Case Study: Health Care Management

The Chairman of CBS has been involved in health care for 30 years. His wife was the lead GP for a major town in the UK and a member of the board of the CCG (Clinical Commissioning Group). Their network of primary and secondary care doctors is currently being mobilised to deliver programmes in the developing world.

Malawi Civil Service Commission and the Ministry of Health

Part of the overall review of the Malawi Civil Services funded by the British Government involved a detailed case study of the Ministry of Health and the two major hospitals in the Country. This was done by the Chairman of CBS over an 18-month period and resulted in a 155-page report. This gave him an in-depth experience of the national health problems in Malawi and of analysing the performance of a Ministry of Health and large hospitals where budgets were exceeded and where costs of establishments, capital and materials was out of control. There was also a critical shortage of medical and technical personnel, medical departments did not have effective management structures and did not cooperate with each other and the relations between doctors , nurses and administrators was poor.

This list of problems is repeated in many African Ministries of Health, their hospitals and primary care units. This conclusion was substantiated by the experiences we had in running the following programme;

The Ministry of Health part of the PPP programme in Ghana

Three of the participants on the programme came from the Ministry of Health. Two of these 3 were senior managers in the Country's largest hospital. Their individual and group projects involved improving the performance of the hospital. They identified the major causes of inadequate performance as the lack of committed and effective managers and supervisors; ineffective management control systems and inappropriate organisational structures. Their implementation plan featured the design of action learning based programmes and the creation of action learning groups among those to be held responsible for improving the utilisation of scarce resources in the hospital. These groups were to be established around the senior management team, the supervisors in charge of support departments and at the level of clinical departmental teams.

The aim of the 3 participants was to introduce an action learning based implementation plan with particular reference to improving the quality of the service offered to external and internal customers (ie patients and other departments and individuals within the hospital). The intention was that the action learning approach would become a permanent feature of the hospital management system.

The design of their proposed programme was based on the work done in Malawi. For example, the workshops were to include inputs on the strategy of hospitals such as what are the critical success factors and the key business processes, how are they cascaded into the wards etc, how performance is measured, what is the level of customer satisfaction, are relations between clinicians and managers good etc? The second workshop was to cover the management of the hospital – how national resources are allocated, is the budget appropriate, how precisely is money spent, where are the people problems (shortages, competence and commitment levels, levels of absenteeism, pay structure, how poor performance is dealt with etc), problems in the way capital equipment is utilised (vehicles, mechanical equipment, boilers etc), what are the material utilisation issues etc?

Subsequent workshops were to deal with issues of particular importance to participants which would become evident during the earlier workshops. Group projects were designed around solving operational problems in the clinical and administrative departments of the hospital. Individual projects were based on the BIP (Business Improvement Plan) model covering how to implement performance improvements in the participants' own departments. Personal Development Plans (PDP) were to improve individual competence and commitment.

It's not enough to know what is good, you must be able to do it. George Bernard Shaw

This quote was of significance to the 3 participants on the action learning programme. Their action plan was approved by the Chief Executive of the hospital but before implementation could begin he was retired. Two other Chief Executives were installed but both were seen as temporary appointments and their tenure lasted for a limited time which did not facilitate considering a change programme.

Future focus

One of the core CBS programmes features the cascade of country national development plans. Our particular interests are in the cascade into infrastructure and health care ministries and their priority projects and in the case of health care, into the major hospitals. A focus on improving effectiveness of the health care delivery should not be constrained by lack of resources to build physical assets. Some of these assets already exist so action learning programmes could start immediately. During this programme the physical and other needs of the Health Ministry can be addressed in the workshops and the action learning projects.