level of health. Strategies used by WHO - In the 1950s the vertical health service strategy which included mass campaigns and specialized disease control programs for selected communicable diseases, such as control of malaria, tuberculosis and vertical diseases. But it was found to be expensive and unsuccessful. 267

Cont. In the mid 1950s the concept/strategy of Basic Health Service came to being. This approach gave more attention to rural areas through construction of health centers and health stations providing both preventive and curative care. In the early 1970s integration of the specialized disease control programs with the basic health services was emphasized. 268

Cont. All these approaches were disease oriented based on high cost health institutions requiring advanced technology to solve the health needs of the people, and thus ultimately failed to reach the desired goal. 269

Cont. In 1977 the WHO set a goal of providing “Health for All by the year 2000” which aims at achieving a level of health that enables every citizen of the world to lead a socially and economically productive life. The strategy to meet this goal was later defined in the 1978 WHO/UNICEF joints meeting at Alma-Ata USSR. In this meeting it was declared that the PHC strategy is the key to meet the goal of “Health for all by the Year 2000”. 270

The PHC approach In 1979/80 two distinct approaches in PHC implementations were grounded for intensive discussion. Selective PHC ( sPHC ) Comprehensive PHC ( cPHC ) 271

S elective PHC This approach states “ With the limited human and financial resources available , to be most effective, health services should be directed toward controlling those diseases producing the largest number of deaths and disability and care should be made accessible to the greater number, using criteria of prevalence , morbidity or severity and disability, risk of mortality and feasibility of control, including relative efficiency and cost of intervention”. 272

Cont. Views health as the absence of disease. Measures achievements in terms of reducing those diseases which are the most harmful and also are the most feasible to control. The low cost strategy of sPHC is to treat and prevent few selected diseases, which have great impact on mortality: GOBI-FF. 273

Cont. G = Growth monitoring through the use of growth charts for promotion of child health and nutrition. O = Oral Health. B = Breast Feeding I = Immunization F = Female Education F = Family Planning 274

Cont. A dvantages of sPHC Decision-making is easier. Results achieved faster. It gives more satisfactory D isadvantages of sPHC Limited scope of activities It is disease-oriented, treats individuals who are sick It doesn’t address the general health problems of the community . 275

Cont. It doesn’t address priorities of the community. It is dictated and the approach doesn’t made self-reliance, i.e. it causes the patient to be dependent on the health professionals. It doesn’t recognize contributions and cooperation by other sectors. 276

C omprehensive Approach Advantages of cPHC It looks at health holistically It is development oriented and sees health as part of the development. It involves people and leads to empowerment It promotes equity. It advocates multi- sectoral collaborations. It deals with priorities of the community. 277

Cont. Disadvantages of cPHC It is expensive to set up an infrastructure. It requires conscious planning. Results are gradual. It is a long and complex process. 278

Differences between cPHC and sPHC 1. Definition of health sPHC views health as the absence of disease cPHC views health from the holistic approach 2. The importance of equity sPHC gauges its success on effective disease control for the least amount of money. cPHC , equity is its pillar. - equal distribution of the available resources. - equitable provision of health care to all people. 279

Cont. 3. The need for a multi- sectoral to health problems - sPHC centers the solution on medical interventions and does not recognize contribution and cooperation by other sectors. - cPHC , health is not merely a disease problem but development problem and, therefore, must be tackled by all those concerned. 4. The importance of community involvement - sPHC has no concern with enabling people to determine their own destiny or involving local people in the planning. - cPHC is community based. 280

PHC Principles 1. Inter - sectoral collaboration It means a joint concern and responsibility of different sectors - H ealth has several dimensions that can be affected by other sectors - T he causes of ill health are not limited to factors related to the health sector Important to:- Save resources (effective use of resources) Identify community needs together 281

Cont. 2 . Community participation Individuals and families develop the capacity to contribute to their health and the community’s development . - Emphasis is on strengthening the capacity of communities to determine their own needs and take appropriate action - should not be passive recipients of services . 282

Cont. the communities should be actively involved: In the assessment of the situation, Problem identification, Priority settings and making decisions, Sharing responsibilities in the planning, implementing, monitoring, and evaluation. 283

Cont. 3 . A ppropriate technology Criteria for appropriateness: Effective :- must work and fulfill its purpose Culturally acceptable and valuable :- must fit into the hands, minds and lives of its users Affordable :- affordable cost by the major/ whole community Environmentally accountable:- should be environmentally harmless Measurable :- needs proper and continuing evaluation if it is to be widely recommended. 284

Cont. 4 . E quity Providing equal health care to all groups of people according to their needs. Giving highest priority to those with greatest health needs Possible definitions of equity include: Equal health Equal access to health care. Equal utilization of health care. Equal access to health care according to need. Equal utilization of health care according to need 285

Cont . 5. F ocus on prevention and health promotion The important tasks for the planners are to readjust the imbalance in allocation of resources to preventive and curative care and enhancing the role of resources available to prevention and promotion. 286

Cont. 6. . D ecentralization Bringing decision making closer to the communities served and to field level providers of services. Greater potential for multi- sectoral collaboration. Enhance the ability to trap new resources for financing health care. It reflects Community participation 287

PHC Strategy 1. C hange in the health care system Total coverage with essential health care. Integrated systems Involvements of communities. Use and control of resources Redistribution of health human resources Reorientation of health human resources Legislative changes Design, planning, and management of health system. 288

Cont. 2. Individual and collective responsibility for health First aspect – is a political issue… Decentralization of decision making. Second aspect – self realization… personal responsibility. For both aspects it is important to have informed and motivated public . 3. Inter- sectoral action of health 289

PHC components/elements Essential H/care: At least 8 elements: Health Education Provision of Essential Drugs Immunization MCH/FP (Family Health) Treatment of common diseases & injuries Adequate supply of safe water & basic sanitations Communicable diseases control Food supply and proper nutrition 290

Cont. Additional elements incorporated in the Ethiopian context after Alma-Ata Oral health Mental health The use of Traditional Medicine Occupational health HIV/AIDS ARI 291

Managing a health team Learning objectives At the end of this chapter, you will be able to; Define team and health team. Differentiate between a team and a group. Understand the approaches of team work in health. List the stages of health team development. 292

Definitions of t eam A team is a small number of consistent people committed to a relevant shared performance goal. It is a special type of group . Preferably 2 – 8 people. Interacting and influencing each other . The members have attitudes of willingness to work and active participation . 293

Cont. The members stimulate each other, are independent and show no domination of one member over another. There is continuous coordination and collaboration among team members . 294

Cont. The members have a shared approach to common goals and are trustworthy and honest . The success of the team is more important than individual achievement, and Consistent people committed to a relevant shared performance goal/work for a common goal. 295

Cont. The heart of a true Team Respect each other, Be Flexibility, Communicate, and Trust each other . 296

Health team - Defined as a group of people who share a common health goal and common objectives , determined by community needs, to the achievement of which each member of the team contributes, in accordance with the functions of others. 297

Cont. A Health Team must Understand and communicate with the community; Encourage community participation in identifying problems and seeking solutions ; and Work in the community, i.e. in H/centers, community meeting places, work places, schools, at home, etc. 298

Cont. Health workers trained to follow the principles in team work are more responsive to the needs of the community they serve. The services they provide are more cost effective and are more satisfied in their career paths and their profession. "Coming together is a beginning, Keeping together is a progress, and working together is a success". Henry Ford. 299

Similarities and Differences of a Team and a Group Group is a collection of two or more individuals interacting and interdependent, which has come to achieve a particular objective . It is characterized by frequent communication among members over time a size small enough to permit each member to communicate with all other members on a face to face basis as a result each group member influences and is influenced by others . 300

Group discussion(10 mins .) The difference and similarities of team and group based on: Accountability Approach to work Areas of responsibility Level of authority 301

Cont. CHARACTERISTICS GROUP TEAM Accountability Members may not be accountable to the action of the group. They are only accountable for individual effort of action. Members share a common goal and purpose, therefore, each team member is mutually accountable for the team’s outcome Areas of responsibility Focus on individual roles, tasks and responsibility, even though group may cooperate Individuals cooperate, communicate and share responsibility among each other Approach to work They communicate the assessment and tasks are distributed to individuals. Individualized approach to work They discuss as a team and determine goals. They jointly develop action plan. They have common approach to work Level of authority The leader is more responsible and authorized than the members The leader is equally responsible and authorized like any member of the team 302

Team Approach Is the way that management attempts to bring about balance among the different people concerned. The success of team’s work depends to a great extent on how well its members work together and with the people they serve . Good management can help a team to work together harmoniously and efficiently through: 303

Cont. Setting and sharing objectives Encouraging good personal relations Distributing tasks Coordinating the activities of the team Applying sound organizational principles 304

Types of Health Team Primary Work teams Executive or Management Leadership teams and Ad-hock teams 305

1. Primary Work teams It comprises the basic structural unit in a team-based organization. Self-directed work teams are selected because they possess skills and talents needed to help this team do its work . Team members don’t have another primary job. Eg . patient care teams, a specialty team in the operating room, or trauma team in the emergency department. 306

2. Executive or Management Leadership teams The primary purpose of this teams is to provide management and leadership at some level in the organization. Members of these teams often have other primary work in the organization and may be members of many teams. These teams exist to lead others or to manage specific functions or processes. Eg . The University Management Committee 307

3. Ad-hock teams T eams that have shorter life spans and may be either problem-solving teams, such as quality teams, or creative teams ,a design or project team. These are temporary teams that are formed to meet a specific purpose. May exist for years, but they are not permanent organizational structures. When the work is finished the team disbands. 308

Members of Health Team There is no universally applicable composition of a health team. The composition could be defined by many factors: task to be performed, the nature of the working place , quality of the expected outcome, availability of particular professionals, etc. 309

Cont. The members of health team include all those working together; e.g. health workers and the supporting staff: clerks, drivers, and cleaners are all parts of the team. It may also include a community health worker chosen by the village people. It is important that their work and contributions be recognized as those of the technical staff. 310

Stages of Team Development 1 . F orming Development acceptable to the group . People’s role change from “individual” to “ member” • Period of orientation or direction . When a group is just being formed, members generally have these feelings: Excitement, anticipation, optimism. Anxiety , fear, or even suspicion about the job ahead… 311

Cont. Polite , fairly formal interactions with other members. Attempt to define the task and decide how it will be accomplished. Attempt to figure out what is acceptable group behavior and how to deal with group problems. Useful activities/tools the team leader can use to help forming groups are: Introduction/inclusion activities. Clarify the mission Establish ground rules for team behavior. Provide any needed training. 312

2. Storming Members oppose the formation of the structure. Become hostile and fight to the ground rule Critical to effective group development, but usually is a difficult time for the team. The task seems harder than they expected . 313

Cont. Useful activities/tools in the Storming phase are: Conflict management techniques. Clarification/teaching of QA concepts, tools, team dynamics, meeting methods, and roles. 314

3 . N orming Members begin to accept the team, their roles on the team, and the individuality of fellow members. Conflicts are addressed and resolved . Group unity emerges . At this stage , members generally have these feelings: Acceptance of membership in the team. Commitment to working out differences. 315

Cont. Giving and receiving feedback constructively. More expression of feelings. “Playful” interactions. Useful activities/tools the team can use in the norming phase are: Continue the development of shared responsibility. Refocus on the agenda or purpose (when necessary). Provide training in QA tools or group process as needed 316

4 . P erforming the team starts diagnosing and solving problems C hoosing and implementing changes. Members accept each other’s strengths and weaknesses, and know what their own roles are Structural issues resolved. Structure supports group dynamics and performance. Structure used for task accomplishment 317

Cont. At this stage , group members generally have these feelings: Satisfaction with the team’s progress. Trust in one another… and exhibit these behaviors: An ability to anticipate group problems and prevent them or to work through them constructively. A willingness to take risks. Commitment to process and goals. Useful activities/tools for the Performing phase are: Training in QA tools or concepts as needed. 318

The WHO definition of Team Work states as “Team work is coordinated action carried out by two or more individuals jointly. Health Care is Team Work: “No one can do everything, but everyone can do something.” 319

Managing resources Human resource Finance Information Equipment (drugs) Time Space 320

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