Health System Management

Dr Prabir Ranjan Moharana MD, DHHM.

Assistant Professor Department of Community Medicine ASR Academy of Medical Sciences

(ASRAM,Eluru,AP)

email: drprabir2007@rediffmail.com

What is Management?

“Management is getting the right things done in right way, in right time, by right persons with right amount of resources and effective use of resources.”

“Health System Management is defined as purposeful & efficient use of health system resources and to get members of the health team coordinated to work harmoniously in order to achieve the desired common Goals and Objectives.”

Management in Health System, Why?

Integration of Health Programs/Departments.

Overload of work & Distribution of work.

Changing Health needs/Health Demands.

Improvement of health care delivery system by applying modern management methods and techniques.

Targets < Objectives < Goals

Goal: Ultimate Desired State (ex- MDG: Goal 6-To Combat HIV-AIDS, Malaria, Tuberculosis & other diseases.

Objective: Planned end point of a health activity.

Deals with the problem in health activity(ex-Blood Safety Program, STD control, Health Awareness, Condom Promotion against spread of HIV).

Targets: Discrete activity in a health activity. Deals with the factors involved in a problem (MDG: Goal 6-Target 7-Condom use in high risk population.

Indicators: To measure the outputs/progress in a health activity.

What are Health System Resources?

Manpower Money Materials Minutes (Time) Knowledge Techniques Skills

Management Methods(Qualitative)

Organizational Design: To meet Health needs/demands.

Personnel Management: Proper person at proper place/ right person for right job.

Communication: Effective sharing of information between different levels of hierarchy.

Information System: Data/Feedback for action(ex-Health Management Information System(HMIS).

Management by Objectives(MBO): Result oriented based on minimum cost and minimum time.

Functions of the Management POSCOD

ORGANISINGPLANNING DIRECTING

STAFFING

DECISIONMAKING CONTROLLING

Functions of Health System Management

Planning of course of action/health activities (implementation & evaluation).

Organizing resources, Organizational structure and assigning a specific job chart.

Staffing: recruitment, training, supervision, monitoring.

Controlling the quality of activities of the members through setting up standards for performance.

Directing and Decision making: issuing orders & instructions.

CORBID: Contd.

Coordinating all the efforts and activities of all the team members/stakeholders and other sectors.

Reporting: to higher levels.

Budgeting: maintaining accounts & spending contingencies.

Innovation of new work methods.

Representation/Delegating of organization at different levels.

What skills needed in a Good Health Manager?

(Always Hire Skills not Persons)

Effective Communication Skill: Patience to listen, Ability to express and emphathise.

Effective Conceptual Skill: Ability to understand the complexities of overall organizational activities, goals, objectives, targets, policies and procedures.

Effective Human Skill: Through motivation, discipline, training, performance appraisal, rewarding etc.

Developing Team-work: Establishing basic trust, oneness, compatibility, team spirit, conducive organizational climate etc.

Who is a Good Health Manager?

Effective Technical Skill: Ability to use knowledge, new methods, techniques and equipments.

Effective Leadership Skill: To empower employees and

motivate them to work efficiently and effectively to achieve health system’s goal.

(i) Competitiveness

(ii) Entrepreneurship

(iii) Innovativeness

(iv) Maintaining Order and rationality

Models of Leadership Skills (I):

The skills are multiple and intersecting each other.

Developing self awareness Managerial Stress

Solving Problems creatively

Model of Leadership Skills(II) :

*Coaching *Self awareness*Counseling * Gaining power*Listening *Empowering others

*Identifying cause *Diagnosing poor *Appropriate strategies performances*Resolving conflicts *creative

environment*Solving problems creatively

*Rewarding/accomplishment

Communicating supportively Motivating Others

Managing Conflict

Gaining Power &Influences

Health Planning: A process of deciding how the future should be better than present.

For proper utilization of health system resources.

For improvement of health services.

National Health Planning defines health problems, identifies unmet needs, surveys resources, establishes priority goals which are realistic & feasible, projects administrative action for accomplishment.

Plan

A blueprint for any action.(What, How, When, Who to do?)

5 Components: Identification & Prioritization of Health Problems. Policies Formulation. Objectives establishing. Budget allocation. Time frame.

Definitions

Health Policy: A guideline/logical frame work for health activities to improve health condition of people.

Program: A sequence of activities designed to implement policies and accomplish policies.

Schedule is a timeframe to complete the action.

Procedures: a set of rules.

Planning is a Cyclic Process(Steps) Step-1. Analysis of the Health Situation.

Collection, assessment, interpretation of information and Demographic data through surveillance .

Epidemiology of diseases, Mortality and Morbidity data

Medical Care Facilities, Technical Manpower, Training facilities.

KABP of population about disease prevention and cure.

Planning is a Cyclic Process Step-2. Establishing Objectives & Goals.

Reduces haphazard activities, uneconomical use of funds, poor performances.

General Objectives/procedures at upper level become more specified and detailed at lower levels.

Resources are directed properly taking into nature of objectives(Short Term/Long Term).

CBA and Input-Output analysis are being used for defining goals, objectives and targets.

Planning is a Cyclic Process

Step-3. Assessment of Resources

In terms of men, money, material, time, knowledge, techniques and skills.

A balance is maintained what is required, what is available and how to be utilized.

Planning is a Cyclic Process

Step-4.Fixing Priorities Prioritizing objectives/activities in order of

importance/ magnitude.

A Good Health manager is a PAPA(Plans well, Analyses critically, Prioritizes Activities and Act timely/promptly).

Formulation of alternate plans.

Planning is a Cyclic Process

Step-5. Writing of formulated Plan

Preparation of detailed plans.

Working guidance to all those responsible for execution eg. Health Care Providers.

Planning is a Cyclic Process Step-6. Programming and Implementation.

Effective organization like staffing, coordination, communication etc.

A standard operating procedures for specific tasks and roles.

Selection, training, motivation, supervision and monitoring of the manpower:ex-SBA & ENC training.

Proper management functions are required here.

Planning is a Cyclic Process

Step-7. Monitoring: “Tracking the tract”. Following the activities during their

implementation whether they are proceeding according to predefined schedule or not.

Keeping the track of the course of activities and taking corrective action before gross failure/deviation occurs.

Planning is a Cyclic Process

Step-8.Evaluation: To assess/measure the degree of achievements of the stated objectives and targets.

Assessment of adequacy, efficiency, effectiveness etc of final outcomes of a health activity.

Important for feed-back, opportunity for correction of deficiency and gaps during phase of implementation.

Pre-Planning

Government Interest: Strong Political Will for Policies.

Legislation: Translating social & health policy to legislation.

Organization for Planning- ex Planning Commission in India

Administration Capacity: For proper intersectoral coordination and implementation at district, state & national level.

Planning is a Cyclic Process of PIE

Planning (P)

Implementation (I)

Evaluation (E)

Planning Cycle

Implement Integrated Programs

Operate & Monitor Programs

Selection of Best Program

Collect date for Evaluation

Formulation of Health Problems Prioritization of

Health Problems

Establishing Objectives & Goals

Train & Orient personnel

Designing alternative programs with solutions

Integrate best programs and develop plans

Formulation of Individual Solutions YES

Evaluate degree of achievements in TOG(Satisfactory?)

NO

Planning Cycle

Operate & Monitor Programs(Execution) Assessment of

Resources

Collect date for Evaluation

Assessment of Health Situation & Problems (Analysis of Health Data)

Establishing Objectives & Goals

Designing Time Frame

Prioritization of Health Problems (Felt Needs)YES

Evaluate degree of achievements in TOG(Satisfactory?)

NO

Management Methods(Qualitative)

Qualitative Method : (Based on principles of behavioral sciences).

1. Organizational Design

2. Personnel Management

3. Communication

4. Information System(HMIS)

5. Management By Objectives(MBO)

Management Methods(Quantitative)

Quantitative Method (Based on principles of Economics, Budgeting & Operational Research)

1. Cost-Benefit Analysis

2. Cost-Effective Analysis

3. Cost-Accounting

4. Input-Output Analysis

5. Model

Management Methods(Quantitative)

Quantitative Method (Based on principles of Economics, Budgeting & Operational Research)

6. System Analysis

7. Network Analysis

8. Planning-Programming-Budgeting-System

9. Work Sampling

10. Decision Making

Cost-Benefit Analysis (CBA)

Cost: A factor of production. Monetary valuation of an expenditure to obtain an asset/service.

The benefits are expressed in monetary terms only. A benefit-to-cost ratio >1 is acceptable.

It is rarely used to assess health programs because in health programs the benefits in terms of births/deaths prevented, illnesses avoided (cost-effectiveness).

It is a form of economic evaluation and measures “value for money” to community.

Cost-Effective Analysis (CEA)

Most widely used in Health Programs/Services.

Similar to CBA but benefits are expressed in terms of “results/outcomes/improvements in health condition”.

not in terms of “money”.

It measures relative cost of alternative ways in achieving objectives and targets.

CEA: contd.

CEA measures benefits in terms of effectiveness ie. Improvement in health condition, reduction in incidence/prevalence of a disease, neonatal deaths prevented etc.

Cost Accounting

A set of procedures used for determining the cost structure of various services & activities in a health program

(1) To analyze cost control operating in each activity/ department/service.

(2) To detect and reduce wasteful expenditure by proper planning & allocation of resources.

(3) To calculate & accumulate Cost Data ie. Cost of hospitalization, cost of work & production, Cost of pricing, cost of reimbursement.

Input-Output Analysis

An economic technique.

Input: Every type of resources utilized eg. Man, Money, Material, Time etc.

Output: Number of cases treated in OPD/IPD per day, Number of immunizations done per week.

System Analysis

A formal analysis of (i) Purpose of a system/ Organisation (ii) Problems within system (iii) Cost effectiveness, risks of an alternative activity/strategy.

A system may be a hospital supply system, hospital management information system, community health service system etc.

Network Analysis

Graphical presentation and analysis of activities and their interrelation in the form of diagrams, flow charts, logical sequences.

PERT :(Program Evaluation & Review Technique)

A Network analysis.

Used for control of Time and Cost in complex programs/projects.

Listing of activities & tasks and presenting them in the form of a network with sequential relationship between them.

Network Analysis(PERT)

4months 2 months

Start 1 month

2 months 1 month

10 months

Plan Service

Staff Trained

Equipment Installed

Staff Recruited

Equipment ordered

Service Started

CPM: Critical Path Method

A Network analysis used for control of Time and Cost in complex programs/projects.

A program is broken into component parts and each part is analyzed in isolation and with relation to other components.

The longest path with greatest time constraint is determined.

CPM: Critical Path Method

The critical path for a program is that step the activities along that step have “total zero slack”.

Any delay in start/activity in that critical step/path will delay the entire program.

Sum of durations for critical activities represents the “shortest possible time” to complete a project. “The path with longest time duration determines the shortest possible time for completion of a project/program”

Network Analysis (CPM)

4months 2 months 1 month

Start 3 month 1 month

2 months 1 month

10 months

Plan Service

Staff Trained

Equipment Installed

Staff Recruited

Equipment ordered

Service StartedRenovation work

Planning-Programming-Budgeting System

An economic framework.

It helps decision makers to prioritize expenses, to allocate resources and to minimize opportunity cost.

It helps for grouping of activities related to each objective.

Work Sampling

Systematic observation & recording of activities of one/more individuals.

Carried out at predetermined/random intervals. Major parameter is “Time”.

Useful in hospitals and done for doctors, nurses, pharmacists, laboratory technicians.

It analyses appropriateness current staff , job description and standardizes performance, determines manpower needs.

Decision Making

Like D/d (Differential Diagnosis) in Medical Practice.

Best decision is not always made at the top levels of organization.

Decision should not be made with incomplete data.

Pick up and carry out the best decision.