MANAGERS WHO LEAD A Handbook for Improving Health Services Cambridge, Massachusetts Copyright © 2005 Management Sciences for Health All rights reserved. Trainers and facilitators may photocopy the exercises, tools, guidelines, and instructions for participants without prior permission, for noncommercial use only. Any translation, adaptation, or commercial use of any part of this book in any form or medium requires prior written permission from the publisher. Th e trademarks or service marks used in this book and CD-ROM, including Microsoft , Word, and PowerPoint, are the exclusive property of Microsoft Corporation. Managers Who Lead is not a product of, nor is it endorsed by, Microsoft Corporation. Management Sciences for Health Tel.: 617.250.9500 784 Memorial Drive Fax: 617.250.9090 Cambridge, MA 02139-4613 USA Web site: www.msh.org ISBN 0-913723-95-9 Interior design and composition: Jenna Dixon Indexer: Barbara K. Timmons Proofreader: Ceallaigh Reddy Funding for this publication was provided by the Offi ce of Population and Reproductive Health, Bureau for Global Health, US Agency for International Development, under the terms of the Management and Leadership Program, award number HRN-A-00-00-00014-00. Th e opinions expressed herein are those of the authors and do not necessarily refl ect the views of USAID. Printed in the United States of America on acid-free paper by Quebecor World with vegetable-oil-based ink. ∞ Th e paper used in this publication meets the minimum requirements of the American National Standard for Information Sciences—Permanence of Paper for Printed Library Materials, ANSI Z39.48-1992. Library of Congress Cataloging-in-Publication Data Managers who lead : a handbook for improving health services. p. cm. Includes bibliographical references and index. ISBN 0-913723-95-9 (alk. paper) 1. Health facilities—Administration—Handbooks, manuals, etc. 2. Leadership—Handbooks, manuals, etc. 3. Health services administration— Handbooks, manuals, etc. I. Management Sciences for Health (Firm) RA 971.M3463 2005 362.1’068—dc22 2005047959 1 2 3 4 5 6 7 8 9 05 06 07 08 09 authors contributors Joan Bragar Galer Ann S. Buxbaum Sylvia Vriesendorp Lourdes De la Peza Alison Ellis Joseph Dwyer Michael J. Hall editors Sallie Craig Huber Janice Miller Sarah Johnson Claire Bahamon Riitta-Liisa Kolehmainen-Aitken Barbara K. Timmons Nicole B. Lubitz Cary Perry Gregory Rodway Steve Sapirie Karen Sherk Barry D. Smith international review board Abdo Hassan Alswasy Luis Eduardo de Menezes Lima Consultant for Obstetrics and Gynecology Deputy Secretary for Education Kom Ombo Central Hospital State of Ceará Kom Ombo Aswan, Egypt Fortaleza, Brazil Timothee Gandaho Zoonadi Joseph Ngwenya Executive Director Country Programme Manager Partners in Population and Development Southern African AIDS Trust Dhaka, Bangladesh Lusaka, Zambia Clare Gibson-Giraud Lourdes Quintanilla Leadership Coach and Facilitator Senior Consultant and Partner Performance Plus Coaching Cali-Des Bordeaux, France Saltillo, Mexico Atanu Majumdar Fenosoa Ratsimanetrimanana UNICEF Consultant Executive Secretary Kolkata, India National AIDS Council Antananarivo, Madagascar Morsy Mansour Irna Senekal Leadership Development Consultant Health Diploma Coordinator Cairo, Egypt Fort Hare Institute for Government Bisho, South Africa To the memory of Dr. Pape Syr Diagne the late Executive Director of the Centre for African Family Studies in Nairobi, Kenya Dr. Pape Syr Diagne was a visionary and passionate leader committed to improving reproductive health. His greatest legacy is the young men and women whom he inspired to follow in his footsteps. Contents Figures vi Tables vi Country examples vi Foreword vii Acknowledgments ix Introduction xi chapter 1 Leading and managing to achieve results 1 chapter 2 Leading teams to face challenges 21 chapter 3 Improving work climate to strengthen performance 51 chapter 4 Moving up the leadership ladder 81 chapter 5 Reorienting roles in the health system 115 chapter 6 Leading change for better health 149 toolkit Resources to support managers who lead 173 Annotated bibliography 271 Index 285 vi managers who lead figures figure 1 Leading and Managing for Results Model 8 figure 2 Leading and Managing Framework 12 figure 3 Integrated Leading and Managing Process 14 figure 4 Th e Challenge Model 23 figure 5 Factors to consider in scanning the environment 30 figure 6 Sample action plan worksheet 41 figure 7 Rewards of a positive work climate 52 figure 8 Causes and eff ects of work climate 54 figure 9 From stage to balcony: A change in perspective 83 figure 10 Shift ing the health system to serve local needs 117 figure 11 Sectors of the health system 118 figure 12 Leading and Managing for Results Model 151 tables table 1 Leader shift s 3 table 2 Leadership competencies 16 table 3 Becoming a manager who leads 17 table 4 Sample action plan format 41 table 5 Learning about your staff 56 table 6 Shift from reactive to proactive language 64 table 7 Distinguishing commitment from compliance 69 table 8 Key leading and managing practices for the fi rst-level manager 89 table 9 Key leading and managing practices for the second-level manager 95 table 10 Key leading and managing practices for the third-level manager 102 table 11 Key leading and managing practices for the top-level manager 109 table 12 Roles that support eff ective local health services 119 table 13 Shift s in focus at the district level 121 table 14 Shift s in focus at the central level 130 table 15 Shift s in focus at the middle level 139 table 16 Distinguishing between routine and complex 151 table 17 Key factors in leading organizational change 154 country examples Improving capacity to respond to a challenge—Example from Guinea 15 Leading with a vision to achieve results—Example from Egypt 43 Improving work relationships, group climate, and performance—Example from Senegal 76 Stimulating political will for local health initiatives—Selected country examples 126 Reorganizing a Ministry of Health to support new roles—Example from Nicaragua 136 Improving morale and resource fl ows through district outreach—Example from South Africa 142 Scaling up changes in the way health managers work—Selected country examples 166 Foreword arly in my career I provided primary health care in a village in Upper Egypt. My own family came from this area and I was deeply concerned Eabout the health of the people there. Working in this remote area with- out support from anyone, I learned how hard it is for a young physician on his own to face the health challenges of an underdeveloped, underserved region. Th is is the front line of health services around the developing world: health workers in rural as well as urban areas. Th ey badly need good managers and supervisors who can enable them to succeed in protecting their communities from the dangers of poor health. Years later, as Coordinator of Population Projects in Upper Egypt, I found myself responsible for these same rural health units. I struggled to give them the support I knew they so badly needed. Th e district team managers and supervisors tried to fi nd a way to improve the quality of services and the service results. But no matter how much clinical training we provided for service providers, or training in planning and data analysis for central and local managers, there were only small improvements in service quality and results. I began to feel that there was a missing piece in the health system. Th ere was something that created a gap between knowledge and skills on one hand, and people’s behaviors and attitudes on the other. Even when health workers knew what was right, they didn’t practice it consistently. People knew about infection control, but they didn’t practice it. People knew about the impor- tance of counseling, but they didn’t apply what they knew. What was missing was something inside their hearts, something that ignites the fi re inside all who want to truly contribute or make a diff erence. What was missing was commitment. © 2005 Management Sciences for Health vii viii managers who lead Th e question became: “How can we inspire this commitment in every health service team and team member?” Th is is the question that health man- agers around the world are asking. How can we take our limited resources and give the best of ourselves to ensure the quality we want our people to have? How can we not be stopped in the face of inadequate systems and limited resources? How can we motivate our staff to be creative in overcoming obstacles, when there are so many? I believe that when people are committed they can produce incredible results. Even if the systems are poor, with commitment they will fi nd ways to con- tinuously improve them. Now you can see a change in Aswan in Upper Egypt. Th is week I visited a rural health unit, much like any in the developing world. I found the man- ager there, a young female physician, Iman. She is a quiet person, and before she was posted to this unit she was afraid that she would not be able to lead a health unit team. She said she thought that leaders had to have loud voices and yell at other people to make them afraid in order to get things done. But Iman has developed her leadership skills with coaching from her dis- trict managers. With the support of her team and of managers in other health units, she is learning how to lead. She now knows that a good manager is suc- cessful not because people are afraid, but because she helps them fi nd ways to overcome the obstacles. Her power as a leader comes from allowing her team to explore new ideas without fear.