Management in Health

Module 01
Part 1: Introduction and Strategic Planning
and Strategic Management

World Bank
Institute

Presentation Script

Management in Health
Module 01: Introduction and Strategic Planning and Strategic Management - Part 1

Presentation Script

Welcome

Welcometothecourseonhealthmanagement.Thecourseisintendedto
provideusefulinformationandmanagementtoolsforpeopleworkingin
subnationalhealthunitsthehealthdepartmentofacityortown,for
example,orthedistrictorregionalhealthoffice.Otherprofessionalsinthe
healthsector(whethermanagersornot)arealsolikelytobenefitfromthe
courseandfindituseful.Thisfirstmodulebeginswithaverybrief
introductiontotheoverallcourse,andthendiscussesstrategicmanagement
andplanning.

Objectives

Thisfirstmodulebeginswithaverybriefintroductiontotheoverallcourse,
andthendiscussesstrategicmanagementandplanning.Bytheendofthis
moduleyouwillbefamiliarwiththetopicsoftheothermodulesofthe
courseandhowtheyfittogether.Webeginthismodulewiththeroleof
governmentinthehealthsectorandwhyitneedstointervene.Wethen
introducestrategicplanningandstrategicmanagementasapproachesforthe
publichealthsectortodefineandachievegoals.Weexplaintwotoolstohelp
withstrategicplanning,andalsodiscussthepurposeandvalueofmonitoring
andevaluation.

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Management in Health
Module 01: Introduction and Strategic Planning and Strategic Management - Part 1

Presentation Script

CourseModules

Thecoursehassixmodules,eachlookingatabasicmanagementfunction,
fromtheperspectiveofasubnationalhealthsystem.Itaimstoprovide
valuablematerialandpracticaltipsandtoolsforstrengtheningyour
managerialskills.Wegreatlyvalueyourcandidanddetailedfeedbackinorder
toimprovethemodulesandensuretheymeettheneedsofhealthmanagers
andothersworkinginhealthsystems.Asnoted,thisfirstmodulecovers
StrategicPlanningandStrategicManagement.Module2onOrganizational
Behaviorprovidestoolsandtipsformanagingpeople.TheFinancial
Managementmodule(number3)concentratesonmanagingmoney,
discussingsourcesoffinancing,andbudgetingskills.TheInformationSystems
module(number4)describestheimportanceofinformationformanagers,
outlinesasystematicapproachtodevelopinginformationsystems,and
providesexamplesofhowmoderntechnologycanimprovetheefficiencyand
usefulnessofinformationsystems.InModule5onCommunicationsyouwill
learnhowtocommunicatemoreclearlyandeffectively,andbuildskillsin
listeninganddeliveringyourmessage.Thesixthmoduleisonchange
management.Peopleoftenresistchange,buttherearewaystohelpmake
peoplemoreopenandaccepting,andwillingtoembracenewandpotentially
betterwaysofdeliveringhealthcare.Ifdonewell,changemanagementcan
greatlyimprovetheacceptabilityofhealthsectorreforms,andhencetheir
successorfailure.

StrategicPlanningandManagementModuleAgenda
Themaintopicofthismoduleisstrategicplanningandstrategicmanagement
keyfunctionsofahealthmanagerinthepublicsector.Butfirst,wewill
considerthespecialrolesthatthepublicsectormusttakeonbecausethey
areimportantforsocietybutwillnotbedonebytheprivatesector.Thenwe

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Management in Health
Module 01: Introduction and Strategic Planning and Strategic Management - Part 1

Presentation Script

willintroducestrategicmanagementandplanning.Ashealthpersonnel,we
allwantourworktomakearealdifferenceinthewellbeingofourclients;
additionally,thefundersandvoterstowhomweareaccountableincreasingly
demandbetterresults.Achievingresultsrequiresefficientpublic
management.

Publicagenciesneedtodevelopacapacityforstrategicmanagement,which
isthemanagementprocessthatintegratesallmajoractivities,functionsand
resources,anddirectsthemtowardachievingorganizationalgoals.Strategic
managementimpliesandrequiresthatthereisastrategy.Sothethirdtopicin
thismoduleistodiscussstrategicplanning,whichistheprocessof
developingastrategy.Agoodstrategyisonethatenablesamanagerandhis
orherteamtoworkefficientlytowardstheimportantgoalstheyhaveset,to
monitorprogress,andifprogresslags,torecognizethisquickly,andtake
actiontogetbackontrack.Wenotetheimportanceandvalueofmonitoring
andevaluation,andexplainthedifferencebetweenthem,beforeendingthe
modulewithaquickrecap.Wewouldliketonotethatthiscourseisnot
prescriptiveanddoesnotadvocateanyparticularmanagementmodel.The
authorsunderstandthatlocalcontextvariesaroundtheworld;thegoalof
thiscourseistogiveyoutoolsthatwillimproveyourmanagementskillsand
allowyoutomanagemoreeffectivelyandstrategically.

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Management in Health
Module 01: Introduction and Strategic Planning and Strategic Management - Part 1

Presentation Script

TheRoleofGovernments

Inyourcountry,whataretherelativesizesoftheprivateandpublicsectorsin
health?Thepercentageofallhealthservicesprovidedbythepublicsector,
andfinancedfromthepublicpurse,varyconsiderablyacrosscountries,and
thebalancethatisrightorbestishotlydebatedinsomecountries.Much
ofthedebaterestsonideologyratherthanevidence,andweneednottake
upthecontroversyhere.Butitisgenerallyagreedthatbecauseprivatesector
entitiesmustmakeprofitsinordertostayinbusiness,therearesome
servicestheywillnotprovide.Marketfailurescreatecrucial,specialrolesfor
thepublicsectortofill.Governmentsareespeciallyneededtoaddress
externalities,providepublicgoods,andtoreduceinequityandpoverty.We
willtakeaminutetoexplaineachoftheserolesintheslidesthatfollow.Of
course,thenonprofitsectorincludingNGOsandfaithbasedorganizations
can,andinmanycountriesdohelpfilltheseroles.(Weshouldalso
mentionafourthveryimportantgovernmentresponsibility,whichobviously
isnotwithinthescopeofthiscoursewerelyongovernmentstoprovidea
frameworkforeconomicgrowthandstability,andforlawandorder.Andof
courseyouwillbeabletothinkofmanyotherimportantrolesthat
governmentsfill.)

WhyGovernmentsNeedtoIntervene:Externalities

Anexternalityisasideeffectorconsequenceofanactionthataffectsathird
party(notdirectlyinvolvedintheaction).Theseexternalconsequencescan
bepositiveornegative.Forexample,immunizationspositiveexternalityis
thatitalsoprotectspeoplenotimmunizedbyloweringoveralldisease
incidence.Goodnutritioninapregnantwomanhasthepositiveexternalityof
ahealthierbaby.Cigarettesecondhandsmokeisanegativeexternalityfor
peoplewhobreatheinthesmokeparticles,asareotherkindsofpollution.
Theseexamplesmostlyconcernindividualbehaviors.Butlargeexternalities

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Management in Health
Module 01: Introduction and Strategic Planning and Strategic Management - Part 1

Presentation Script

alsocanarisefromorganizationsdecisionsandactions.Forexample,a
hospital(orotherorganization)mightsavecostsbydisposingofuntreated
waste,buttheresultingpollutionwouldhavehighcostsforsociety.The
pursuitofprofitscanhavestrongnegativeexternalities.Anexamplewouldbe
veryhighpricesforpatentedantiretroviraldrugstotreatHIV,puttingthem
outofreachformostpeoplelivingwithHIV.Typically,externalitiesarenot
takenintoaccountindecisions,soprivatecostsandbenefits(thecostsand
benefitsforthepersonororganizationtakingthedecision)canbevery
differentfromsocialcostsandbenefits(thetotalcostsandbenefitsofthe
actiontoallthoseaffected),andleadtoundesirable,suboptimaloutcomes
forsociety.Whengovernmentsstepintoincreaseactivitieswithstrong
positiveexternalitieslikeimmunization,anddecreaseactivitieswith
negativeexternalitieslikesmoking,societyisbetteroff.

WhyGovernmentsNeedtoInterveneProvidePublicGoods

Publicgoodsarethingsthatcanbeusedbyonepersonwithoutreducingthe
amountavailableforothers,andwhich,onceprovided,aredifficultto
excludepeoplefromusing.Aclassicexampleofapublicgoodiscleanair.My
breathingdoesnotreducetheamountofairleftforeveryoneelsetobreathe
(unlessweareinaveryconfinedspace).Anditwouldbeveryhardtoexclude
somepeoplefrombreathingtheair,orchargethemfordoingso.Sothe
privatesectorwouldhavenoincentivetoinvestincleanair,becausethey
wouldnotreceiveanyreturnontheirinvestment.(Youwillnoticethelink
betweenthispublicgoodandtheconceptofexternalitiesmanypublic
goodshavepositiveexternalities.)Publichealthinformationisanother
exampleofapublicgoodoncewehaveinvestedinresearch,produced
information,andputitintothepublicdomainusingmassmedia,althoughits
easytothinkofwaystochargeforaccesstoinformationthroughsome
media,onepersongettingandusingtheinformationdoesnotuseupanyof
it.

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Management in Health
Module 01: Introduction and Strategic Planning and Strategic Management - Part 1

Presentation Script

WhyGovernmentsNeedtoInterveneReducePoverty,ImpureEquity

Mostpeopleconsiderthatthepublicsectorisresponsibleforsocialjustice,
bystrivingforfairopportunitiesandtreatmentforall.Someregardhealth
careasahumanrighttowhichallareentitled,atleasttotheextentthatitis
affordablebysociety.Withoutgovernmentintervention,onlythewealthyare
likelytobeabletopayforqualityhealthcare.Furthermore,illnessisoneof
themainfactorscausingorworseningpoverty.Andpoorpeoplegenerally
havepoorerhealthstatusandgreaterhealthcareneeds.Thismakes
governmentinterventiontoensureaccesstoatleastbasichealthcare
important.Obviously,peoplehaveverydifferenthealthcareneeds,which
leadstoausefuldistinctionbetweenequalityandequity.Equaltreatment
impliesthesameforeveryone.Equityinvolvesfairnessandvaluejudgments,
andtakesaccountofdifferingneedsandcircumstances.Onecriteriafor
equityinhealthisthatpeoplewithsimilarlevelsofneedshouldhavesimilar
healthcare,andthosewithgreaterneedsshouldgetmorecare.

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Management in Health
Module 01: Introduction and Strategic Planning and Strategic Management - Part 1

Presentation Script

GovernmentsHelpEnsureHealthCareforthePoor

Ofcourse,publicresourcesarelimitedrelativetoallthecompetingpriority
needs.Sothepublicsectormaychoosetotargetpublicresourcestothepoor
whoareseldomcoveredbyhealthinsuranceandareleastabletoafford
healthcare.Privateforprofitprovidershavelittleincentivetoestablish
healthfacilitiesinareaswherepoorpeoplelive.TheGovernmentcan
intervenebyprovidinghealthservicesdirectly,contractingprivateproviders
toprovidethem,orstructuringsubsidizedinsuranceorotherfinancing
schemes.Subsidizedvoucherprogramshaveprovedpopularandeffectivein
somecountries.Intheseprograms,peoplepayaffordablesmallamountsfora
voucherwhichentitlesthemtospecificservicessuchaspreandpostnatal
careandattendeddelivery.Theypresentthevoucherattheprovideroftheir
choice,whoisreimbursedatanagreedrate.Thisenablesservicesand
beneficiariestobetargetedwell.Withoutgoodtargeting,itisoftenthecase
thathigherincomepeoplearemorelikelytouseservices,andthebenefitsof
publicfundingcanthusgodisproportionatelytothewealthy.Inorderto
participateintheprogram,providersmustmeetqualitystandardsandbe
approved,whichgivesthemanincentivetoimprovetheirservices.
Higherqualityservicesbenefitallpatients,whethercoveredbytheprogram
ornot.Pleaserefertothelistofresourcesfortheurlforan8minuteyou
tubevideodescribingthesafemotherhoodvoucherprograminKenyaone
exampleofatargeted,subsidizedprogramtoensurepriorityhealthservices
forpoorwomenandtheirinfants.

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Management in Health
Module 01: Introduction and Strategic Planning and Strategic Management - Part 1

Presentation Script

StrategicPlanningandManagement

Buthowdoesacityordistrictorprovincialhealthauthoritydecidethatits
goingtodesignandimplementaspecialtargetedprogram,ordefineand
tacklesomeotherpriority,andthengoaboutdoingitsuccessfully?Ideas,
decisions,commitmentandactioncancomeaboutinallsortsofways.One
systematicwayisthroughstrategicplanningandmanagement,inwhich
managersanalyzedataandsetprioritiesandtargetscreatingavisionforthe
future,andthenfigureouthowtorealizethatvision,developingplansand
procedures,andfollowingthroughbymanagingforresultstoensurethat
thetargetsaremet.Strategicplanningisthefirstpartofstrategic
management.Butplansareonlythebeginningtheymustbeimplemented.
Strategicmanagementensuresthattheresourcesandprocessesarealigned
toenableplanstobecarriedoutsuccessfully.Italsoentailsmonitoring
progressandcosts,makingchangesandimprovementsasneededand
evaluatingoutcomes.Sometimespeopleusethetermsstrategicmanagement
andstrategicplanningasiftheyarethesamething,butwepreferdefinitions
ofstrategicmanagementthatencompassstrategicplanning,aswellasthe
decisionsanddaytodayoperationalmanagementofpeople,resourcesand
processesthroughwhichplansareimplemented,monitored,reviewed,and
adjusted.

OneModelofStrategicManagement

Therearemanydifferentmodelsofstrategicmanagement,butthebasic
elementsarecommon.ThisdiagramistakenfromaHandbookonStrategic
ManagementforSeniorLeaderswrittenfortheUSNavy.Asyoucansee,
StrategicPlanningisacorepartofstrategicmanagement.Thismodelalso
includespreplanning,implementation,resourceallocationandmeasurement
andevaluation.PrePlanningcouldincludeanalyticworktocompiledata
neededforplanning,oreffortstoensurethatkeystakeholderssupportthe
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Management in Health
Module 01: Introduction and Strategic Planning and Strategic Management - Part 1

Presentation Script

worktodevelopastrategicplan.Forexample,youmaywanttodevelopa
strategicplantotacklethethreemaincausesofprematuremortalityinyour
region,ortoimprovethehealthindicatorswhichareworstinyourarea
relativetotherestofthecountry,orthehealthindicatorswiththegreatest
disparitiesbetweenlowandhighincomegroups.Apreplanningstepwould
betocompilethedataonthehealthchallenge,waysthatothershavetacked
it,andsuggestionsfromprovidersandpatients.Beforebeginningworkona
plan,thereneedstobeclarityontheplanpurposeandscope.Oncethe
strategicplaniscompleted,itneedstobecommunicated(whichthismodel
callsdeployment)andthencarriedout.Implementationinvolvesresourcing
theplan,puttingitintoaction,andmanagingthoseactions.Strategic
managementalsoincludesmeasurementandevaluationoftheresults
trackingimplementationactions,collectingandanalyzingdataonprogress
andimpact,andcommunicatingthoseresultstoallstakeholders.Ofcourse
resourcesneedtobeallocated,managedandmonitoredforalltheseaspects.

StrategicPlanning

Letslookalittlemorecloselyatstrategicplanningandstrategies.Strategic
planninghasbeendefinedasadisciplinedefforttotakefundamental
decisionsandactionsthatshapeandguidewhatanorganizationis,whatit
does,andwhyitdoesit.Strategicplanningisa"bigpicture"approachthat:
identifiesandrespondstothefundamentalissuesfacingan
organization;
takesaccountofexternaltrendsandforcesthatarelikelytoaffectthe
organizationanditsmission;
attemptstobepoliticallyrealisticbytakingintoaccounttheconcerns
andpreferencesofinternalandexternalstakeholders;

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Management in Health
Module 01: Introduction and Strategic Planning and Strategic Management - Part 1

Presentation Script

reliesheavilyontheactiveinvolvementofseniorlevelmanagersand
sometimeselectedofficials,assistedbystaffwhereneeded;
isactionoriented,stressingtheimportanceofdevelopingactionplans
forimplementingstrategies;and
focusesonactionsandresults.

Amajordangerandacommonproblemisspendingalotofscarcetime
andresourcesonstrategicplanningbutthennotactuallyimplementingthe
strategy.Somestrategiesarecompletelyunrealistic,orcannotbefunded.
Sometimessomuchtimeisspentdevelopingastrategythatthereishardly
eventime,energyandresourcestodoroutinethings,letalonetoimplement
thestrategy.Sorememberthataboveall,strategicplanningis
actionoriented.

1.AnalyzeEvidence

Akeyearlystepinstrategicplanningistoanalyzetherelevantdataand
evidence.So,forexample,indevelopinganHIVstrategy,itisessentialto
understandwhoisbeingnewlyinfectedandthetransmissionmechanismsfor
newinfections.Ifmostnewinfectionsareamonginjectingdrugusersorsex
workers(orboth),thenpreventionandoutreacheffortsmusttargetandwork
withthosepopulationsandtheirsexpartners.If,ontheotherhand,most
newinfectionsareoccurringamongcouplesinwhichonepersonis
HIVpositive,thenaverydifferentpreventionapproachandfocusisneeded.
Thestrategicplanshouldstateclearlyandconciselythemaindataonwhich
strategicdecisionsrest.

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Management in Health
Module 01: Introduction and Strategic Planning and Strategic Management - Part 1

Presentation Script

2.DefinetheVisionSetObjectives,Targets

TheAbiyeSafeMotherhoodprogramwassparkedbydata.Thenewlyelected
governorofOndostateinNigerialearnedthatOndosmaternalmortalityrate
wasamongtheworstinthecountry,despitethefactthatthislush,oilrich
stateproducesmoreprofessorspercapitathananyotherstate!Hedecided
tomakepreventingmaternalandchilddeathsapriority,andtotryand
ensurethatnomorewomenwoulddieasaresultofchildbirth.This
illustratesakeypartofstrategicplanningtodefinethevisionoroverallgoal,
andthespecificobjectivesortargetsthatwillhelpmakethevisionareality.
WhenthegovernorofOndotalksaboutthisprogram,hedescribesthevision
asbeingthatnomorewomenshoulddieasaresultofpregnancyand
childbirth.Asyoucanseeinthisslide,thevisionstatementofthenew
maternityhospitalthatwasbuildinthestateaspartoftheprogramis
couchedasaconcrete,timebound,quantifiedobjectiveofachieving
MillenniumDevelopmentGoals4and5.

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Management in Health
Module 01: Introduction and Strategic Planning and Strategic Management - Part 1

Presentation Script

3.SelectActionsPrioritize,ChooseandCost

Oncevisionsandoverallgoalsaredefined,strategicplanningmustdecide
howtosetaboutachievingthem.InOndo,thestrategicplanningidentified
fourdelaysimplicatedinmostmaternaldeathsdelayindecidingtoseek
care,delayinreachingafacility,delayinbeingseenonceatthefacility,and
delayinbeingreferredwhenneeded.Thenthestrategicplanningcameup
withwaystotackleallthedelays,includingtryingsomeinnovations.For
example,todealwiththedelayinseekingcare,communitymeetings
informedpeopleabouttheservicesavailableandimportanceofusingthem,
andallpregnantwomenwereregistered.ThentrainedHealthRangerswere
eachassigned25pregnantwomen,whomtheyvisitintheirhomeseach
week,givingadviceonnutritionandmalariaprevention,andcheckingfor
dangersignsofpossiblecomplications.Alittletrainingandpracticeovercame
initialreluctancetoridemotorbikes.Anotherinnovationistolendeach
registeredpregnantwomenacellphonewithtollfreeaccesstoHealth
Rangers,andhealthfacilities.Healthfacilitieswererenovatedandsomenew
onesbuilttofilllargegapsincoverage,includingatertiarycarematernity
hospital.Vehicleswereboughttoensuregoodtransporttofacilitiesandfor
referral.Toimproveavailabilityofsuppliesinallfacilities,supplypacks"were
developedfornormal,complicatedandCsectiondeliverieswhichcut
pilferingofsuppliesfromtheaverageveryhighlevelof2030%.Tocopewith
shortagesofdoctors,"taskshiftingandsharing"assignedmanynewtasksto
nurses,suchasallpostoperativecareforCsections,andalldischarges,
leavingdoctorsfreetooperateallday.Patientsaredischargedquickly,freeing
bedsandreducingwaittimes.Andthestatefoundtheresourcestoprovide
maternalcarefree.

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