HEALTH SERVICES MANAGEMENT

The need for managers in health care

Healthcare is an expansive industry that ranges from preventative care, to emergency services, to follow-up and
rehabilitation. Health care organizations are complex and dynamic. The nature of organizations requires that
managers provide leadership, as well as supervision and coordination of employees. Organizations are created
to achieve goals that are beyond the capacity of any single individual. This is more so in health care
organizations where the scope and complexity of tasks carried out in provision of services are so great that
individual staff operating on their own can’t get the job done.

Managers are therefore needed to make sure certain that organizational tasks are carried out in the best way
possible to achieve organizational goals and that appropriate resources including financial and human
resources, are adequate to support the organization.

Definition and functions of Management

Though management is universal, there is no agreed definition. Choice can be made to suit that situation in
which it’s applied. The simplest definition is “the getting of things done”.

Other definitions

Generally, there is no acceptable definition of management as an activity though the classic definition is still
hard to be that of Henry Fayal who as the 1st scholar stated that;

• To manage is to fore cast, to plan, to organize, to command, to coordinate and to control. He further said
that a role is an obligation.
• EELBREACH 1957 stated that management is local process which consists of planning, controlling,
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coordinating process (meaning managing more than one process).
• KOONTZ ODENEL 1976, stated that management is an operation initially dissected by analyzing the
managerial activities i.e. planning, organizing, staffing, directing, leading and controlling.
Management therefore is a process which enables organizations to achieve their objectives by planning,
organizing and controlling their resources including gaining the commitment of their employees through
motivation.

The principle underlying the definitions is commitment to purposeful action not to act for its own sake i.e.
focusing on the goals. HSM can be observed as getting people both health workers and non health workers
work together harmoniously to make effective use of resources to deliver health services effectively to the
community they serve.

Management is a process that enables organizations to achieve their objectives through human and other
resources (getting things done).

Is an element that helps Health Workers to manage various resources used in health services, effectively and
effectively.

The aim for teaching Health Services Management (HSM) is to equip the students with relevant skills that will
enable them to effectively manage health services. Management means getting things done. It’s working with
and through people in order to achieve organizational goals and objectives.
Therefore management enhances teamwork as opposed to work in isolation. This therefore requires a manager
to be flexible in order to succeed. HSM means getting people work together harmoniously using resources
effectively to deliver health services to the individuals and the community they serve.

The manager who is stiff causes “a red tape” i.e. a breakdown in organization. In proper management
information should flow from subordinates to the supervisors and vice-versa.

In management, there is control of resources including human resources for remembrance. Resources including
human resources are considered under 4m’s i.e.

• Manpower
• Material
• Money
• Movement

Manpower resources cannot be bought from shelves like any other resources. This means manpower is not
always available particularly in the right kind. Management has been applied since the beginning of civilization.

In communities, people have always worked together to grow crops, build temples, etc.
 Qualities of a good manager

• A good manager is that one who knows when, where, what and how to act i.e. good manager is  flexible
 Kind
 Patient
• Knows the importance of accountability
• A good manager must be able to account for whatever he/she has used or done.
• Should be transparent
• Able to consult because he’s not working in isolation  Should be polite and able to share knowledge
with others  Should be knowledge i.e. up dated and never challenged.

However management incurs some problems

• Biasness
• Lack of knowledge and skills
• Inadequate resources e.g. money and other equipments in the Health Unit, manpower, etc.
• Environmental hazards e.g. blocked toilets, no water etc.
• Lack of cooperation from colleagues
• Poor communication both verbal and written, no telephone, lack of transport
• Beauracracy:Tendency to go through very many processes before arriving at the final decision
• Competition in management where two managers are competing to be in charges of a unit, conflicts may
occur.
• These make it difficult to manage. These can hinder the effectiveness of management.

Management as a collective effort

While more often than not, we tend to focus on the role of senior manager or lead administrator of an
organization, it should be realized that management occurs through many others who may not have “manager”
in their position title. Examples of these managerial positions in health care organization are:-

2 Health Care setting Management Position

Ward Incharge

Special Clinic Incharge

Outreaches Coordinator
 Records Department Director of Medical Reports

Nursing Senior /Principal Nursing Officer

Functions of Management

Managers implement management functions as they carry out the process of management.

1. Planning. This function requires the manager to set a direction and determine what needs to be
accomplished. It therefore means setting priorities and determining performance targets.
2. Organizing. This management function refers to the overall design of the organization or the specific
division, unit, or service for which the manager is responsible. Further it means designating reporting
relationships and intentional patterns of interaction.
Determining positions teamwork assignments and distribution of authority and responsibility are critical
components of this function.
3. Staffing. This function refers to the acquiring and retaining human resources. It also refers to developing
and maintaining the workforce through various strategies and tactics.
4. Controlling. This function refers to monitoring staff activities and taking appropriate actions for corrective
action to improve performance.
5. Directing. The focus in this function is on initiating action in the organization through effective leadership
and motivation of and communication with subordinates.
6. Decision making. This function is critical to all the aforementioned management functions and means
making effective decisions based on consideration of benefits and drawbacks of alternatives.
7. Motivating. Stimulating individuals to put more efforts in their duties.
Management skills

In order to carry out the above mentioned functions, the manager needs to posses key skills including.

Conceptual skills. These are skills that involve the ability to critically analyze and solve complex problems e.g.
finding the best way to provide a certain service.
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Technical Skills. These are skills that reflect expertise or ability to perform a specific work task. For example
designing a computerized staff monitoring tool.

Interpersonal skills. These are skills which enable managers to communicate well with other individuals,
regardless of whether they are peers, supervisors or subordinates e.g. a manager counseling an employee whose
 performance is below expectation or communicating to subordinates the desired performance level for a
service for a given time period.

Skills versus Organizational hierarchy

The importance of management skills differ at various levels in the organizational hierarchy:-

Lower level Management. For lower level managers, technical skills are of greatest importance, human skills
are also helpful in interaction with subordinates, but conceptual skills are normally not critical for them.

Middle level Management.For middle level management, the need for technical skills decreases, human
(interpersonal skills) are still essential and conceptual skills gain importance.

Top level Management. For top management conceptual and human skills are still very reliable but there is less
need for technical abilities. This is true for large companies but in small organizations, technical skills may still
be quite important.

PRINCIPLES APPLIED BY HSM

In HSM work involves more than one person and as a result, two or more complementary principles must be
applied to management namely; Division of labour and convergence of work.

Division of labour

This was devised by Henry Fayol who said that the more people are involved in work specialization, the more
efficient they become.

When work is divided and coordinated, the group becomes a team. In a team, there is specialization and
division of labour by each category of staff. It’s done to fully utilize the skills of each member in order to
achieve the objectives. Management is the assigning of a balanced proportion of work to each kind of staff in
the organization.

Team approach
4 This is the way in which management attains or brings about a balance amongst different members of the team
and the work they do. e.g. Consider different people involved in management of patients from the time they
come to the hospital till discharge or the number of people (different with different skills) involved in a
successful surgical operation. Therefore, in the division of labour, work must be shared or divided among a
number of different categories of technically skilled people. To achieve the objectives, the study of work
relations and equitable resource allocation should form a major area in management. Its governing principle is
that of “convergence of work”. Convergence of work

It means that activities the various people who do the work, come together in order to achieve the objectives.
The activities should be designed and directed in such a way that they support each in moving towards a
common goal.

It also implies that work impressions are the way in which members of the team interact with one another; it
should contribute to the success of each activity and general effectiveness. In general, health activities are
studied described and performed under 3 main sub-headings mainly.
 o Service activities
o Developmental activities
o Support activities
A service activity e.g. immunization usually requires some proceeding developmental activities e.g. training
immunizers and some continuous support e.g. provision of supplies. These 3 activities need to be managed so
as to bring about convergence of work, balance of resources and harmonious work relations and ultimately
intended results.

Other related principles are;

Substitution of resources

It’s also widely applied in the effective use of resources after when resources that are normally used to provide
services become too expensive. Here the cheaper alternatives are used to produce intended results.

Delegation

It’s also one of the principles of management in which someone with authority “temporarily gives” the
authority to another person so as to enable that person take responsibility when need arises. The decision to
delegate is reached after making sure that the person to be delegated is capable of performing as expected.
Management by exception This means two things:

1st to be selective and not to be overloaded with routine unnecessary information. Keep your mind available for
critical information on which you will be required to act e.g. practice your attitude.

2nd make big decision first.

To be overloaded with plenty of decisions may result in neglecting the most important ones or what has been
called “postponing” decisions until they become necessary. In short, management by exception means
selectivity in information and prioritization in decision.

Like division of labour also Henry Fayol put down some other principle of management. These include: -
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1. Authority with corresponding responsibility. If responsibilities are allocated, then the post holder needs the
requisite authority to carry out the duties.
He/she should be responsible for his /her actions. It is not uncommon in some organizations to find
powerless managers.
 

2. Specialization/division of Labour. This is a principle of work allocation/specialization so that individuals

do activities which they are best suited for hence more efficiency of the organization.
3. Discipline. For an enterprise to prosper there must be orderly behaviour for all its employees. Employees
must adhere to the rule’s standards of the organization.
4. Unity of command. This is the idea that an employee should receive instructions from only one supervisor.
This generalization still holds even where we are involved with team and matrix structures which involve
reporting to more than one boss. The basic concern is that tensions and dilemmas arise where we report to
two or more bosses.
5. Unity of direction. There should be only overall manager and only one plan to which everybody adheres to.
6. Subordination of individual interest to the general organization’s interest. This principle denotes that one
employee’s interest or those of one group should not prevail over the organization as a whole.
7. Staff Remuneration. The staff remuneration should be as fair as possible in view of the organization’s
costs and profitability.
8. Scalar chain/line of authority. The line of authority in the organization runs from top to bottom in a straight
line.
Communications should normally follow this path, although managers should be able to communicate
across the organization to peers at the same level of authority.
9. Order. To run well as organization, there should be a place for everything. Orderliness also implies steady
evolutionary movement rather than wild anxiety provoking unpredicted movement
10. Equity. Fairness and a sense of justice should pervade the organization in principle and practice. An
organization runs best when there is friendliness among employees and managers and when managers act
fairly towards others.
11. Stability of staff. Employee turnover is unhealthy for organizations because time is needed for employees to
adapt to their work and perform effectively. Stability of tenure promotes loyalty to the organization.
12. Initiative. At all levels of the organization, zeal, enthusiasm and energy are enabled by employees having
the scope for personal initiative.
Subordinates should be given the opportunity to conceive and execute plans as long as they are in line with
the overall organizational plan.
13. Team work. For proper organizational functioning, there is need for building and maintaining harmony
among the workforce, team work and sound interpersonal relationships.
 14. Centralization /delegation. There should be a balance between centralization and delegation. Authority and
responsibility should not be too centralized in one manager.
HEALTH MANAGEMENT INFORMATION SYSTEM (HMIS)

Health Information system is a vital tool in health services management. It plays an import role at every
level/stage of health services management e.g. planning, implementation, control and monitoring/evaluation of
health services. HMIS involves collection, complication, analysis, interpretation, utilization and dissemination
of data on health. The information can be used for planning, implementation and evaluation of health activities.

Data and information

Although these 2 words are used interchangeably as one, there are significant differences between them. Data
consists of facts and figures e.g. number of patients attended to, number of children immunized and number of
staff just recorded in the files. This is not information.

It is only after these fats are analyzed for facilitating decisions that they become information.

Collection of data

Source of data

In Uganda, data can be collected from various sources. Routine collection of health data is from;

 The health facilities e.g.

 Morbidity and Mortality
 Special investigations
 Quarterly and annual reports
The community. Through surveillance reports e.g. survey, census, and epidemic reports and on spot
observation.
 Other sectors
 Agriculture e.g. food production

6  Education e.g. literacy levels, student involvement

 Administration e.g. manpower, finance supplies
 Media (News papers, magazines, radios and TV)
 

Types of his forms used to collect data

Health data is routinely collected through a set of his registers and forms
 Outpatient register

 Outpatient card MF5 (>5 years)

 Outpatient tally sheet

 Child health care card MF5 (< 5

years)
• ANC tally sheet MF 454
• ANC card
• Maternity return/discharge register MF49
• Monthly summary report MF77
• Inpatient return /discharge register MF 74
• Lab registers
• Lab tally sheet MF 1999 A
• Environmental health tally sheet and special investigation forms namely
 EDP sheet
 Surveillance forms for special health problem e.g. AIDS/T.B etc.

Analysis of data

The first step in analyzing the data is to determine the various types of information obtained from the HMIS
forms. Each and every form seeks particular information about the patient or client e.g.

7 Outpatient card MF5

Record of an individual’s health status. Theinformation which can be obtained on this card includes Diagnosis,
Treatment, weight record, immunization of under 5 years.

Inpatient return discharge register can also give information on case morbidity patterns, case fertility rates as
well as, major causes of admissions age specific mortality rates.
 Maternity return/discharge register MF49 can indicate

• No. of mothers delivered

• Still births
• Maternal death rates
• Complication of deliveries

Antenatal tally sheet MF 49A provide information on:

• Utilization of services
• Complication of pregnancy
• Proportion by trimester tendency

Child health tally sheet MF 45A can indicate:-

• Incidence and prevalence rate of malnutrition

• Utilization of vaccines

Lab tally sheet MF199 shows:

• Rate, work load utilization of reagents

• Common investigations done Environmental tally sheet:
This gives information on access to safe water, housing indicators, mortality rates, access to PHC workers.
Information can also come from reports, usually from the health related sources e.g. Administrator reports
provide information for managerial purposes on manpower, finances and supplies. Censuses and surveys can
provide information on population (demographic) and other specific finding respectively.

Presentation of information

To make use of various types of information, the information should be presented in a logical and
understandable way by using 2 methods.

8 • Numerical presentation i.e. Percentages and rates

• Pictorial presentation i.e. maps and graphs, histograms, pie charts etc.

Utilization health information service

This is a useful management tool even for the operational level of the health worker. Operational health workers
can use it in the following respects, planning, Supervision check list, accountability, monitoring and evaluation.
 

HMIS as a planning tool

As a planning tool HMIS achieves the following;

• Assessment of the work load at the Health Unit

• Resource requirement for specific activity in a specific period e.g. drugs personnel, stationary, other
logistic or materials
• For casting and reviewing disease and mortality patterns over seasons or periods.

Use of HMIS as superiority checklist

To determine performance of workers

• To access training needs
• To faster distribution of facilities/resources
• To keep inventory check
• To determine travel plans
• To identify priority attention items.

HMIS use in accountability

The coverage and utilization rates of a service do commonly explain the utilization of materials or funds availed
for the specific activity. The resources supplied should be reflected by the activity. The resources supplied
should be reflected by the services provided by the community or target groups.

HMIS use in monitoring and evaluation

The services provided can be accessed through continuous collection of information to determine coverage,
accessibility and utilization of such services. The morbidity and mortality patterns may reflect effectiveness of
services.

Maintenance of HMIS
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The Health worker should first and foremost appreciate that HMIS or the data is more useful to the DHO or the
health planning unit for the better utilization. Therefore the health workers should ensure that the health data he
collects or submits to high authorities is;

• Complete data
 • Accurate and accurately recorded
• Regularly recorded
• Collected and compiled by the H/staff with good knowledge and skills in HMIS
• Well stored and easy to retrieve

•  Copied to relevant activities

The collection, compilation and analysis of health data should be done within the limited resources available to
the Health worker. He should be very familiar with types and resources of various forms being used and the
quantities required over a specified period. The ordering should be based on set targets, facilities available or
previous coverage.

There should be proper custody and /or security of record. As a method of motivation, HMIS reporting should
be a two-way system to ensure feedback can reach the one who collects the information and the subsequent user
at a higher level.

The health data /information should be kept in a summarized form for as long as it is still wanted.

Flow of health information

The health worker in charge of health unit should collect all the information from the various health services
preferably from all health programmes such as EPI, ANC, MCH, General OPD and others to summarize the
monthly forms. He must use HMIS information for his own day to day running of the health facility as well as
for long term planning purposes. It is also necessary that health workers send a copy of the summary monthly
report to the DHO’s office. Urban H/Units send it through the municipal council to the DHO’s office. At the
DHO’s office, all summary monthly reports of various health facilities including hospitals are compiled into a
monthly summary report for the district which is sent to the HMIS unit of MOH in Entebbe.

After the analysis of the data from all Health Units, important information should be sent back through the
DHO’s office to the respective Health Units. The information sent back should consist of queries, advice or a
comparison with other units or the districts. Another flow of information is from the DHO’s office through the
Chief Administrative Officer (CAO) who reports to the ministry of local government. This information is
mainly administrative e.g. salaries, personal, general problems in the health facilities, etc.

Note. Since some of this information is also health related, the ministry of local government will discuss the
reports with the ministry of health and give feed-back accordingly.
 

HEALTH SERVICE MANAGEMENT RECORDS

Meaning of records

Records consist of information kept in the health unit about the work of the unit, health conditions in the
community and individual patients as well as information on administrative matters such as staff, equipment
and supplies.

Records are written information kept in notebooks; they may also be kept on tapes or be computerized. Records
are administrative “memory” an important tool in controlling and assessing work.

Note: Failure to keep patients records accurately will lead to mis-diagnosis, miss management and difficulties
in follow up of patients /clients.

Types of records kept in health unit

• Inventory
• Drugs
• Registration book
• Admission/discharge books
• Monthly returns
• Report books
• Notification form
• Birth/death certificates
• Patient’s records

Inventory

Inventory is a list of items that are found in a certain place/unit (including those in use and storage). Each
section of a health centre/unit keeps an inventory of its non-expendable equipment i.e. equipment that is used
10 for several years e.g. furniture, trolleys, drip stands, weighing scales, etc. Expendables are those used in a short
time e.g. match box, cotton wool, disposable syringes and needles etc. New equipment issued to the unit must
be added to the inventory.

Advantages of Inventory taking

• Any loss is easily identified and prompt report is made

 • Any shortage is easily identified and new order made
It helps in identifying equipments that need repair or replacement

Interval of Inventory taking

It is important to have a careful physical checking of all equipment at frequent intervals:

Monthly. Checks should be made/carried out by a nursing officer incharge. However, the staff does it on daily
basis as they handle and take over in their different shifts (even students). Sign for the equipment and report any
loss to the incharge.

Three Monthly.Checks are carried out by the Principal Nursing Officer (PNO) or inchargeof the Health Unit. In
other times, the inventory is carried out when a new incharge is taking over a unit/hospital. During handing
over and taking over and signs for the equipment he/she finds on that unit.

Points of Importance

• Involve all the staff

• Identify any loss
• Mark all equipment
• Keep the books safely

Importance of Records

• Source of information that keeps the patients identified

• Assist the hospital discharge its obligation to the patients and community
• Assists physician to give logical services to the patient
• Protects the physician in case of legal suits
• An indispensable tool for teaching and research
• Legal document for claims e.g. Insurance and compensation
• Basic element for vital health statistics
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• Donors use records to compare alternative methods of Health care delivery and to assess progress with
effectiveness and efficiency.
• Records give information which is a vital resource for health planning, implementation and evaluation
• Records help in handing over and taking over between Health workers of all categories by giving a
written report.
 

METHODS OF KEEPING RECORDS

1. Filling
a) Alphabetical filling

Files are arranged in an alphabetical order according to the 1 st letters of the main name of staff member or
patient. This method is when there are large numbers of papers on a single subject. In Health services, it is
useful for each staff member to have an individual file. In it, there are personal particulars, employment and
salary details, leave dates, implemental dates and any other correspondence relating to personal problems.

b) Numerical filling

Filling by subject is the most useful system by general purposes in small health units, all papers, documents;
letters that do not belong to any existing file should be listed. A file should then be established for each subject
category e.g. correspondence about patients. E.g. Copies of referral papers, correspondence with
supervisor/administrator like from district regional office at a higher level, then Health Unit and all other
correspondences e.g. funds and finance-requisition papers. Correspondence with supervisors/administration e.g.
district regional office at higher level, then health units and all other correspondences e.g. funds, and finance-
requisition forms, receipts, issue vouchers, petty cash voucher.

c) Geographical filling

There should be a file for each village. It contains names of leaders, dates of markets, special problems,
travelling times and distance’s e.g. bus services.

d) Modified unit filling system

Is a method used in filling, the unit number is called modified unit filling system. The numbers indicated are the
2 last numerical numbers of the case file. All cases files ending in the number indicated are filed together. It
means therefore that each file has 6 digits i.e. 00-00-00’ are last indicating the filling area while the next last
number indicate position of the file.

e) Filling by subject

At the end of the reports

 2. Coding and indexing

This is a system on which diseases classified in accordance to aetiology and manifestation nature as indicated in
international classification of diseases (ICD). This is WHO classification which is up –to-dated every 10 years.
A code number is provided for each type of disease/injuries and ill-defined conditions.

Each code specifying a type of condition is allocated to what is referred to as a disease diagnostic card. The card
indicates the patient number, resistance, and age, and sex, discharge, alive or dead. It’s from these cards that the
compilation or mortality and morbidity data is done. The system allows comparison on specific disease among
different countries.

3. Cataloguing

It’s arranged in order like a list of names, places, goods, and this special order helps the user to get out what he
wants at any time. Staff files, files for support staff, offices e.g. finance, patients etc.

Retrieving information

It means looking up for information/records. Records can be found out by using the following system.

Tracer system

This is a method of tracing of files during the filing period i.e. finding out where the file is and who took the
file. The types of tracer systems are:

(i) Common tracer

Is used for any records. It indicates the number of the file, when it is taken, where it is taken, and expected
return date. Its advantage is that it can be used for many different records. Also, when the record is taken, the
common tracer stays.

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 (ii) Personal tracer

When a file is initiated, a tracer is created. It has details of the record. The file and tracer are kept together.
When the file is to be taken out, remove the tracer, write particulars indicating where the file is taken and keep
the tracer record.

It’s advantage is that it tells you how, who moved the file in other departments. It’s disadvantage is that it is
inactive.

(iii) Library tracer

Small cards are kept within the book. When the book is borrowed, records are done on that tracer card; it’s
removed and kept in another place. There it will be put back on return of the book.

(iv) Requisition holder

It is used particularly in stores. It has ordered items and quantity when issued of tick; indicate who has issued
and who has taken.

(v) Master index

A system used to get patient’s records over when he can’t remember the number. It’s a key to the numerical
filed records and it contains name, address and other particulars contained in the identification. It’s a small card
as the one indicated below.

Name…………………………………………………………………….Hosp No.

Other Name…………………………………………………………….D.O.D

Address…………………………………………………………………

Age………………………………………………………………………
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Sex………………………………………………………………………
 PLANNING HEALTH ACTIVITIES

Planning is a process of thinking and using it’s results to do something. It is a forecast planning is one of the
management functions. It requires a well-developed sense of the future and makes one to think of what could
happen if certain steps are taken. Planning as a management function involves setting goals for future
organizational performance. Goals are defined as activities and needed resources to be used. Lack of planning
or poor planning can hurt organizational performance.

Planning includes the following

Identification of health problems, finding means and ways of solving these problems. In management, all
resources including man power need planning and organization so that a good plan make clear tasks to be
performed as well as considering other resources to be involved in terms of money, material and time.

Effective planning addresses itself to the following questions

• Where is the community now?

• Where does the community want to go?
• How will the community get there?
• How much does it cost to reach there?
14 • How will the community know that they have reached?

Where is the community now?

This question seeks information regarding the health status of the community, common diseases in it, existing
health services and facilities, as well as the resources available. Information got/collected shows existing
 problems of the community. Some of these problems may be related to health, agriculture and other social
services.

The Health worker in collaboration with the community and other government and NGOs must attend to these
problems in order to improve the health and well being of the community. In management, this task is called
situation analysis.

Where does the community want to go?

After identifying the various problems (gaps) facing the community, the Health worker lists the problems in
order of significance, their severity, popular demand of the community etc. then the community decides of how
they will solve these problems and what to handle first.

How will the community get there?

This is an attempt to find and use fair ways and means of solving identified problems or rather achieve the set
objectives. These ways and means are called activities. They are action the H/worker takes to solve the
identified problems.

How will the community know that they have reached there?

This means how the community knows they have achieved the set objectives. To do this the H/worker together
with the community will determine where the community is in relation to the set objectives. This is called
evaluation. It shows the success, failures, obstacles encountered strength and weakness of H/services (SWOT).

PLANNING CYCLE

Situation analysis

Evaluation Setting the priorities

Activities

Implementation
 Identification of

Strategies and Activities

Situation analysis

Summaries the profile of the catchment area of the population which includes the geographical and
administrative features including;

• Demographic profile
• Socio-economic set up
• The main health problems in the area
• The life style of the people
• Beliefs and attitudes to health seeking behaviours
• Infrastructure
• Human and other resources available
• Health existing data in terms of HMIS. (Health management information systems)  Community based
management information system

TYPES OF PLANS

There are 2 types of plans: These are:-

• Standing plans
• Single use plans

Standing plans
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Are those plans that remain roughly the same for long period of time used in organizations e.g. policy, roles,
procedures.
Single use plans

This includes programs, budget, work plans, projects etc. These focus relatively in unique situations with an
organization and may be used only once. Plans can also be termed as long term, short and intermediate plans.
 Steps used in planning

The following are guidelines/steps applied a planning: -

• Looking at the situation

• Recognizing problems
• Setting objectives
• Reviewing obstacles
• Scheduling the activities

POINTS TO CONSIDER WHEN PLANNING

Performance review:

It reflects on the previous performance in the priority areas and puts emphasis on achievements against set
targets. Areas of poor performance, reasons for achievement made and reasons of areas of failure to perform as
planned. Planning activities of management of the next financial year.

Uganda uses philosophy of health support supervision programme (HSSP, PHC and minimum health care
package, MCHC. During the planning process, there are 3 different financial years you consider: - Current, the
previous and next financial year. One crucial aspect of this planning component is target setting.

Targets are defined as specific objectives that are quantified and are meant to be achieved over a period of time.
These targets should be set in the next financial year fitting in the overall context of the national and district
targets. The availability of targets provides the implementers /Health workers/community with something to
work towards i.e. have an objective to achieve.

Objectives have x-tics

The following are characteristics of an objective.

S - Specific
M - Measurable
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A - Achievable/ attainable

R - Realistic /relevant
T - Time bound
Specific
 An objective should be in writing not ambiguous or confusing but rather clear to all Health workers.

Measurable/ Observable

General objectives are difficult to interpret or to measure. There should be an indication for the achievement e.g.
state in figure like to reduce malnutrition by 10%.

Attainable /Achievable

An objective should be feasible i.e. resources should be available and it should be possible to overcome the
obstacles.

Realistic

Overly optimistic put unrealistic objective serve as moral deflators and are not effective but also an objective
should not be easily achieved for an easily achievable objective is less challenging.

Relevant

It should easily fit in the general health policy or relate to the problem to the solved or reduced.

Time bound

Time /period should be indicated in which the objective intended to be accomplished otherwise, there will be a
tendency of postponing activities that will cause delay to implement e.g. to reduce the no of measles by 10% (in
the year specified) e.g. 2010compared to 2008.

Other points to consider during planning

Mutually supportive:

One objective should not be achieved at the expense of the other objective. Objectives should be prioritized so
that those with top priority are achieved.

Cross cutting inputs for the activities

17
These are inputs required for implementation of activities across the board e.g. infrastructure, human resources,
drugs, equipment and other logistics. Balancing resources in different departments according to need.
Budget

This is the costing and financing of the inputs for health. Use agreed standard unit cost as much as possible as
provided by ministries of health, financing, planning and economic development, local government and the
district. Modification of these standards has to be justified.

Note:

• Supervision, monitoring and evaluation activities should be planned for because these are continuous
throughout
• In planning, also the in charge of the health facility makes a work plan that helps schedule activities that
are intended to be done including materials and responsible personnel.

Exercise: There is the district programme about spraying of control of malaria for months January and February
2012. Draw a rough work plan for such activity.

IMPLEMENTATION OF HEALTH SERVICES

Implementation means putting activities planned in action or in practice. It is the operation stage i.e. without
implementation, plans remain theoretic. It is during implementation that inputs/resources are used to achieve
organization goals. In implementation management is considered with achievements and performance.

Four main types of decision making that have to be considered during implementation.

 The 1st type consists of all those that ensure the programmed activities are executed as planned and
services delivered as intended.
 The 2nd type is concerned with deployment of personnel in the places to perform these activities.
 The 3rdinvolves allocation of other resources in terms of money, material and time.
 The 4th type is concerned with information needed it’s processing and it’s common in support of
previously agreed decision and of evaluation. Thus, these decisions can be summarized as
 Coordination of activities
 Allocation of resources
 Provision of information
 COORDINATION OF ACTIVITIES

E.g. Suppose there is a programme of retraining about TB management due to take place next week. There will
be proceeding activities as: -

• Selection of candidates for training

• Preparation for planning materials
• Assignment of the responsible trainers
• Arrangement of training venue

Deployment of personnel

Management that deals with deployment of work force to carry out unplanned activity may be grouped into the
following

• Organizing
• Directing
• Supervising

N.B: Job description, standard operating procedures and duty rosters are the tools used by organizing manager
to the organized work. Organizing, directing and supervision are not entirely separate management functions.

Allocation of resources

At the implementation stage allocation of resources depends on the type of resources. Resources may be
physical e.g. supplies including drugs, instruments, time, space and infrastructure. Information is dealt with
separately in Health management information system. The allocation of resources includes monitoring and
control of resources. This means watching for the availability consumption and use of supplies, quality control
and quantity control as well as appropriate recording.
The non-expendable equipment’s are usually ordered through the PDA, once out of function and beyond repair
(PDA-procurement disposal authority). Time is a non- new able resource. Similarly, it’s subjected to the
18 monitoring and controlling so that it is used efficiently.

Most physical resources also imply the logical decision i.e. procurement, clearance, storage, forwarding and
distribution, replacement on replenishing of goods both consumable and non consumable e.g. drugs, vehicles,
beds etc.
 Accounting

As are renewable resources, money is subjected to accounting, the purpose of which is to keep tract of money
and compare receipts and expenditure and ensure that funds are used/expended only on the purpose they are
allocated. Organization is another element found in resource allocation. Some resources like work space and
records need organizational decision. It is generally necessary for physical resources in regard to storage.

Procurement

Getting items to use by whatever means (donations, loans etc).

Processing of information

The key decisions concerning information are as follows. Indications for answer the following.

• Have you got the debt needed for each indication

• Have set priorities for the needed information collected first

What (Information Audit)

This is the way you decide on what information you need in the country. There is a lot of information so it is
better to decide on the relevant data. The criteria that information must support and satisfy the need/decision
making are relevance, validity, reliability, timely and cheaper.

From where?

Once the nature of information is identified, management should decide from which services, particular
information should be obtained e.g. government offices, village registers, household registers, community
surveys, interviews and observations.

How?

The question of processing information then arises i.e. raw information (Data) should be collected, analyzed
recorded and reported. Processing information may be undertaken in different places by different people.
19
To whom?

Depending on the degree of specificity of the decision for when information is needed, it should be easy to
decide to whom the information should be communicated. The information that goes into a planned activity
schedule often needs updating of the implementation process.
 N.B: Information processing provides no equitable health care increasing services for those in great need. It
allows raising criteria e.g. seriousness of disease, the disease feasibility of control and community acceptance.

Summary

Implementation function of management is concerned with day to day decision about the timeof execution of
activities within the organization.

EVALUATION OF HEALTH ACTIVITIES

Definition

To evaluate means “to put value” to something e.g. an object or an activity in terms of money and /or input. Its
purposes are to check that corrective actions are taken immediately. In his/her evaluation role, the health worker
has to judge whether the outcome of health activities is really what he desired when he started planning to
address the needs of the community. Generally, the term evaluation is used to include the whole process of
examination/measurement and ultimate judgment of the value of health care. It can also be defined as the
periodic assessment of the change in the targeted results that can be attributed to as intervention.

In this context, the term assessment sometimes is used as synonym for evaluation in relation to observation of
performance of students as they demonstrate skills or competences in carrying out a health out a health care
task. The term appraisal is normally used instead of evaluation. In evaluation the health worker asks himself
three questions.

• What has been achieved as a result of the health activities?

• Were the resources for those activities used efficiently?
• If necessary, are other activities required to improve the results?

The effectiveness of the health activities and the efficient use of resources, especially money, personal and
materials judged by a set of indicators. The extent to which their indicators (When questions) are fulfilled
determines the success of the activities. E.g. in a certain area UNEPI has set a target of 75% immunization
20 coverage for all children under 5 years, the set target is the indicator of success.

If they reach 81%, they will have done very well if they only reach 60% coverage, Health workers have to find
reasons how it went wrong and how they can improve it to reach 75%.

EVALUATION OF HEALTH SERVICES

Definition

Evaluation is a process that assesses an achievement against present criteria i.e. it is a systematic process that
determines the extent to which service needs and results have been or are being achieved and analyse the
reasons for any discrepancy.

Monitoring is a planned, systematic process of observation that closely follows a course of activities and
compares what is happening with what is expected to happen.

Where does M/E fit?

Programme Management Cycle

Problem Identification

Implementation M/E Goal and objective

and service delivery setting.

Designing Implementation

Plans

As in the management cycle above M/E should be at the centre of each stage in the management cycle.

Forms of evaluation

Retrospective evaluation. This is when program/project evaluation is done when the programme/projects have
been functioning for some time.

Prospective evaluation. Is when a new program is being introduced within a service. A prospective evaluation
identify ways to increase the impact of a programme.

It examines and describes a program’s attributes; and identifies how to improve delivery mechanisms to be
more effective.
 NB: Prospective Evaluation, determines what ought to happen (and why) while retrospective evaluation
determines what happed (and why).

Formative evaluation

This is the evaluation of components and activities of a program other than their outcomes (structure and
process evaluation).

Summative Evaluation

This is the evaluation of the degree to which a programme has achieved its desired outcomes and the degree to
which any other outcomes (positive or negative) have resulted from the program.

Who conducts Evaluation?

Internal Evaluation (self evaluation) in which people within a program sponsor, conduct and control the
evaluation.

External evaluation in which someone from beyond the programme acts as the evaluator and controls the
evaluation.
Phases of evaluation

• Planning the evaluation

• Selecting the appropriate evaluation methods
• Collection and analyzing information
• Reporting findings
• Implementing evaluation recommendations.
a) Planning the Evaluation
• Determine the purpose of the evaluation
• Decide on the type of evaluation
• Decide on who conducts the evaluation (evaluation team)
21
• Review existing information in programme documents including monitoring information.
• Describe the programme (how it works its objectives, strategies and management process).
b) Selecting appropriate Evaluation methods
• Identify evaluation goals and objectives (SMART)
• Formulate evaluation questions and sub questions
 • Decide on the appropriate evaluation design
• Identify measurement indicators
• Develop an evaluation schedule
• Develop a budget for the evaluation

Examples of evaluation questions and Indicators

Evaluation area Evaluation question Examples of measurable
Indicators
Staff supply Is staff supply sufficient Staff- to –client ratios
Service utilization What is the program’s usage Percentage of utilization
levels
Accessibility How do members of the target Percentage of target
population perceive service population who are aware of
availability programme in the area
Client satisfaction How satisfied are the clients Percentage of clients who
report being satisfied with the
service received.
Evaluation Plan/Schedule

After deciding on the evaluation areas, indicators and questions, an evaluation schedule/work plan is made as in
the tables below.

Table 1: The Evaluation Plan

Evaluation Sources of Location Data collection Responsible

objectives and information methods party
questions

22

Table 2: Evaluation Work plan

Tasks Responsible Jan Feb Mar April May June July Aug Sept Oct
party
 c) Collecting and analyzing information
• Develop data collection instruments
• Pre-test data collection instruments
• Undertake data collection activities
• Analyze data
• Interpret the data

MONITORING OF HEALTH ACTIVITIES

Health activities occur at the same time and health team needs to watch and monitor the work.

Defn

Monitoring is the process of observing whether the activity or service is occurring as planned during
implementation. It is a systematic continuous collection and analysis of selected indicators to enable managers
know whether the activities were being carried out as planned and yielding the intended results on the targeted
population.

How well are we progressing?

The monitoring system is a set of procedures through which information flows within the organization at
different management levels needs to support decision making.

Monitoring is gathering information to know whether the previous agreed course is being maintained, resources
are wisely spent and staff utilized effectively. It is the complication of work and collecting indicators.
It enables management to: -

• Know of activities that are being implemented or planed

• Have feed back to improve operation

23 • Take corrective action

Monitoring and continuous changes to the programme are more effective than major changes when the situation
is serious. Besides keeping update, monitoring has an added advantage that new opportunities are exploited as
they arise before they get out of hand.
 Reasons for monitoring

• Track progress of implementation of health activities

• Identify problems and correct them in time
• Identify over and underfunded areas
• Facilitate re-adjustment
• Ensure accountability for action by implementers
• Indicate if project is on course
• It is a basic and universal management factor, identifying strength and weakness
• Identify whether the material and financial resources are efficient whether people in charge have
necessary technology and personal qualifications
• Monitoring of inputs/resources ensures that work progresses according to the schedule

• Resources consumption is within the planned limits

Monitoring inputs is concerned with use of resources, progress of activities and the way they are being carried.
It ensures the expected functional activities are performed according to set norms procedures.

• Work standards are made

• Meetings are held as needed
• Communication occurs as necessary

Monitoring outputs

• It ensures that products meet specialization services are delivered as planned e.g. training results in new
skills or her level of skills.
• Decisions are timely and appropriate
• Records are reliable and reports are used
• Conflicts are resolved

24 • The community is satisfied

In short monitoring and control of outputs are concerned with the work progress, staff performance and service
achievement.

Steps in health activity monitoring

• Planning
 • Implementation
• Assessment of planned objectives
• Decide of the scope
• Select indicators and standards
• Choose data sources to develop
• Corrective procedure

Implementation (carrying out/monitoring)

• Collect data, tabulate and analyze data present the findings

• Take appropriate action
• Identifying the problem
• Identifying the cause
• Get data to find unknown cause
• Implement the solution
• Monitor results of action

Principles of monitoring

This helps to make the process more structured standardized and improved.

• Determine what you want to monitor and what interval

• Determine how to monitor, develop a checklist
• Monitor as planned
• State any problems identified and describe each problem
• Identify causes of each problem
• Identify and implement solution
• Provide feedback to the health worker

Methods of monitoring health activities

1. Reports: Written or verbal reports concerning particular aspects of work, any special problems. Written
reports should be briefly kept with specified headings. The managers /supervisors should give immediate
feedback to the one reporting.
 2. Visits: Are particularly important because they add to human touch. Besides, 1 st hand information,
knowledge is obtained. They help to boost morale of communities and health staff.

3. Check list: Ensure that all aspects have been inquired into as there may be over sight or other pressing
problems may be present on the check list, observe performance and recognizes differences in procedures,
standards and output.
4. Meetings: Are important to review other local targets, discussing reports and future planning. It enables
discussion of progress difficulties with staff and the communities.
5. Complaints: In all human interactions, there are bound to disaffect people. In general complaints are good
indicators that there is something wrong. Complaints are a one way of identifying problems at an early
stage.

Summary

Monitoring means watching the progress, achievement and standard of work of the programme It
can be done by every staff member with the help of a check list, by studying records and reports.
It can result in program redirected and it’s a tool that promotes quality health care.

SUPERVISION OF HEALTH SERVICES

All health services are expected to provide some managerial or administrative supervision or appraisal of
workers below them or even of the work they themselves are doing.

When is it necessary

It’s always necessary. It aims at accessing performance of the workers under your care for quality of
work/service they are doing with the aim to improve it. The following should be looked into:

• Quality and quantity of services being offered

• Availability and conditions of resources or facilities used to do work e.g. inventory, checklists, personnel
25 and facility.
• Community’s need for the services
• Constraints faced by workers that may necessary hinge on work resources or those that may be outside
their scope.
• Items/activities that require priority attention
 Qualities

• Good leadership and do not take over the work of those you are supervising
• Give clear and good guidelines to enable the supervised achieve the set goals and objectives
• He is the team leader who is tasteful and motivating
• He is an effective communicator, links those under him with higher authorities through report making.
• Servant of workers he is supervising and in competent enough to guide them
• A good trainer who gives support supervision to enable them attain knowledge, promotion, outlets, ability
to plan and execute the work.  Ability to supervise others as well.

Requirements

• Supervisory check list to ensure that ideas (items) or activities that need priority attention are attended to
and no activities are left out/forgotten
• Regular and frequency of supervision
• Adequate interaction with supervisees to all cordial discussions for better learning from each other
• Problem solving and alleviating the supervisor anxiety by providing some solution to his/her
problem/corresponding activities

ORGANIZATIONAL STRUCTURE OF HEALTH SERVICES IN UGANDA.

The National Health Care System

This constitutes the institutions, structures and actors whose actions have the primary purpose of achieving and
sustaining good health. It is made up of public and private sectors.

The Public Sector includes: -

• Government health facilities under the Ministry of Health (MOH)

• Defence Ministry’s Health services
26 • Internal affairs Ministry’s (Police and Prisons) Health Services
• Local Governments’ Health Services.
The Private sector includes: -

• Private Health Providers (PHPs)

• Private Not for Profit (PNFPs) Providers
 • Traditional Health Practitioners
Sector Organization, function and management

The MOH provides leadership for the health sector and takes the leading role and responsibility in the delivery
of curative, preventive, promotive, palliative and rehabilitative services to the people of Uganda. There has been
decentralization with districts and Health Sub districts (HSD) playing key roles in delivery and management of
health services at district and HSD respectively. The health services are structured into: -

Level of Care Population Type of Facility Level

Health Centre I 1,000 Village Health Team Village (LCI)
Health Centre II 5,000 Dispensary Parish (LC II)
Health Centre III 20,000 Health Centre Sub County (LC III)
Health Centre IV 100,000 Health Sub district County ( LC IV)
Health Centre V 500,000 District Hospital District (L C V)
Health Centre VI 2,000,000 Regional Referral Hospital Region
Health Centre VII 30,000,000 National Referral Hospital National

The Ministry of Health and National Level Institutions

The core functions of the MOH are:-

• Policy analysis , formulation and dialogue

• Strategic planning
• Setting standards and quality assurance
• Resource mobilization
• Advising other ministries, departments and agencies on health related matters
• Capacity development and technical support supervision
• Provision of nationally coordinated services including: health emergency preparedness and response and
epidemic prevention and control.
• Coordination of research
• Monitoring and evaluation of the overall health sector performance.
 National Autonomous Institutions

Most functions of the MOH have been delegated to autonomous institutions. These include:-

• Specialized clinical services

 Uganda Cancer Institute
 Uganda Heart Institute
• Specialized Clinical Support Services
 Uganda Blood Transfusion Services (UBTS)
 Uganda Virus Research Institute
 National Medical Stores
 National Public Health Laboratories
• Regulatory bodies /authorities
 National Drug Authority
 Medical and Dental Practitioners Council
 Allied Health Professional’s Council
 Pharmacy Council
 Nurses and Midwives Council
• Uganda National Research Organization (UNHRO) coordinates national research activities.
• Health Service Commission managers human resources for health
• Uganda Aids Commission (UAC) guides multisectoral response to HIV/AIDS.

Hospitals

Hospitals represent the top end of a continuum of care providing referral services, for both clinical and public
health conditions to the district health services. They play an important complimentary role to primary care and
constitute an important and integral part of the National Health System.

27 Hospital Infrastructure

In Uganda hospitals services are provided by public, private not for profit and private institutions. The degree of
specialization varies between hospitals. Public hospitals are divided into three groups, according to the level of
services available and their responsibilities, general, regional referral and national referral hospitals. Private
hospitals are designated general hospitals, but the services they offer vary with some providing specialist
services, usually found only in referral hospitals.
 General Hospitals

These hospitals provide preventive, promotive, curative maternity, inpatient services, surgery, blood
transfusion, laboratory and medical imaging services. They also provide service training, consultation and
operational research in support of community- based health care programmes. Examples of general hospitals
include Kitagata, Itojo, Ishaka Adventist and Comboni.

Regional Referral Hospitals (RRHs)

These offer specialist clinical services such as psychiatry, Ear, Nose and Throat (ENT), Ophthalmology, higher
level surgical and medical services, and clinical support services (laboratory, medical imaging and pathology).
They are also involved in teaching and research. This is in addition to services provided by general hospitals
examples of RRHs include, Mbarara, Masaka, Fort-Potal, Mbale and KIUTH.

National Referral Hospitals

These provide comprehensive specialist services and are involved in health research and teaching in addition to
providing services offered by general hospitals and RRHs.

DISTRICT HEALTH SYSTEM

The 1995 Constitution and the 1997 Local Government act mandates the district local government to plan,
budget and implement health policies and health sector plans, local governments have the responsibility for the
delivery of health services, recruitment, deployment, development and management of human resources for
district health services, development and passing of health related by laws and monitoring the overall health
sector performance. The local governments manage public general hospitals and health centres and also provide
supervision and monitoring of all health activities including those in the private sector in their respective areas
of responsibility.

Health Sub-district

This is the immediate lower level after the district in the hierarchy of district health services organization. The
28 Health sub-district is mandated with planning, organization, budgeting and management of health services at
this and lower health centre levels.

It carries an oversight function of overseeing all curative, preventive, promotive and rehabilitative health
activities including those carried out by the PNFP, and PFP service providers in the HSD.
 Conscious of the central role of the HSD in the delivery of the Uganda National minimum health care package
(UMHCP), high priority was given to the HSD during the health care strategic plan II.

This was ensured through preferential allocation of the necessary personnel and elements of health
infrastructure for making HSDs effective. The leadership of the HSD is located in an existing hospital or HC IV
(Public or PNFP).

Other functions of HSD

• Provision of second level referral services for the HSD including life saving medical surgical and obstetric
emergency care (such as blood transfusion, caesarean section, and other medical and surgical emergency
interventions.
• Provision of the physical base of the HSD management team.

Health Centre III

This is usually based at sub county level and headed by a clinical officer with the following purposes:-

• Provision of basic preventive, promotive and curative care services to communities in its catchment
area
• Support supervision to HC IIs in its catchment area
• Act as first level referral services for sub counties
• Support community based activities including training and supervision of community health workers.
Health Centre II

These are based at parishes (  500 people) and provide the following services

• They provide the first level of interaction between the formal health sector and communities  They
provide only outpatient care and community outreach services
• Health education
29
• Collection of basic statistics
• They are usually headed by an enrolled nurse or midwife.

Village Health Teams (H. C. I).

A network of village health teams (VHTs) has been established in Uganda which is facilitating health
promotion, service delivery, community participation and empowerment in access to and utilization of health
services.

Roles of VHTs.

• Identifying the community’s health needs and taking appropriate measures

• Mobilizing community resources and monitoring utilization of all resources for health.
• Mobilizing communities for health interventions such as immunization, malaria control, sanitation and
promoting health seeking behavior
• Maintaining a register of members of households and their health status.
• Maintaining birth and death registration.
• Serving as a link between the community and formal health providers.

• Community based management of common childhood illnesses including malaria, diarrhea and pneumonia,
as well as distribution of any health commodities availed from time to time.

The district Health Officer and district Health Management Team

The district health services are headed by a district health officer (usually a medical officer with additional
training in management). Together with other health officials of the district, he is concerned with the overall
management of the district health services. Other members of the district health management team usually
include:-

• District Biostatistician
• District Health Educator
• District Nursing Officer
• District Stores Manager ( Medical)
• District Cold Chain Manager
• District Environmental Health officer
• District Laboratory focal person
• District Tuberculosis and leprosy supervisor
 • District vector control officer
• Heads /Incharges of HSDs in the district
• Any other member deemed necessary by the DHO.

Functions of district management team

The district health officer using his district health management team is responsible for all health related
activities in the district including:-
 District Planning.The DHO is responsible for coordinating all health service planning in the district in
cooperation with other district officials.
 Supervision of district health activities. Supervision of all government and PNFP health facilities through
regular visits,, and advice to staff concerned and ensuring that appropriate records are kept. Supervision
of all special health programmes such as the expanded programme on immunization (EPI), TB and
Leprosy control and family planning among others

 Training of health personnel.Any basic training in the district should be coordinated by the DHO’s office.
The DHO is also responsible for the continuing education of all health staff in the district and supporting
the training of community based health workers.
 Clinical work. Basing on his expertise, the DHO can also routinely take part in clinical work, especially
when there is shortage of health workers.
In summary, the functions of the DHO are summarized in the scheme below;-

30
 Administration /Supervision

Clinical work DHO Training

DHMT

Planning

THE UGANDA NATIONAL MINIMUM HEALTH CARE PACKAGE

Emphasis during the implementation of the HSSP II was placed on a limited set of interventions which have
been proven effective in reducing morbidity and mortality supplemented by vertical programmes on high
morbidity diseases like HIV/AIDS, malaria, tuberculosis etc.

The HSSP II defines the Uganda National Minimum Health Care package (UNMHCP) and it has four clusters
namely:
(i) Health Promotion, Disease Prevention and Community Health Initiatives;
(ii) Maternal and Child Health;
(iii) Prevention and Control of Communicable Diseases
(iv) Prevention and Control of Non-Communicable Diseases (NCDs)

Cluster 1: Health promotion, Environmental Health and Community Health Initiatives

This cluster aims at increasing health awareness and promoting community participation in health care delivery
and utilization of health services.
This is done through production of IEC materials and distribution to all health facilities in Uganda and
31 implementation of the VHT strategy.

Where VHTs are functional, they have contributed to increasing health awareness, demand and utilization of
health services and significantly led to decongestion at health facilities as they timely treat minor illnesses.
 VHTs have further helped to increase community participation in local health programmes.The core activities in
this cluster include;

a) Health promotion and education

Health promotion and education aim is to create health awareness, promote public participation and
involvement in health care delivery and increase demand and utilization of the services provided by the sector.
This should result in adaptation of appropriate healthy life styles and health seeking behavior. The sector
strategy for reaching communities and house hold in the establishment of village health teams (VHTS in all
villages in Uganda.

Community empowerment and participation is the strategy for enabling communities to take care, responsibility
for their own health and well- being and to participate actively in the management of their local health services.

b) Environmental health.

The improvement of environmental health aims to contribute to the reduction of morbidity, mortality and
disability among the people of Uganda, through improvement in housing, use of water, food hygiene promotion,
waste management and control of vector vermin.

c) Control of diarrhea.

There is a continuing need to strengthen national capacity all levels to prevent and effectively control epidemics
of diarrhea. The epidemics of diarrhea (cholera and dysentery) are due to poor sanitation, low safe water
coverage, poor domestic and personal hygiene practices and constant mass movement of populations. d) School
health.

The school health programme was introduced to create an enabling environment for delivering quality
education, for inculcating health habits and practices in children in their formative years when they are most
receptive. During HSSP II the school health programme will be integrated with the district activities.
32
e) Epidemic and disaster prevention, preparedness and response.

The element aims at improving national and district levels in order to promote health prevent disease and reduce
death among the affected population.

f) Occupational health.
Due to the current increased industrial agricultural (esp. horticulture) development in Uganda, threats from
emerging and re-emerging diseases, there is need to scale up interventions in occupational health. There is need
to promote occupational health services and practicals in work places with special emphasis on the all sectors.

Cluster 2: Maternal and child health

Maternal and child health conditions carry the highest total burden of disease with perinatal and maternal
conditions accounting for 20.4% of the total disease burden in Uganda. This cluster therefore addresses this
challenge.
a) Sexual RH and rights.

This address obstetric emergencies (emergency obstetric care) operational EMOC service at HC III, HC IV and
hospital level including establishment of maternal death reviews). The management of family planning
commodities improved and increasing the uptake of F/P services reduce the unmet need for F/P. Increase the
attendance visits per pregnancy and reduce births at home. Advocacy and IEPC stating the importance and
availability of RH services. Scale up goal oriented ANC including IPT and PMTTCT

Community mobilization and capacity building for reproductive health care including capacity to identify and
refer high risk pregnancies and complicated deliveries and also male involvement in sexual /RH.

b) New born health and survival.

Half of deaths in infants occur in the neonatal period. The majority of the deaths result from asphyxia, infectious
birth injuries and complications of premature births. Therefore in UNMHCP there areinterventions to reduce
such deaths that include.

• Provision of essential care during pregnancy including T.T immunization, proper nutrition including
iron/folate supplements and prevention of maternal, infections e.g. STD’s  Infection control during and
after delivery  Provision of mama kits.
• Improving new born resuscitations
• Provision of essential care during the post natal period including promotion of immediate and exclusive
breast feeding, thermal control, clean cord practices and vitamin A supplements.
 • Counseling and education of newborn care practices especially careful management of low birth weight
babies and timely recognition and antibiotics treatment of pneumonia, sepsis and meningitis 
Sensitization and education on danger signs for the new born.
• Promote appropriate care seeking and home care practices for new born health including encouraging
fathers to assume more responsibility for child care.
• Strengthen post natal care follow up of the mothers and infants for both ordinary and PMTCT mother/baby
pairs
• To achieve these, the following approaches are in place
 Integrated child survival
 Integrated management of childhood, illness
 Expanded programme on immunization
 Nutrition

Cluster 3: Communicable diseases control

Communicable diseases account for 54% of the total burden of disease in Uganda with HIV and AIDs,
tuberculosis (TB) and malaria, being the leading causes of ill health. The HSSP II prioritized the prevention and
control of HIV/AIDS, malaria, tuberculosis and diseases targeted for elimination.
Therefore the objective of cluster 3 is to reduce the prevalence and incidence of communicable disease by at
least 50% and therefore contribute towards achieving the health related MDGS and the overall plan of poverty
eradication plan in Uganda.

Cluster 4: Prevention and control of NCDs, disabilities and injuries and mental health problems
The National health policy calls for the assurance of basic essential clinical care including emergency care and
care of common illness and injuries.

If recognizes that while infectious disease must priority, selective attention will be given to all the key
determinants of health in Uganda including un health life styles, non- communicable diseases and the rising
toll of accidents.
33
Objective

To decrease the mortality and morbidity due to non- communicable diseases, injuries and common
emergencies.
 The non communicable diseases (NCD) include the chronic illness that are prolonged, do not resolve
spontaneously and are rarely cured completely e.g. hypertension, Diabetes mellitus, bronchial asthma , stroke,
cardio vascular diseases, sickle cell disease, cancer and arthritis.

In this cluster thefollowing will be addressed.

• Injuries, disabilities and rehabilitative health

• Gender based violence
• Mental health and control of substance abuse
• Integrated essential clinical care
• Oral health
• Palliative care

QUALITY ASSURANCE

Definition

These are activities and programmes intended to assure or improve the quality of care

The concept includes the assessment or evaluation on quality of care, identification of problem or short comings
to overcome these deficiencies and following up monitoring to ensure effectiveness of corrective steps.

Quality health care

Providing quality care means doing the right thing. WHO definition of quality health care consists of standards
of intervention that are known to be safe, affordable to the society in question and hence ability to produce an
impact on mortality, morbidity, disability and malnutrition.

Other definitions

All health care should be safe, timely, effective efficient equitable and patient centered. Quality health care in
family medicine is the achievement of optimal physical and mental health through accessible safe,
34 costeffective care that is based on best feasible response to the need and preferences of patient, family,
personal values and beliefs (American academy of family physicians 2006). Generally look at the way things
are done and key emphasis is on ensuring that;

• Right action has been done in right way and

• At right time
 Perspectives on Quality Health Care

Different stake holders have different perspectives on what constitutes good quality health. Client /patients,
service providers, mangers, policy makers and donors all have different perspectives e.g.

• Perspective of quality
• Addressing client’s concerns
• Waiting time and privacy
• Accessibility
• Customer belief
• Respect
• Good relations

Assignment: What are the rights of a patient?

Health care and Administration management perspective

• Logistic management
• Support supervision
• Appropriate standards and guidelines
• Infrastructure
• Balance of cost and quality
• Innovative training
• Education of community

Provider perspective (Health Care provider)

Historically quality has meant clinical quality of care offering technically competent effective, safe care that
contributes to an individual well being.

Programme manager
35
Recognize that support services e.g. logistic and record keeping areimportant to the quality service delivery.

Donor’s perspective

Additionally key elements of quality include cost, efficiency and outcomes for population as a whole.
The provider perspective quality of care would include.

• Clear job description

• Clear and performance feedback
• Motivation to perform as expected.
• Knowledge and skills-job based on formal and technical competences.
• Organization- support- strategic direction, job roles and responsibilities support supervision. 
Environmental –adequate and proper tools, supplies and work place.

Effectivenesses; achieving intended results i.e degree to which desired results are achieved.

Efficiency of service. The ratio of the output of service to the associated cost of service.

Safety. The extent to which risks of injury, infection, other harmful side effects are minimized. This implies
reduction of risks to patient, provider and community.

TEAM WORK

A team is a group of two or more individuals, who perform some work related task, interact with one another
dynamically, have a shared past, have a foreseeable shared future, and share a common fate.

Teamwork involves different people and different people working together to maximize their efficiency and
reach a common goal.
In health care setting teamwork is defined as a dynamic process involving two or more healthcare professionals
with complementary backgrounds and skills, sharing common health goals and exercising concerted physical
and mental effort in assessing, planning, implementing or evaluating patient care.

Benefits of team work

• Problems solving: A single brain can’t bounce different ideas off of each other. Each team member has a
responsibility to contribute equally and offer their unique perspective on a problem to arrive at the best
possible solution. Teamwork can lead to better decisions, products, or services.
• Accomplish tasks faster: A single person taking on multiple tasks will not be able to perform at a same pace
as a team can. When people work together they can complete tasks faster by dividing the work to people of
different abilities and knowledge.
 • Healthy competition: A healthy competition in groups can be used to motivate individuals and help the team
excel.
• Developing relationships: A team that continues to work together will eventually develop an increased level
of bonding. This can help people avoid unnecessary conflicts since they have become well acquainted with
each other through team work.
• Everyone has unique qualities: Every team member can offer their unique knowledge and ability to help
improve other team members. Through teamwork the sharing of these qualities will allow team members to
be more productive in the future.
• Improved Morale: Teamwork allows employees to take greater responsibility for decision making and also
allows team members to control more of the work process. This can lead to improved morale as employees
gain more authority and ownership over the projects they are working on. The extra responsibility can lead
to a more rewarding work environment and lower turnover. Working on a team also gives employees a
greater sense of belonging and of recognition, which helps them take more pride in their work, and their
company.

Dangers of team work

Teamwork may have an "unintended effect of fermenting hostility toward the managerial goal of making the
teams fully self-managing.

There is a potential of "social loafing" (i.e., an individual's doing less work in a team than what he/she would
normally do working individually). In order to minimize social loafing, management can make individual
performance more visible while in a team setting. This can be done by forming smaller teams, specializing
specific tasks to certain individuals, and measuring individual performance.

How to Improve Teamwork in the Workplace

Once you have your team in place, here are a few general tips to make sure the collaborative process runs
36 smoothly:

• Don't let individuals get lost in the shuffle. Even though a team is a collaborative effort, each member
should be allowed to feel a sense of ownership and accomplishment. Members should be rewarded for a
job well done, and given encouragement and guidance when they need additional help completing a task.
 • Let each team member actively take part in the decision-making process. Making each member feel
integral to the group's success is crucial for the team's morale.
• Minimize the importance of rank; instead take advantage of the entire group's talents and skills to
contribute to its overall success. However, there must be one clear leader who can make the final decision
if the team can't agree.
• Keep the balance of work equal. One or two team members shouldn't be shouldering the burden for the
entire group. Everyone should have a manageable and relatively equal workload.
• Build a foundation of trust and mutual respect. Each team member should be encouraged to share his or her
opinions openly and respect everyone else's point of view - even if they don't agree with it.
• Maintain open lines of communication. Everyone in the team should share ideas or express concerns with
one another and with the company's management.
• When conflicts arise, take a positive approach. Avoid confrontation and blame. Keep your focus on the
issues.

MOTIVATION
Motivation is a psychological feature that arouses an organism to act towards a desired goal and elicits, controls,
and sustains certain goal-directed behaviors. It can be considered a driving force; a psychological one that
compels or reinforces an action toward a desired goal. Motivation is the purpose or psychological cause of an
action.

Motivation is an inner drive to behave or act in a certain manner. "It's the difference between waking up before
dawn to pound the pavement and lazing around the house all day’’. These inner conditions such as wishes,
desires and goals, activate to move in a particular direction in behavior.

Intrinsic and extrinsic motivation

Motivation can be divided into two types: intrinsic (internal) motivation and extrinsic (external) motivation.

Intrinsic motivation
37

Intrinsic motivation refers to motivation that is driven by an interest or enjoyment in the task itself, and exists
within the individual rather than relying on external pressures or a desire for reward. Intrinsic motivation is a
natural motivational tendency and is a critical element in cognitive, social, and physical development.
 Health workers who are intrinsically motivated are more likely to engage in the tasks more willingly as well as
work to improve their skills, which will increase their capabilities.

Extrinsic motivation

Extrinsic motivation refers to the performance of an activity in order to attain an outcome, whether or not that
activity is also intrinsically motivated. Extrinsic motivation comes from outside of the individual. Common
extrinsic motivations are rewards (for example money or grades) for showing the desired behavior, and the
threat of punishment following misbehavior.

Competition is in an extrinsic motivator because it encourages the performer to win and to beat others, not
simply to enjoy the intrinsic rewards of the activity. A cheering crowd and the desire to win a trophy are also
extrinsic incentives.

Maslow's hierarchy of needs

Maslow's theory is one of the most widely discussed theories of motivation. The American motivational
psychologist Abraham H. Maslow developed the hierarchy of needs consisting of five hierarchic classes.
According to Maslow; people are motivated by unsatisfied needs. The needs, listed from basic (lowest-earliest)
to most complex (highest-latest) are as follows:

• Physiology (hunger, thirst, sleep, etc.)

• Safety/Security/Shelter/Health
• Belongingness/Love/Friendship
• Self-esteem/Recognition/Achievement
• Self actualization

The basic requirements build upon the first step in the pyramid:
38
• Physiology. If there are deficits on this level, all behavior will be oriented to satisfy this deficit. Essentially,
if you have not slept or eaten adequately, you won't be interested in your self-esteem desires.
• Subsequently we have the second level, which awakens a need for security.
• After securing those two levels, the motives shift to the social sphere, the third level.
• Psychological requirements comprise the fourth level
 • The top of the hierarchy consists of self-realization and self-actualization.

Maslow's Hierarchy of Needs theory can be summarized as follows:

• Human beings have wants and desires which influence their behavior. Only unsatisfied needs influence
behavior, satisfied needs do not.
• Needs are arranged in order of importance to human life, from the basic to the complex.
• The person advances to the next level of needs only after the lower level need is at least minimally
satisfied.
• The further the progress up the hierarchy, the more individuality, humanness and psychological health a
person will show.

Workers in any organization need something to keep them working. Most of the time, the salary of the
employee is not enough to keep him or her working for an organization.

An employee must be motivated to work for a company or organization. If no motivation is present in an

employee, then that employee’s quality of work or all work in general will deteriorate.

People differ on a personality dimension called locus of control. This variable refers to individual's beliefs about
the location of the factors that control their behavior. At one end of the continuum are high internals who
believe that opportunity to control their own behavior rests within themselves.
For such individuals internal motivation is paramount. At the other end of the continuum there are high
externals who believe that external forces determine their behavior. For this group extrinsic motivation is more
important.

Tips for Motivating Employees

Motivated employees make fewer mistakes, have higher productivity, and tend to remain with a company.
Motivating employees is an element of performance management. It is accomplished through several important
performance management strategies including:
• Job security: A stable working environment is a very important trait. Organizations that have a lowturnover
rate and provide employees with job security will have highly motivated employees. People who are afraid
of losing their jobs will be less motivated to do well and may become disengaged.
 • Good pay: Proper compensation, promotions and raises are always helpful. However, once an employee has
reached a respectable salary other incentives such as a good work environment, job security, safety, and
respect weigh more heavily.
• Perks or incentives: Keeping employees happy by providing various perks and incentives. For example,
some companies have corporate events like company picnics or quarterly dinners. Other companies offer
their employees discounted travel fees or merchandise.
• Continuing education programs/scholarships: Offering programs such as continuing education classes,
tuition reimbursement, and scholarships show employees that you are interested in them and their future.
• Opportunities for growth: The opportunity for promotion and advancements motivates employees to
perform well and achieve their goals.
• Recognition: Recognizing and rewarding employees for outstanding performance and going above and
beyond the call of duty. This helps employers show their employees that their hard work does not go
unnoticed.

Intrinsic motivators

• Sense of meaningfulness. This reward involves the meaningfulness or importance of the purpose you are
trying to fulfill. You feel that you have an opportunity to accomplish something of real value—something
that matters in the larger scheme of things. You feel that you are on a path that is worth your time and
energy, giving you a strong sense of purpose or direction.
• Sense ofchoice. You feel free to choose how to accomplish your work—to use your best judgment to select
those work activities that make the most sense to you and to perform them in ways that seem appropriate.
You feel ownership of your work, believe in the approach you are taking, and feel responsible for making it
work.
• Sense ofcompetence. You feel that you are handling your work activities well—that your performance of
these activities meets or exceeds your personal standards, and that you are doing good, high-quality work.
You feel a sense of satisfaction, pride, or even artistry in how well you handle these activities.
39
• Sense of progress. You are encouraged that your efforts are really accomplishing something. You feel that
your work is on track and moving in the right direction.

You see convincing signs that things are working out, giving you confidence in the choices you have made and
confidence in the future.
 CONFLICT RESOLUTION

A conflictis an inherent incompatibility between the objectives of two or more characters or forces.

In many cases, conflict in the workplace just seems to be a fact of life. We've all seen situations where different
people with different goals and needs have come into conflict.

The fact that conflict exists, however, is not necessarily a bad thing: As long as it is resolved effectively, it can
lead to personal and professional growth.

In many cases, effective conflict resolution can make the difference between positive and negative outcomes.

The good news is that by resolving conflict successfully, you can solve many of the problems that it has brought
to the surface, as well as getting benefits that you might not at first expect:

• Increased understanding: The discussion needed to resolve conflict expands people's awareness of the
situation, giving them an insight into how they can achieve their own goals without undermining those of
other people.
• Increased group cohesion: When conflict is resolved effectively, team members can develop stronger
mutual respect and a renewed faith in their ability to work together
• Improved self-knowledge: Conflict pushes individuals to examine their goals in close detail, helping them
understand the things that are most important to them, sharpening their focus, and enhancing their
effectiveness.

However, if conflict is not handled effectively, the results can be damaging. Conflicting goals can quickly turn
into personal dislike. Teamwork breaks down. Talent is wasted as people disengage from their work. And it's
easy to end up in a vicious downward spiral of negativity and recrimination.

40 If you're to keep your team or organization working effectively, you need to stop this downward spiral as soon
as you can. To do this, it helps to understand two of the theories that lie behind effective conflict resolution:
Conflict Resolution Styles

Competitive: People who tend towards a competitive style take a firm stand, and know what they want. They
usually operate from a position of power, drawn from things like position, rank, expertise, or persuasive ability.
This style can be useful when there is an emergency and a decision needs to be made fast; when the decision is
unpopular; or when defending against someone who is trying to exploit the situation selfishly. However it can
leave people feeling bruised, unsatisfied and resentful when used in less urgent situations.

Collaborative: People tending towards a collaborative style try to meet the needs of all people involved. These
people can be highly assertive but unlike the competitor, they cooperate effectively and acknowledge that
everyone is important. This style is useful when you need to bring together a variety of viewpoints to get the
best solution; when there have been previous conflicts in the group; or when the situation is too important for a
simple trade-off.

Compromising: People who prefer a compromising style try to find a solution that will at least partially satisfy
everyone. Everyone is expected to give up something and the compromiser him- or herself also expects to
relinquish something. Compromise is useful when the cost of conflict is higher than the cost of losing ground,
when equal strength opponents are at a standstill and when there is a deadline looming.

Accommodating: This style indicates a willingness to meet the needs of others at the expense of the person's
own needs. The accommodator often knows when to give in to others, but can be persuaded to surrender a
position even when it is not warranted. This person is not assertive but is highly cooperative. Accommodation is
appropriate when the issues matter more to the other party, when peace is more valuable than winning, or when
you want to be in a position to collect on this "favor" you gave. However people may not return favors, and
overall this approach is unlikely to give the best outcomes.

Avoiding: People tending towards this style seek to evade the conflict entirely. This style is typified by
delegating controversial decisions, accepting default decisions, and not wanting to hurt anyone's feelings. It can
be appropriate when victory is impossible, when the controversy is trivial, or when someone else is in a better
position to solve the problem. However in many situations this is a weak and ineffective approach to take.

Once you understand the different styles, you can use them to think about the most appropriate approach (or
mixture of approaches) for the situation you're in. You can also think about your own instinctive approach, and
learn how you need to change this if necessary.
 Ideally you can adopt an approach that meets the situation, resolves the problem, respects people's legitimate
interests, and mends damaged working relationships.

The "Interest-Based Relational Approach"

The second theory is commonly referred to as the "Interest-Based Relational (IBR) Approach". This type of
conflict resolution respects individual differences while helping people avoid becoming too entrenched in a
fixed position.

In resolving conflict using this approach, you follow these rules:

• Make sure that good relationships are the first priority: As far as possible, make sure that you treat the
other calmly and that you try to build mutual respect. Do your best to be courteous to one-another and
remain constructive under pressure.
• Keep people and problems separate: Recognize that in many cases the other person is not just "being
difficult" – real and valid differences can lie behind conflictive positions. By separating the problem from
the person, real issues can be debated without damaging working relationships.
• Pay attention to the interests that are being presented: By listening carefully you'll most-likely understand
why the person is adopting his or her position.
• Listen first; talk second: To solve a problem effectively you have to understand where the other person is
coming from before defending your own position.
• Set out the "Facts": Agree and establish the objective, observable elements that will have an impact on the
decision.
• Explore options together: Be open to the idea that a third position may exist, and that you can get to this
idea jointly.
By following these rules, you can often keep contentious discussions positive and constructive. This helps to
prevent the antagonism and dislike which so-often causes conflict to spin out of control.

Conflict Resolution Process

41

Look at the circumstances, and think about the style that may be appropriate. Then use the process below to
resolve the conflict:
 Step One: Set the Scene

Make sure that people understand that the conflict may be a mutual problem, which may be best resolved
through discussion and negotiation rather than through raw aggression.

If you are involved in the conflict, emphasize the fact that you are presenting your perception of the
problem.Useactive listening skills to ensure you hear and understand other's positions and perceptions.

• Restate.
• Paraphrase.  Summarize.

And make sure that when you talk, you're using an adult, assertive approach rather than a submissive or
aggressive style.

Step Two: Gather Information

Here you are trying to get to the underlying interests, needs, and concerns. Ask for the other person's viewpoint
and confirm that you respect his or her opinion and need his or her cooperation to solve the problem.

Try to understand his or her motivations and goals, and see how your actions may be affecting these.

Also, try to understand the conflict in objective terms: Is it affecting work performance? damaging the delivery
to the client? disrupting team work? hampering decision-making? or so on. Be sure to focus on work issues and
leave personalities out of the discussion.

 Listen with empathy and see the conflict from the other person's point of
view.  Identify issues clearly and concisely  Remain flexible. 
Clarify feelings.

Step Three: Agree the Problem

42
This sounds like an obvious step, but often different underlying needs, interests and goals can cause people to
perceive problems very differently. You'll need to agree the problems that you are trying to solve before you'll
find a mutually acceptable solution.
 Sometimes different people will see different but interlocking problems – if you can't reach a common
perception of the problem, then at the very least, you need to understand what the other person sees as the
problem.

Step Four: Brainstorm Possible Solutions

If everyone is going to feel satisfied with the resolution, it will help if everyone has had fair input in generating
solutions. Brainstorm possible solutions, and be open to all ideas, including ones you never considered before.

Step Five: Negotiate a Solution

By this stage, the conflict may be resolved: Both sides may better understand the position of the other, and a
mutually satisfactory solution may be clear to all.

However you may also have uncovered real differences between your positions. This is where a technique like
win-win negotiation can be useful to find a solution that, at least to some extent, satisfies everyone.

There are three guiding principles here: Be Calm, Be Patient, Have Respect.

Key Points

Conflict in the workplace can be incredibly destructive to good teamwork.

Managed in the wrong way, real and legitimate differences between people can quickly spiral out of control,
resulting in situations where co-operation breaks down and the team's mission is threatened. This is particularly
the case where the wrong approaches to conflict resolution are used.

To calm these situations down, it helps to take a positive approach to conflict resolution, where discussion is
courteous and non-confrontational, and the focus is on issues rather than on individuals. If this is done, then, as
long as people listen carefully and explore facts, issues and possible solutions properly, conflict can often be
resolved effectively.
43

LEADERSHIP STYLES

A leadership style is a leader's method of providing direction, implementing plans, and motivating people.
There are many different leadership styles that can be exhibited by leaders in the political, business or other
fields.
 Authoritarian

The authoritarian leadership style or autocratic leader keeps strict, close control over followers by keeping
close regulation of policies and procedures given to followers. To keep main emphasis on the distinction of the
authoritarian leader and their followers, these types of leaders make sure to only create a distinct professional
relationship. Direct supervision is what they believe to be key in maintaining a successful environment and
follower ship.

In fear of followers being unproductive, authoritarian leaders keep close supervision and feel this is necessary in
order for anything to be done.

Examples of authoritarian communicative behavior: a police officer directing traffic, a teacher ordering a
student to do his or her assignment, and a supervisor instructing a subordinate to clean a workstation.

All of these positions require a distinct set of characteristics that give the leader the position to get things in
order or get a point across.

Authoritarian Traits: sets goals individually, engages primarily in one-way and downward communication,
controls discussion with followers, and donates interaction.

Paternalistic Leadership

The way a Paternalistic leader works is by acting as a father figure by taking care of their subordinates as a
parent would. In this style of leadership the leader supplies complete concern for his followers or workers. In
return he receives the complete trust and loyalty of his people. Workers under this style of leader are expected
to become totally committed to what the leader believes and will not strive off and work independently. The
relationship between these co-workers and leader are extremely solid.

The workers are expected to stay with a company for a longer period of time because of the loyalty and trust.
44
Not only do they treat each other like family inside the work force, but outside too.

These workers are able to go to each other with any problems they have regarding something because they
believe in what they say is going to truly help them.
One of the downsides to a paternalistic leader is that the leader could start to play favorites in decisions. This
leader would include the workers more apt to follow and start to exclude the ones who were less loyal.

Democratic

The democratic leadership style consists of the leader sharing the decision-making abilities with group members
by promoting the interests of the group members and by practicing social equality.

This style of leadership encompasses discussion, debate and sharing of ideas and encouragement of people to
feel good about their involvement.

The boundaries of democratic participation tend to be circumscribed by the organization or the group needs and
the instrumental value of people's attributes (skills, attitudes, etc.). The democratic style encompasses the notion
that everyone, by virtue of their human status, should play a part in the group's decisions. However, the
democratic style of leadership still requires guidance and control by a specific leader.

The democratic style demands the leader to make decisions on who should be called upon within the group and
who is given the right to participate in, make and vote on decisions.

Traits of a Good Leader include;

• Honest — Display sincerity, integrity, and candor in all your actions. Deceptive behavior will not inspire
trust.
• Competent — Base your actions on reason and moral principles. Do not make decisions based on
childlike emotional desires or feelings.
• Forward-looking — Set goals and have a vision of the future. The vision must be owned throughout the
organization.

Effective leaders envision what they want and how to get it. They habitually pick priorities stemming
from their basic values.

• Inspiring — Display confidence in all that you do. By showing endurance in mental, physical, and
spiritual stamina, you will inspire others to reach for new heights. Take charge when necessary.
• Intelligent — Read, study, and seek challenging assignments.
• Fair-minded — Show fair treatment to all people. Prejudice is the enemy of justice. Display empathy by
being sensitive to the feelings, values, interests, and well-being of others.
 • Broad-minded — Seek out diversity.
• Courageous — Have the perseverance to accomplish a goal, regardless of the seemingly insurmountable
obstacles. Display a confident calmness when under stress.
• Straightforward — Use sound judgment to make a good decisions at the right time.
• Imaginative— Make timely and appropriate changes in your thinking, plans, and methods. Show
creativity by thinking of new and better goals, ideas, and solutions to problems. Be innovative!

Research has found that this leadership style is one of the most effective and creates higher productivity, better
contributions from group members and increased group morale. Democratic leadership can lead to better ideas
and more creative solutions to problems because group members are encouraged to share their thoughts and
ideas.

While democratic leadership is one of the most effective leadership styles, it does have some potential
downsides. In situations where roles are unclear or time is of the essence, democratic leadership can lead to
communication failures and uncompleted projects. Democratic leadership works best in situations where group
members are skilled and eager to share their knowledge. It is also important to have plenty of time to allow
people to contribute, develop a plan and then vote on the best course of action.

Laissez-faire

The laissez-faire leadership style is where all the rights and power to make decisions is fully given to the
worker. The laissez-faire style is sometimes described as a "hands off" leadership style because the leader
delegates the tasks to their followers while providing little or no direction to the followers.

If the leader withdraws too much from their followers it can sometimes result in a lack of productivity,
cohesiveness, and satisfaction.

Laissez-faire leaders allow followers to have complete freedom to make decisions concerning the completion of
their work. It allows followers a high degree of autonomy and self-rule, while at the same time offering
45 guidance and support when requested. The laissez-faire leader using guided freedom provides the followers
with all materials necessary to accomplish their goals, but does not directly participate in decision making
unless the followers request their assistance.

This is an effective style to use when:

 • Followers are highly skilled, experienced, and educated.
• Followers have pride in their work and the drive to do it successfully on their own.
• Outside experts, such as staff specialists or consultants are being used.  Followers are trustworthy and
experienced.

This style should NOT be used when:

• Followers feel insecure at the unavailability of a leader.

• The leader cannot or will not provide regular feedback to their followers.

Transformational

A transformational leader is a type of person in which the leader is not limited by his or her followers'
perception. The main objective is to work to change or transform his or her followers' needs and redirect their
thinking. Leaders that follow the transformation style of leading, challenge and inspire their followers with a
sense of purpose and excitement.

They also create a vision of what they aspire to be, and communicate this idea to others (their followers).There
are three identified characteristics of a transformationalleader:

• Charismatic leadership has a broad knowledge of field, has a self-promoting personality, high/great
energy level, and willing to take risk and use irregular strategies in order to stimulate their followers to
think independently
• Individualized consideration
• Intellectual stimulation

DELEGATING AUTHORITY AND RESPONSIBILITY

To delegate is to give another person some of one’s authority or in other words, to give another person the
power to make decisions. Authorities and responsibility may go together but are not the same people use
46
authority to get work done for which they are responsible.

Rules of delegating authority and responsibility

• Be clear about what is delegated exactly.

• Select the person who you are sure can do the work
 • Explain to others that you have delegated work and to whom.
• Do not interfere unless asked to and be prepared for mistakes.
• Give support as needed and follow-up the progress of work.

N.B

• It saves time for other duties

• When work is spread over a large area, as in rural health work, the health workers on the spot must be
able to make decisions according to circumstances
• Delegation of responsibility saves delays that occur when awaiting decisions from a central office or
other distant authority.
• Health workers who are allowed to make decisions enjoy their work more and become more
knowledgeable and skillful

Disadvantages

• If wrong decisions are made, the work may not be done or it may be done less well.
• A leader may delegate all the work, leaving very little to do
• A leader may delegate decisions to people with insufficient experience.

ORGANISING HEALTH –TEAM ACTIVITIES

Learning objectives

• Design job descriptions and use them in managing a team

• Coordinate activities of the team  Career path of a clinical officer

The distribution of tasks among the members of a health team is one of the manager’s most important functions.
Unfair distribution of work causes dissatisfaction and sometimes quarreling. Work should be arranged in such
as way that team members use their individual skills and talents. Distribution should ensure no ‘over work’ or
under work. Health tasks are varied and this variation in tasks makes organization in health work a challenge
47
to the team leader. Job descriptions are the means of helping to distribute tasksamong the health team.

Using Job Descriptions

A job description states:

• The objectives, activities and programmes of the holder of the post concerned
 • The authority of a health worker i.e the decisions that the health workers is expected to make and has a
right make.
• The responsibility of a health worker, i.e the expected degree of achievement of tasks and functions .

The purpose of the job descriptions is to define exactly for the holders of different posts, their fellow workers
and their supervisors.

• What the holders of the posts are expected to do

• What standards they are expected to reach
• To whom they are responsible
• Whose work they supervise

Uses of detailed job description

• Job descriptions are a valuable tool for the organization of work

• A job description clearly states what each health worker must do and is expected to achieve.
• A job description helps prevent arguments between people about who should do what. They help also into
the distribution of the equipment needed to do the work.
• A job description helps to prevent gaps and overlaps. If often happens that certain tasks are not done
because nobody accepts responsibility for them.
• A job description can show the need for training, for instance if it includes a duty for which the health
worker has not been trained nor needs further training
• Job descriptions are useful as a basis of evaluating team members’ performance. However, they should be
interpreted flexibly, as guidelines, rather than too strictly or literally. Content of a job description 1. Job
title
This is the standard title for the person doing the work or jobs e.g nurse/midwife/clinical officer.

2. Date

The date is included because a job description is not final. People and roles change, and job description should
be received and if necessary, revised at least once a year.

3. Job summary

This is a summary of the main responsibilities of the job.

 4. Duties

This is the control and most important part of the job description. Each duty should be an identifiable entity, a
recognizable part of the job holder’s work. Each duty should correspond to one or more programme objectives,
which should be listed. The health worker can then see how his or her duties contribute to the improvement of
the health of the community.

5. Relations

These are simple statements concerning:

a. The title of the person to whom the job holder is accountable. For a particular task, one person can be
responsible to only one superior. However, one person can hold more than one job and for different jobs
may be responsible to different superiors.
b. The titles of people supervised by the job-holder.

6. Qualifications

A section on qualification describes the basic training and level of experience required for the job.

7. Training and Development

Every job description should be accompanied by a programme for further training and development of the
person holding the job. This may be for example, a regular programme for reading or of in–service training, and
opportunities to attend professional meetings. Like every other elements of the job description, this should be
discussed in full and worked out with the job-holder.

8. Review and Appraisal

49
48 This is a statement describing the process for review and appraisal of the performance of the job holder.
Normally the supervisor is expected to carry out such a review periodically. The review and appraisal statement
should state clearly who has this responsibility.
The appraisal may take the form of an annual confidential report written by the supervisor, simple statements
that work is satisfactory, or a recommendation for a change in the duties, or the promotion, of the job-holder
N.B. Job descriptions help to guide work organization.

Example of a job description

Job tittle : Medical Clinical Officer

Date : 21st September 2011

Job Summary : A clinical officer is a health worker who provides

Promotive, preventive, curative and rehabilitative

Services within the health facility and the

Catchment area.

Duties
(a) Management : The clinical officer manages Resources in the health
Facility and the health services given in his catchment area.
(b) Community health: The clinical officer carries out the following tasks.
• Carries out community diagnosis
• Plans, organizes and conducts integrated PHC in the area
• Promotes school health activities
• Evaluates health services in the community
 Institutes correcttreatment including health education, rehabilitation counseling,
and the conducts operational research.
(c) Clinical care : The clinical officer carries out the following

• Diagnosis andmanagement of common health conditions at the health facility.

• He/she identifies emergences and gives appropriate treatment
• Conducts normal deliveries
• Carries out minor procedures/surgical operations
• Provides nursing care to patients
• Identifies and refers patients that cannot be managed at that level
• Identifies and reports notifiable diseases
• Identifies some medical- legal conditions and takes appropriate action e.g.
 rape, assault, defilement.

CAREER PATH OF CLINICAR OFFICER

On completion, clinical officers are appointed to the civil service as clinical officer grade II. He /she is
promoted after 2 years in service and should be confirmed. After 4 years, he /she are promoted to senior clinical
officer grade II, this can be either after 5 years or 6 years. He /she is then promoted to senior clinical officer
grade 1 after working for about 10 years. After senior clinical officer grade 1, he/she is promoted to
principal/chief clinical officer.

CAREER DEVELOPMENT; OPPORTUNITIES AND AVENUES.

The following opportunities are available for career development.

• Ophthalmology
• Psychiatry
• Anaesthesia
• Medical education (Tutorship)
• Pediatrics
• Public Health
• Ear, Nose, Throat (ENT)
• Medicine and Surgery
• Health service management
• Health promotion and education

Eligibility for the above courses will be that a clinical officer should have been confirmed and served for a
50 minimum of two years. After a post basic training, a clinical officer iseligible for a salary increment.

For tutorship, a clinical officer should have served for a minimum of three years and after this course, a clinical
officer goes to U4.
 PERFORMANCE APPRAISAL

Performance Appraisal is the systematic evaluation of the performance of employees and to

understand the abilities of a person for further growth and development. Performance appraisal is
generally done in systematic ways which are as follows:

1. The supervisors measure the pay of employees and compare it with targets and plans.
2. The supervisor analyses the factors behind work performances of employees.
3. The employers are in position to guide the employees for a better performance.

Objectives of Performance Appraisal

Performance Appraisal can be done with following objectives in mind:

• To maintain records in order to determine compensation packages, wage structure, salaries raises, etc.
• To identify the strengths and weaknesses of employees to place right men on right job.
• To maintain and assess the potential present in a person for further growth and development.
• To provide a feedback to employees regarding their performance and related status.
• It serves as a basis for influencing working habits of the employees.
• To review and retain the promotional and other training programmes.

Accomplishments of performance Appraisal

It is said that performance appraisal is an investment for the company which can be justified by following
advantages:

1. Promotion: Performance Appraisal helps the supervisors to chalk out the promotion programmes for
efficient employees. In this regards, inefficient workers can be dismissed or demoted in case.
2. Compensation: Performance Appraisal helps in chalking out compensation packages for employees. Merit
rating is possible through performance appraisal. Performance Appraisal tries to give worth to a
performance. Compensation packages which includes bonus, high salary rates, extra benefits, allowances
and pre-requisites are dependent on performance appraisal. The criteria should be merit rather than
seniority.
 3. Employees Development: The systematic procedure of performance appraisal helps the supervisors to
frame training policies and programmes.
4. It helps to analyse strengths and weaknesses of employees so that new jobs can be designed for efficient
employees. It also helps in framing future development programmes.
5. Selection Validation: Performance Appraisal helps the supervisors to understand the validity and
importance of the selection procedure. The supervisors come to know the validity and thereby the
strengths and weaknesses of selection procedure. Future changes in selection methods can be made in this
regard.
6. Communication: For an organization, effective communication between employees and employers is very
important. Through performance appraisal, communication can be sought for in the following ways:

• Through performance appraisal, the employers can understand and accept skills of subordinates.
• The subordinates can also understand and create a trust and confidence in superiors.
• It also helps in maintaining cordial and congenial labour management relationship.  It develops the
spirit of work and boosts the morale of employees.

All the above factors ensure effective communication.

7. Motivation: Performance appraisal serves as a motivation tool. Through evaluating performance of

employees, a person’s efficiency can be determined if the targets are achieved. This very well motivates a
person for better job and helps him to improve his performance in the future.

Biases during appraisals.

Managers commit mistakes while evaluating employees and their performance. Biases and judgment errors of
various kinds may spoil the performance appraisal process. Bias here refers to inaccurate distortion of a
measurement. These are:
1. First Impression (primacy effect): Raters form an overall impression about the ratee on the basis of some
51 particular characteristics of the ratee identified by them. The identified qualities and features may not
provide adequate base for appraisal.
2. Halo Effect: The individual’s performance is completely appraised on the basis of a perceived positive
quality, feature or trait. In other words this is the tendency to rate a man uniformly high or low in other
traits if he is extra-ordinarily high or low in one particular trait. If a worker has few absences, his
supervisor might give him a high rating in all other areas of work.
 3. Horn Effect: The individual’s performance is completely appraised on the basis of a negative quality or
feature perceived. This results in an overall lower rating than may be warranted. “He is not formally
dressed up in the office. He may be casual at work too!”
4. Excessive Stiffness or Lenience: Depending upon the raters own standards, values and physical and
mental makeup at the time of appraisal, ratees may be rated very strictly or leniently. Some of the
managers are likely to take the line of least resistance and rate people high, whereas others, by nature,
believe in the tyranny of exact assessment, considering more particularly the drawbacks of the
individual and thus making the assessment excessively severe. The leniency error can render a system
ineffective. If everyone is to be rated high, the system has not done anything to differentiate among the
employees.
5. Central Tendency: Appraisers rate all employees as average performers. That is, it is an attitude to rate
people as neither high nor low and follow the middle path. For example, a professor, with a view to play
it safe, might give a class grade near the equal to B, regardless of the differences in individual
performances.
6. Personal Biases: The way a supervisor feels about each of the individuals working under him - whether
he likes or dislikes them - as a tremendous effect on the rating of their performances.
7. Personal Bias can stem from various sources as a result of information obtained from colleagues,
considerations of faith and thinking, social and family background and so on.
8. Spillover Effect: The present performance is evaluated much on the basis of past performance. “The
person who was a good performer in distant past is assured to be okay at present also”.
9. Recency Effect: Rating is influenced by the most recent behaviour ignoring the commonly demonstrated
behaviours during the entire appraisal period.

Therefore while appraising performances; all the above biases should be avoided.

LOGISTICS MANAGEMENT

Definition of Logistic
52
It refers to material equipment that is used on the day to day activities by health workers. It involves supply,
distribution and replacement of material

Types of material equipment (Logistics)

There are two:-

 • Expendable termed as consumable
• Non expendable termed as capital

Expendable equipment:-

It is the equipment that is used for short time e.g Matchbox, cotton wood, lab stains, disposable syringes, gloves
etc.

Non- expendable

Is that equipment that last for several years and needs care and maintenance e.g weighing scale, tables, beds,
microscope, vehicles, bed, pans, trolleys, trays, etc.

Procedures of managing equipments

These are four procedures of management of equipment.

• Ordering
• Storing
• Issuing
• Controlling /maintaining

Ordering:-

Ordering of equipment is usually done by the senior staff incharge, who has authority. When ordering, the
incharge should make sure that there is still a balance on stock which will be used before a new stock is
delivered (head time consideration).

The ordering staff must have the skills to do it which includes:-

• Listing the relevant equipment

• Balancing the requirements with available resources and making cost estimates
• Use the catalogue
53
• Purchasing
• Balancing quantity with demand (to avoid shortages and surplus)
• Completions e.g order forms or requisition forms
• Listing equipments needed with specifications of the type of each item and the quantity required.

No. Item Quantity Price per unit Total price

 Ugsh
1. Body thermometers 20 1,500/= 30,000/=
2. BP machine 20 3,000/= 60,000/=
(mercury sterilizer)
3. Little sister 1 200,000/= 200,000/=
Total 290,000/=

Using a catalogue

A catalogue is a book that contains a list of articles for purchase from a certain place. It is a communication tool
the manufacturer supplier uses to enable the customer make a final decision of what is to be bought(also termed
as pre-former invoice).

It is used whenever things are ordered at a distance. Therefore while ordering; one needs to note the exact item,
number, description and price.
Purchase of new equipment

Before purchasing new equipment, several factors should be considered which means asking yourself and your
colleagues a number of questions.

Uniformity

• Does the equipment you are proposing to buy match with equipment which is already being used
locally.
• Nationally, is it proved to be good?

Sustainability

• How expensive are replacement’s spares and consumables?

• Will replacement parts be available for a reasonable price in the future?
• Does a local agent supply them?

Training / Complexity

How easy is the equipment to maintain?

 • Is special test equipment needed?
• Can hospital staff be trained to maintain equipment or need outside experts?
• Are special tools required to carryout maintenance or adjustment?
• Does it have any accessories which are expensive that will do the job just as well?

Safety

• What risks or challenges are associated with the piece of equipment?

• Will costly building alterations or services be required to accommodate the equipment?
• Will there be need for special protective clothing for users?

Durability and Robustness

• Will the equipment withstand the local conditions (temp, humidity, drought, dust)?
• Manufacturers should be able to supply relevant records if requested to do so.

Cost

• Do not buy cheapest just because it is cheap. The most expensive design or makeup may be cheaper in the
longer term.
• Buy equipment best suited to your hospital needs.

Specifications

If requested to do so, the world health organization (WHO) will confirm whether or not the equipment you are
proposing to buy meets their standards.

BALANCING QUANTITY AND DEMAND

While making an order, the incharge should ensure the quantity matches with demand. However it’s therefore
54
not easy thus a need for unpredictable demand forecasting will be used without definite information. There
should be a method of estimating the quantity of them to be ordered.

Thus call for eliminating very expensive items which are rarely used to be purchased at the time they are needed
or have just a few for emergency handling while critical needed items must be in place all the time.
 Completing an ordering form (requisition form)

An order form or requisition form is usually supplied together with the catalogue. Different suppliers, stores or
films have their own particular order forms.

Example of order form

Item number Number of Type quantity Price /unit Total
Article

STORING

Equipment is stored in two places

• A main or reserve store where stocks are kept but not used  Place of use after issue

To store equipment, the following skills are necessary

• Recording the receipt of new articles and the issue of articles

• Keeping the stock book as ledger on balance

Perceiving New Items of Equipments into Store

This involveschecking of the equipment whether new or 2 nd hand. Equipment should be accepted in hospital if
only after specific checks and tests have been carried out and found satisfactory.

The equipment should be received in the presence of purchasing officer, maintenance engineering officer;
maintenance staff; maintenance staff member and user representative.

This team together should:-

• Undertake a site inspection to confirm that necessary services (water supply, drainage, electricity supply)
are available
55 • Check the delivery note
• Keep all packaging materials in case the equipment needs to the transported again.
• Check the contents against the delivery note, ensure reports are there and manufactures instructions are
provided
 • Check if the serial number of the package matches with that on the equipment  Check equipment
damage
• Report any omissions or damages to the supplier as soon as possible, register the guarantee, if appropriate.
• If the equipment is to be connected to the electricity check the plugs, switches and everything  Include
the equipment register, giving it a serial number
• Carry out test runs of equipment
• Organize staff training for performance and users of the equipment

Apart from equipment checking, on receiving new equipment item, some documents are delivered with items
like delivery note should be checked and signed keeping a copy of each from the supplier who also gets a copy.
Invoices and delivery notes must be kept in separate files which are labeled.

Each item is recorded on a separate page in the stock book or ledger, noting the following:-

• Date on which the item has been delivered

• Reference number of the items from catalogue and places of purchase
• Invoice number of statement account
• The quantity of items

KEEPING LEDGER BALANCE

Each item is recorded, on a separate page every time a similar item is bought and added to the total stock. Each
time the item is issued, it is subtracted from the total stock, thus the balance on stock.

Item Date Received Invoice Qty Qty Issued Balance in

Number Received store
11/01/12 Uganda 632/12 10 rolls 2 rolls 14 rolls
medical
stores
16/01/12 - - 4 10 rolls
56
20/01/12 - - 4 rolls 6 rolls
25/01/12 - - 3 rolls 3 rolls
28/01/12 Uganda 768/12 8 rolls - 11 rolls
medical
stores
Issuing equipment

A health centre has several sections/departments e.g medical, surgical, treatment room, maternity, lab, etc and
each department is responsible for the equipment in its section. After equipment has been received and recorded
in the stock book, it is stored and later issued for use as it is needed.

Three papers work procedures areinvolved in issuing (writing the issue in stock ledger, issue of voucher which
must be signed and inventory record of the section receiving and issuing the equipment.

Ledger record

When an issue is entered in the stock ledger, the balance of items remaining in stock is accumulated by adding.
Controlling and maintenance

Expendable equipment must be maintained to avoid wastage on expendables and kept in good working
condition. To control and maintain equipment, the following skills are needed: _

• Convincing staff that equipment must be cleaned, inspected and kept in good working order
• Reporting any defects- immediately and returned to its correct place after use
• Using an inspection check list and inspection schedule
• Detecting the discrepancies (discrepancy is a difference between what is reported and what is found out)

THE VALUE OF USE OF EQUIPMENT RECORDS

Good management takes care of equipment by:-

• Introducing and motivating staff to feel responsible for the equipment they use
• Ordering supplies when needed
• Storing supplies safely
• Controlling the use of supplies

There are several reasons for keeping equipment records, requisition forms, stock cards/ledgers, issue vouchers,
inventories, etc.
 • Previous order records make subsequent orders quicker or easier. They should have supplies address, item
reference numbers, normal quantities required.
• The balance in the ledgers shows when to order for more supplies thus avoids items to be out of stock
which improves effectiveness of health services
• Issue vouchers encourage workers to take responsibility of equipment and can indicate who is responsible
for loss or breakages.

In summary accurate records save time and contribute to the economy, efficiency and smooth functioning of the
health service.

FINANCIAL MANAGEMENT

Managing money in health services is complex and a responsibility done by accounts finance officers. However,
sometimes the in charge of a Health centre may be asked to record the spending of money (to keep accounts).
Prior to spending the money, managers are also required to make budgets of what they need in line with the
available funds. E.g government may give a health centre an allocation of funds 500,000/= to withdraw drugs
from GMS. The Health Centre will not get the money but will order for the drugs equivalent to 500,000/= and is
accountable for it. A written accountability must be kept of each order or requisition used against the allocation.

Visible money or cash

This is money that is seen and handled. It is advanced to the health centre for health workers to spend for the
work of the health service. It is not safe to have a large amount of cash at the health centre as it may be stolen.
For this reason, visible money is usually small in amount and is called “Petty cash”.

Keeping and allocations ledger (spending “invisible “money)

The allocated invisible money by government or any other organization) is usually of a definite purchase and
can only be spent for that purpose e.g. drugs, equipment or transport. Accurate records of how the allocation is
spent must be kept in an allocation ledger (accounts book). E.g. allocations ledger

57 Date Description /purpose Document reference( folio No.) Order or requisition

Filling in an allocation ledger

Allocation of invisible money may be monthly quarterly or annually. When granted the data, the purpose and
the amount are recorded in the allocations ledger. The reference number of the document that confirms the grant
 of the money is written in the column headed document reference (folio number) in order that the original
document can be found again when necessary.

When a purchase is made, the date, the order (requisition) and amount are also recorded. The number of the
requisition form or order form is written in “Document reference (folio number) column. From this number, the
order (requisition) can be found again in the files that hold copies of the order forms or requisition. At certain
intervals, perhaps monthly or quarterly, the amount paid out is totaled and deducted from the amount allocated.

The unused moneyis brought forward (BF) and added to the new allocation for the next months and quarterly or
yearly or according to the interval chosen e.g using petty cash, imprest system or spending visible money.

Petty cash means small money; this is forwarded to the health unit to be used exclusively for certain authorized
Health services e.g Postage stamps, telegram, calls from public telephone calls, cleaning materials, soap, and
detergent, antiseptic, furniture polish and office needs like paper, envelopes, glue, pins etc. Sundries,
matchboxes, paraffin and candles.

The Imprest system

An imprest is an advance of cash given for a particular purpose but can be replenished as necessary. It is spent
as need arises. Whatever the period the imprest is replenished provided the money provided has been accounted
by presentation of receipts, this prevents misuse of function.

The Petty Cash Voucher

Each time money is spend for the petty cash it must be recorded, numbered and is kept and filled in order. Each
petty voucher must have a receipt attached to it from the person who sold the item. Vouchers must be kept
carefully because the finance offer, chief cashier or audities may need to look at them in their supervisory roles.

Note: Keep the petty cash vouchers under lock and the way.

Managing Drugs

58 The use of drugs is only one aspect of health service but it is one of the most important, thus we have 3
statements.

• Drugs are important

• Drugs are powerful
• Drugs are expensive
 Management of drugs supply is one of the most important responsible functions of a health worker. He/she
should use them with skill, knowledge and accuracy otherwise, they are dangerous.

Purpose of Drug management

It is to use drugs wisely and avoid wastage, have enough for patient’s needs. The following ways are how
money can be wasted in drugs;

• Using too many drugs on one patient (polypharmacy)

• Using expensive drugs when cheaper ones could be equally effective and safe.
• Prescribing before diagnosis is made “just to try them”.
• Using a larger dose than necessary.
• Using drugs which patients have no faith in such that they may forget to take them.
• Poor maintenance e.g. those kept in fridge if not well maintained lose their potency become ineffective
• Issuing too much (from store) at one time so that they are used extravagantly or even stolen.

The ward in charge has the responsibility of teaching, both staff and patients about use of drugs with emphasis
on drug compliance, to the patients. Patients with TB and leprosy who have to take drugs for a long period need
special explanation and encouragement.

They must continue taking the tablets even when they feel better otherwise, the disease will become active
again.

Preparing a standard drug list

Mostly health centres make a drug list of the commonly used drugs thus; Maternity units have drugs like
Ergometrine, pethidine etc. peadiatric ward/ clinic drugs include; vaccines, ORS, Vit A, Albendazole, X-pen
etc.

The list is usually made by the in charge or medical officer. Such a list should be selected from the list of
59
essential drugs at this national level. The nature of health worker and knowledge about diseases and treatments
are constantly changing as new drugs appear therefore standard drug lists may be constantly changing as new
drugs appear therefore standard drug lists may be out dated and or inadequate if continuous revision and
changes are not made not for the following reasons:-
 • Diseases are treated which were not previously treated
• Patients who were admitted in the hospital are now treated as outpatients
• New drugs have become available
• The budget for drugs is no longer sufficient to purchase all the drugs and cheaper alternatives are needed.

While changing a drug list on must consider the following;

• What disease and health conditions are expected in the health centre
• Which drugs are available and could be used for these diseases are health problems.  The comparative
effectiveness, convenience, toxicity and cost of alternative drugs.

How to decide between alternative drugs

Procedure for modifying a standard drug list

• Find out the conditions treated for the last 6 months. If there is any condition for which no drug is available
include the drug on the list
• Look at the list of drugs; if there is any duplicate (drugs of same action) e.gAsprin sodium and paracemol,
choose one drug for each purpose and remove the rest/others
• Find out if there is any absolute drugs never used for quite a long time e.gcaster oil that stay in shelves for
long time, remove them from the list.

Choosing appropriate drugs

When many patients are being treated for a certain disease in an endemic area, choose the least expensive drugs,
when fever patients are being treated for a disease an expensive drug may be chosen.

Estimating drug requirements – (Ordering and storing drugs)

Calculating drug, requirements

It’s essential to estimate appropriately how much drug is needed to avoid wastage or shortage. This can be done
basing on the previous experience or by calculating.

Formula

Total dose of average course of drug X usual no. of Pts treated with the drug with the purchasing interval.
 e.g supposing an average no. of patients are prescribed panadol the average course of panadol is 2 x 3 days,
purchasing interval is 3 months.

Then it means 6 tabs x 10 x 90 = 5400 tabs, 5 tins of 1000 tab tin and 400 tabs should be ordered every 3
months. There is need to use clinic records and registers.

Ordering for drugs

The same procedure must be followed as for ordering equipment, using a modified standard list, the exact type
and quantity. Only brand name drugs are ordered. When satisfied that they are effective and safe, they are
generally clean. They quantity, dosage, form, strength should be stated and a cost estimate made when an order
form is completed. While ordering drugs one should consider the brand names and if generic names are used
one has to be careful because in developing countries, there are large numbers of spurious (false) useless and
even dangerous drugs (genetic preparations). WHO has instituted a certification scheme on the quality of
pharmaceutical products which the countries maypurchase. In these countries, the authority that controls
importation of drugs will know which genetic preparations are safe for use.

Stocking Drugs

• Orderly stocking is an essential part of drug management

• Drug received should be recorded in a stock card or stock ledger as for any other equipment

Storing drugs

• Most drugs must be kept dry, cool and away from light in cupboard i.e best for these conditions  Keep
tablets in air light containers and have each bottle/tine labeled.
• A red star should be placed on the tins that have expiry date in the current year, in that they are used first.
• Dangerous drugs must be kept in double locked cupboards, with special registers.

Stock card system

• The stock card is sometimes used instead of ledger. It is used the same way as for ledger when balancing
60
equipment
• Each drug is put on a separate card as each item is put on a separate page on the ledger.
• The card relating to each particular drug is preferably pinned to the shelf next to the drug stock to which it
refers.
 ITEM PROCAINE BENZYL PEN FORTIFIED
Date From or To Received Issued Balanced Remarks
8th/2/2010 G.Ms 100 vails - 10 vials Exp. Feb 2011
10/ovials
20th /2/2010 OPD - 100 900 Exp. Dec 2010
25th /2/2010 Medical - 50 950 Exp. March 2012
1/3/2010 GMS 2000 - 2950 Exp. Dec 2010
1/3/2010 Surgical - 200 2750 Exp. Dec 2010
Issuing and controlling the use of drugs

Drugs are issued from a locked store cupboard, by the person in charge of the drug or section using the drug.
Drugs are issued regularly and is known quantities and this permits monitoring and control of drug usage.
Infrequently used drugs may be issued like every 6 months and frequently used drugs may be issued weekly or
monthly. Drugs on the dangerous drug list are controlled by special laws and are issued only on prescription.
Each issue of a drug is recorded on the appropriate stock card, calculating the balance and checking against
stock in the shelf.

This monitoring helps the health worker to:-

• Notice when stocks need re-ordering

• Check drug against patient treatment
• Become rapidly aware of discrepancies
• Check changes in drug use in different sections of the Health unit. N.B.
• Discrepancies should be and the necessary remedies taken
• Controlling the overuse of drugs is solved by educating the staff in the proper use of drugs.

A/B or Double – shelf system of drug stock control

61 The A/B or double shelf stock control system can be used either for all drugs or only for important and life
saving drugs. When a new drug stock is received, it should be divided into two parts that can be labeled A and
B and placed separately on two shelves. Part B should be sealed in a plastic bag or otherwise wrapped and
placed on the bottom shelf. As a reminder, it should be labeled “Not to be used” until new order is sent”. When
part A is finished, the order for the new stock should be sent. Part B should then be used which by the time it is
finished should have been delivered.
 Controlling life saving drugs

Sometimes, a patient condition is so acute, severe or critical that only the immediate use of certain drugs can
save his life. It is of vital importance that such drugs are always in stock as their absence in an emergency may
result inpatient’s death, unnecessary tragedy and a failure of health service management. To avoid this, it is
essential to:-

• Make a list of life saving drugs

• Place them together on the same shelf
• Check the shelf frequently
• Order new stocks whenever stocks are depleted by half.

Examples of emergency drugs are adrenaline and oxygen

N.B: The emergency drugs should be placed on a tray in certain corner/placed accessible to every staff. It
should be checked every day and handled over between shifts.

TIME MANAGEMENT

You have had expressions such as time is money, time ships away and time does not wait for the king. All those
expressions are true but whether time flies or drags for you depends on how you manage it. Time management
also make some managers say “I don’t have time or have too many things to do ‘unfortunately the amount of
time available is strictly limited. Therefore if you are going to make the best use of it, you have to improve the
skills in time management. You are the person responsible for managing yourself and your time is available to
all of us regardless of the type of job we do.

However if not properly managed, time will be wasted and once it’s gone, you can’t get it back. Managing
yourself and your responsibility means organizing your time and using it sensitively. It’s only after you
organize yourself that you can organize other people and other resources when you waste your time, along
chain of activities are affected, e.g. if mother has brought her child for immunization she can’t go back to
milk her cow in time because she has been delayed for long hours at the health centre.
62
The milk truck that takes milk will leave the truck thus she will lose her income for that day, will not be able to
pay for her child’s medical fee that day. Economists can quantify the opportunity cost for such delays. Time is a
non renewable resource and even can’t take placeunless there is time for it. Once wasted or abused time can’t be
recovered, bought or increased: Using time effectively is a management skill.
 Techniques of time management

To be able to manage time and therefore organize yourself, it’s importantthat youbear in mind the following
important points.

• You must know what your responsibilities are. Are you doing things which you could have delegated to
someone else?
• Decide how to organize your activities. You have to plan how best to use your time to produce maximum
results.
• Develop a system which helps youreduce the time you spend on unimportant tasks and increase the time
you spend onunimportant tasks.

Finding out how you spend your time

In managing health services, you have many responsibilities and activities to carry out. It is important to find
out how much time is spent talking to staff health centre, meetings, supervising activities, in rural health
facilities training the health workers, doing ward rounds or attending to financial and administrative matters,
visiting the administrative headquarters etc. You can find out how much time you spend on these activities by
keeping a daily dairy for a few days termed as an inventory of your time. This is achieved by keeping track e.g.
events and the time. It takes great effort to carry this activity out. An example is the form of a table shown
below.

DAILY TIME –DAIRY OF INCHARGE OF A HEALTH UNIT

Name of staff member…………………………………….Day……………..Date…………

Time Patients People Administration District Break Remark

s s
OPD Ward Staff Meeting Office Stock
inspection

63 7:30am 1hour
8:30am 1hour
9:30am 1hour
10:30am 10min 20min 30min Tea
11:30am 1hour
12:30am 20min 1hour 40min
13:30pm 30min weekly
14:30hrs
Total 3hrs 1hr 30min 1hr:30min

After recording the activities for a minimum of 2 weeks, you can do analysis of how you used your time. It will
give you a clue whether you spend too much on low priority task or too little on high priority tasks. You should
encourage staff to use the same balance to find out how they use their time. Thus it helps you to make long term
as well as immediate improvement in your time management practices and helps you identify where you misuse
time and therefore decide what you can do to improve on how you spend your time.

Some of the ways of managing time at work

Administrative responsibilities

Time for correspondence and necessary for health workers to provide proper. Co-ordination and effective
communication with other officials. The same time is used to develop objectives for the work, write
jobdescription, and write reports.

Caring for the patients

Time with patients should be sufficient to take accurate history, diagnosis, treatment as well as to give them
health advice.

Time for supervision

Time with staff is important to provide support supervision (Staff development). This is the time used to teach
junior staff and students to assess achievement of the objectives and give feedback tojunior staff. The same time
is used to conduct staff meeting.

Time with the community (Home visits)

To promote community participation hence health delivery. The health worker meets with village health
committees to identify health problems, discuss ways of overcoming them, implement the solutions and assess
the success.

Recreational time
 For health mind and body the health worker should plan time for recreation.

Domestic activities

The main reason a health worker is employed is to offer health services to the community or individuals. This
however, is influenced by the domestic demands of the health workers. He/she should therefore plan time for
attending to his/her domestic affairs, preferably outside working hours.

Types of time plans

Time tables
These should be made for routine daily work, weekly activities, monthly activities and yearly activities.

In addition, to the above time labels , the health worker should on each morning make a daily to do list, a lot of
activities that should be done that day i.e duty allocation.

Assignment: List examples of time wasters/Robbers/productivity killers.

Suggestions for saving time

After you have identified your weakness in managing time, try these suggestions for having time.

Eliminate paper work.

Do not allow paper to accumulate and always, make a decision or delegate or fill when action has been taken.
Learn to make decision, not to post-pone action.

Organize your desk

This helps you to know where to find everything, have as little as possible on your desk and work on one paper
at a time. Things you use on regular basis should be within easy reach. You must have a workable filling
system.

Conduct regular meetings

64 It saves you time to communicate to many people at once instead of talking to many people individually.

No interruption time.

Set aside a block of time which should not be interrupted and use this time to complete a task. During this time
no telephone calls, visitors or other interruption of any king should be permitted. Your secretary will take your
telephone messages.
 Open time

Let people know interruptions are alright schedule time for people to drop in with their concerns, be strict and
stick to hours.

Learn to say No

Do not accept duties that are not your responsibilities or those that you can’t handle at that time.

Plan for emergencies

You can predict when your work load increases e.g. you can anticipate when reports must be submitted. For
medical officers may need to attend to court on perform post mortems.

Learn to complete your work

Avoid leaving your tasks unfinished, finish fully what is initiated, and meet all the deadlines.

Take a break

This time helps you reduce stress. You should do task not work related but task that you like, break tea, lunch.
In addition to enjoying your meal, you can have a short walk, say prayers or read a novel/literature not related to
work.

Pays offs from time management (ADV)

These range from personal satisfaction to relationship with your colleagues.

Greater Job satisfaction

Working under intense time pressure can lead to stress and time anxiety. Time anxiety can lead you down. If
you can focus on positive accomplishment yourenthusiasm for your work will increase. You will be able to
meet more of your personal needs. Great personal satisfaction will lead you to greater achievements.

Increased productivity
65
Planning your time properly and eliminating time wasters, has an impact on increased productivity. Highly
motivated workers can achieve more in less time than those who just put in their 8 hours.
 Increased inter personal relationships

A health manager who is under pressure often has little patience for communication or for working effectively
with others.

On the other hand, a health manager, who has a reasonable time schedule will relate more successfully with
others.

Better future direction

A major who plans time properly has the ability to know the direction in which he/she is moving both new and
in future.

Reduced stress

A major source of stress for manger is a combination of heavy, work load, time limitations. As result of the
reduced time anxiety one may feel better mentally, physically and emotionally.

A summary of tips that you can use to improve your time management

• Take an inventory of how you spend your time

• Develop a system to help you use your time better
• Use tools such as a diary, a daily planner and a worker schedule to plan and use your time most
efficiently
• Set goals, prioritize your work
• Understand your productivity (energy cycle)
• Identify your time robbers and develop a plan to eliminate them, develop a plan to eliminate them.

Managing paper work

Definition of an office
66
An office is a place where paper work is done, documents and letters are stored. It is not always a whole room.
It may be a desk or table or a corner of a room. Paper work mainly correspondences and maintenance and use of
records, is an essential part of management of a health service and almost all health activities involve paper
work.
 Its quantity and efficiency play a large role in the effectiveness of health care activities and programmes.
Without a well arranged record’s system, neither clinical care nor community health work can be monitored or
controlled.Paper work is the communicator, (correspondence, the information system (reports) and the memory
system (records and registers) of a health service.

We shall deal writing referral letter and other official letters, plus organization of record system. Down is the
functions of an office and the corresponding paper work.

Activity or function Paper work

1. Correspondence patient referral letter

(Letter writing)
2. Administration problem Letter to or from the supervisor
3. Health care activities Registers
• Pt attendance
• Treatment Clinical notes
• In patients (Administrators) Ward register
• Discharges Discharge letter forms  Maternal care
Antenatal cards  Child care Child health care cards.
4. Environmental Survey Report forms
5. General activities Monthly report forms
6. Health Education Posters, leaflets.
7. Staff management
• Staff problems Staff files
• Staff meeting minutes of meetings
8. Administration of funds and
Equipment
• Storing Store ledgers
• Issuing Issue vouchers or invent  Funds
Cash books, receipts, and petty
Cash voucher.
 Sometimes health units keep records of the births and death that occur in its catchment area.

How to write official letters

There is an internationally accepted way of stating facts in official correspondences, though the exact places
where these facts are written varies from country.

An example of a correspondence letter

Address (coming from )

Date, months, year
Reference no (if any)

Name or Title (To whom is it Written)

Address Reference (If any)

Dear Sir /Madam

SUBJECT UNDERLINED

With reference to your letter dated …………………………..No………………………

I wish to ………………………………………..

Yours faithfully Signature

Full names and Title –typed or written in
Capital letters

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 HOW TO WRITE A REFERRAL LETTER

When a patient is being referred to a health centre or hospital at a higher level for advice and treatment a letter
containing accurate details should be sent. The information will help the medical officer who sees the patient to
understand the history and background of the patients conditions and treatment to date.

The following rules are a guide to referral letter writing.

• Use the customary format for official letter writing or full in the official provided referral form. In place of
the subject heading write the name of the patient and age.
• Stage the exact date when the patient was first seen (examined). Do not use statements such as a week
ago, which may lead to confusion.
• State the approximate date, week month when the patient first became ill.
• Give a summary of the main complaints (history) and clinical findings.
• Give the results of any lab investigation
• Most important, give details of all treatment to date including doses of drugs
• Include a polite request for advice or treatment
• Sign the letter/form with the names and your title e.g Nurse, incharge, Nursing officer etc as the person
referring the patient.
• Write the pt’s address, name and address of the nearest relative at the bottom of the letter. Examples of
the referral letters
Maternity unit

…………………H/C

P.O.Box ……………….

Date month year

THE CONSULTANT OBSTETRICIAN

68
DISTRICT HOSPITAL

P.O.BOX……………………

Dear Doctor,

Mrs………………………………….Age…………………………………
 I saw the above mentioned patient who carries this letter for the first time today; it was her first visit to the
Health centre although she is about 38 weeks pregnant. She does remember her LNMP (first date).

She complains of swelling of the feet for the last 2 weeks, she has no other complaints. On examination, I
found albumen in urine and the B.P is 140/110 mmg. She seems to have pre- eclampsia and needs hospital
adminission. I have sedated her with phenorhabitone 50 mg for the journey.

We send her kindly requesting you for further advice and treatment.

Thank you.

Name and Title

Signature

Pt’s address Relative’s name and address.

N.B. All the time the office/table should be organized. Do not allow papers to accumulate and use filling system
to keep important documents that will make it easy to retrieve information whenever needed.

Planning time arrangements

Events are arranged in daily, weekly, monthly or yearly time periods, depending on their frequency or
regularity. Time planners are written in various common forms as timetables. Forms are used in the following
ways

Time table

For daily or weekly regularly recurring events

Schedule
69
For intermittent irregular or variable events including details of where the events take place.

Roster

• For duties planned for different staff members for different times
• For long arrangements of several different events or activities
Plans in health service

As well managed health unit may need the following time plans.

• Weekly timetable showing the time of the week when certain irregular events always occur e.g. staff
meeting
• Several schedules showing the detailed dates on which intermittent events occur and where they occur
e.g visits to peripheral health centres or mobile clinics.
• Several duty rosters for different sections of the work e.g night call out patient duties  A programme
of any special health activity e.g nutritional campaign.

An annual over view of events

• Sometimes the timetable, schedule and roster may be combined.

• Health centre weeklyactivities and time table.

List of regular activities

 Out patients - Daily
 Ward round - Once a week
 Stock inspection - Once a week
 Hygiene round - Once a week
 Office correspondence - Once a week
 TB or Leprosy clinic - Once a week
• Home visits
• Staff meeting
• Clinical seminar
• District visits to peripheral Health centre

Time Mon Tue Wed Thur Fri Sat

7: 30 am Out patient Out patient Out patient Out patient Out patient Outpatient
ward round
 10:30 am BREAK

11: 30 am Ward round Ward round Ward round TB/Leprosy District Hygiene
clinic round
12: 30 pm BREAK

14: 00pm Stock Home Staff Clinic seminar Home

inspection visits meeting visits

Space management

Workspace may not always be enough or adequate. It’s important to make use of limited available space.

The major features may include:-

 Shortage of rooms 
Small rooms

Rooms can have double functions if they are carried out at different times. Two related rooms can be combined
in one room. This applies to shortage of rooms e.g. can have a morning immunization session and then after
noon adolescent and reproductive health programme. Different integrated activities can be carried out under one
roof.

To small rooms: - The available space, should be used more efficiently where people are few. Small rooms can
be used if unnecessary people and furniture are removed from the room plus an efficient storage for files.

Management of transport

Most Health Units have some means of transport at the Health Unit level. These include:- bicycles, motorcycles

70 and vehicles depend on level of Health facility. For such transport means to be useful for the intended results,
some minimal management procedures or instructions need to be instituted these include:-
• Keeping an update inventory record of various types of vehicles, under your care as regards make up or
type, registration number and other identification marks brought in and what conditions and who uses
(responsible officer)
• Servicing and maintenance
 This entails careful handling to prevent break down or routine maintenance, work on the vehicle should strictly
be followed. Early inspection before departure for long distance should be done ensuring adequate fuel and
oiling. All vehicles should have a programme travel specifying when, why, by whom and of what purpose.

For each vehicle should bemaintained so as to avoid fuelwastage and unnecessary movement or unauthorized
journey, with a proper working speedometer to show mile age reading on departure, on arrival and total distance
covered.

This should be followed to achieve intended purpose.

Training use of vehible:- vehicles should be handled by properly trained driver/personal who are well
composed and of good integrity.

Management of personnel

People are the most important resources of any country and as such should be managed properly.

It’s important to manage staff properly b’se 80% of health budgets is spent on salaries and staff benefits, the
personnel are crucial assets. Secondary, managing staff is more complex than managing other resources.

The field concerning personnel administration has subsequently changed names to management, manpower
management; human resources management. All means the same i.e the organizational function concerned with
the management of employees.

When personnel are well damaged can make the best use of the available resources. Health staff management
involves several approaches and sub functions which include the following functions:-

• Planning, organization, directing and controlling all the human activities of the organization.
• It is concerned with the people at work and their relationships within the organization
• It strives to bring together and develop into an effective organization people who make up an organization
71 as well as the well being of individuals and working groups so as to make the best contribution to the
organizations success.

Management responsibilities of an in-charge of a health unit

The incharge is responsible for proper operation and management of a health unit ultimately the incharge is
responsible for:
 • Monitoring the staff in terms of the quantity of work, quantity of the work they do and punctuality
• Determining the allocation of staff on different duties
• Accounting for revenue and ensuring efficient and honest use of it
• Ensuring constant availability of drugs and other supplies
• Ensuring timely reporting, keeping the files updated and in good order (filling)
• Plan and follow up activities, ensuring that they are executed as expected.
• Equally, the in –charge is expected create a strong bond between the Health Unit and the communities in
the services which in his catchment area.
• The in –charge is entrusted to improve the coverage of preventive services e.g. Immunization notification
of diseases etc.
• The in –charge is also entrusted to every pt (client)

By Mr. iremba Wilfred

Irembawilfred0608@gmail.com
0774122842

END

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