A realistic approach to the evaluation of the quality management movement in health care systems: a comparison between European and African contexts based on Mintzberg's organizational models

The quality movement is gaining momentum worldwide in the field of health care. Initiated in industrialized countries, it steadily grows in Africa. However, there is no evidence that approaches designed to address issues in a given organizational context have the same effect in another one where issues present differently. Along the epistemological paradigm of realistic evaluation proposed by Pawson and Tilley, we use Mintzberg's organizational models to compare the configurations of European and African health care organizations and the trends followed by the quality management movement in both contexts. We illustrate how European health systems traditionally emphasize professional autonomy while African health systems are structured as command and control hierarchical systems. We illustrate how the quality movement in Europe emphasizes standardization of procedures, a characteristic of a mechanistic organization, while excessive standardization is part of the quality problem in Africa. We suggest that instilling professionalism may be a way forward for the quality movement in Africa to improve patient focus and responsiveness of responsible professionals. We also suggest that our interpretation of broad trends and contrasts may be used as a useful departure point to study the wide contextual diversity of the African experience with quality management.     

Roles of managers in academic health centers: strategies for the managed care environment

This article addresses survival strategies of academic health centers (AHCs) in responding to market pressures and government reforms. Using six case studies of AHCs, the study links strategic changes in structure and management to managerial role performance. Utilizing Mintzberg's classification of work roles, the roles of liaison, monitor, entrepreneur, and resource allocator were found to be used by top-level managers as they implement strategies to enhance the viability of their AHCs. Based on these new roles, the study recommends improving management practices through education and training as well as changing organizational culture to support management decision making and foster the continued growth of managers and their AHCs.     

How do health service managers respond to qualitative research?

During 1992 a qualitative evaluation of a government health service-run community health worker (CHW) project in South Africa found that project workers were doing good work despite serious structural shortcomings related to lack of community participation and inadequate integration of the project in the health district system. Recommendations were made to develop the project in order to enhance community involvement, to build closer integration between the project and the services offered at the health centre, and to collaborate with non-government CHW projects in neighbouring areas.The evaluation study was followed up one year later by interviews with health managers to determine their response to the evaluation. The managers reported that they had found the qualitative data valuable for understanding how clients perceived the health service, and for planning a more community-responsive service.Despite this, the recommendations from the evaluation were not implemented and political developments in the district resulted in the CHW project being closed down. It is concluded that qualitative evaluators need to carefully explore the political context of primary health care interventions in order that their research provides useful data for decision-making.     

Innovation to improve health care provision and health systems in sub-Saharan Africa – Promoting agency in mid-level workers and district managers

Initiatives to address the human resource crisis in African health systems have included expanded training of mid-level workers (MLWs). Currently, MLWs are the backbone of many health systems in Africa but they are often de-motivated and they often operate in circumstances in which providing high quality care is challenging. Therefore, assuming that introducing additional people will materially change health system performance is unrealistic. We briefly critique such unifocal interventions and review the literature to understand the factors that affect the motivation and performance of MLWs. Three themes emerge: the low status and inadequate recognition of MLWs, quality of care issues and working in poorly managed systems. In response we propose three interrelated interventions: a regional association of MLWs to enhance their status and recognition, a job enrichment and mentoring system to address quality and a district managers’ association to improve health systems management. The professionalisation of MLWs and district managers to address confidence, self-esteem and value is considered. The paper describes the thinking behind these interventions, which are currently being tested in Kenya, Nigeria, South Africa and Uganda for their acceptability and appropriateness. We offer the policy community a complementary repertoire to existing human resource strategies in order to effect real change in African health systems.     

Towards an evidence based health care management

Inspired by the development of Evidence Based Medicine, this article introduces a new approach for health care management called Evidence Based Management. This approach promises to improve the practice of health care management, at the same time as it may stimulate research on the organization and management of health care. Evidence Based Management means that health care managers should learn to search for and critically appraise evidence from management research as a basis for their practice. This will require some new managerial skills that should be included in the education and training of health care managers. It will also require a new orientation for research on health care management. There will be a demand for more applied research, and also for research with a more positivist orientation. Copyright © 1998 John Wiley & Sons, Ltd.     

Policy and organizational implications of gender imbalance in the NHS

PURPOSE: The purpose of the paper is to examine the policy and organizational implications of gender imbalance in management, which research suggests exists in the NHS. DESIGN/METHODOLOGY/APPROACH: The research in this paper involved a qualitative approach with an analysis of elite interviews conducted with a non-random sample of officials involved in health policy and interviews with a random sample of senior managers in NHS Scotland. The research formed part of a larger study, which explored the enablers and inhibitors to female career progression in various Scottish sectors. FINDINGS: The paper finds that gender imbalance in management exists in the NHS. This is manifested in a masculine organizational context, leadership and policy decision-making process, which have implications for female career advancement opportunities and subsequently access to macro policy decisions. RESEARCH LIMITATIONS/IMPLICATIONS: The paper involved a sample (30 percent) of senior managers and examined policy processes in NHS Scotland. To improve the external validity of the findings further research should be conducted in NHS organizations in England and Wales. PRACTICAL IMPLICATIONS: The findings in the paper suggest that gender imbalance in management and a masculine organizational context and leadership style within the NHS create a less than conducive environment for female employees. This has practical implications in terms of levels of part-time employment, career progression and attrition rates. ORIGINALITY/VALUE: The paper adds to the debate of gender and organizational studies by examining the health sector, which has high levels of female employment but low levels of female representation at senior management levels. The paper therefore adds to an often-neglected area of study, women in leadership and senior managerial positions. The paper is original in its approach by examining the micro and meso organizational dimensions which impact on women's ability to influence macro health policy.     

Self-care in mental health services: a narrative review

Self-care is an important approach to the management of long-term health conditions and in preventing ill-health by living a healthy lifestyle. The concept has been used to a limited extent in relation to mental health, but it overlaps with the related concepts of recovery, self-management and self-help. These related concepts all entail individuals having more choice and control over treatment and a greater role in recovery and maintaining their health and well-being. This paper reviews qualitative empirical research that provides information on the nature of self-care in mental health from the perspective of people experiencing mental health problems. Twenty qualitative studies were identified from a systematic search of the literature. The methods used in these studies were critically appraised and key themes across studies identified self-care behaviours and processes supporting self-care. The paper also highlights challenges to this approach in mental health and provides a conceptual framework of the relationships between self-care support, self-care behaviours and strategies, and well-being for the individual. It also highlights limitations in the current evidence base and identifies areas for future research.     

The impact of blue space on human health and well-being - Salutogenetic health effects of inland surface waters: a review

Water is one of the most important physical, aesthetic landscape elements and possesses importance e.g. in environmental psychology, landscape design, and tourism research, but the relationship between water and health in current literature is only investigated in the field of environmental toxicology and microbiology, not explicitly in the research field of blue space and human well-being. Due to the lack of a systematic review of blue space and well-being in the various fields of research, the aim of this review is to provide a systematic, qualitative meta-analysis of existing studies that are relevant to this issue. Benefits for health and well-being clearly related to blue space can be identified with regard to perception and preference, landscape design, emotions, and restoration and recreation. Additionally, direct health benefits have already been stated. The studies included in the review are mostly experimental studies or cross-sectional surveys, focusing on students as the subject group. There is a need for more qualitative and multi-faceted, interdisciplinary studies, using triangulation as a method to achieve a resilient image of reality. A broader study design considering all age groups would contribute to identifying benefits for the whole of society. The inattentiveness to blue space makes it difficult to measure long-term effects of blue space on well-being. There is still little respect for water and health in planning issues, although salutogenetic health benefits can be identified. To close the gap regarding missing systematic concepts, a concept for assessing salutogenetic health effects in blue space is provided. Blue space is considered therein as a multi-dimensional term including four dimensions of appropriation, as well as at least five ontological dimensions of substantiality. The aim of the concept is to support researchers and practitioners analysing health effects in blue space.     

Rejection of an innovation: health information management training materials in east Africa

A shift towards decentralization in many low-income countries has meant more skills are demanded of primary health care managers, including data and information handling at all levels of the health care system. Ministries of Health are changing their central reporting health information systems to health management information systems with emphasis on managers utilizing information at the point of collection. This paper reports on a research study to investigate the introduction of new information management strategies intended to promote an informational approach to management at the operational health service level in low-income countries. It aims to understand the process taking place when externally developed training materials (PHC MAP), which are intended to strengthen health management information systems, are introduced to potential users in an east African country. A case study has been undertaken and this research has demonstrated that the dynamic equilibrium approach to organizational change is applicable to the introduction of new information management strategies and management approaches in low-income countries. Although PHC MAP developers envisaged a technical innovation needing implementation, potential users saw the situation as one of organizational change. Contributions to theory have been made and many implications for introducing new information systems or the informational approach to management are identified. This theoretical framework could also facilitate the introduction of future information management innovations and would allow practitioners to perceive the introduction of information management innovations as one of organizational change that needs to be managed. Consequently, issues that may facilitate or inhibit adoption could be identified in advance.     

Conducting qualitative research in the health sector: researcher issues and dilemmas.

This article contributes to bridging the gap between research activity and the practical implementation of management decision making in the health sector by reflecting upon some of the issues and dilemmas for researchers, whether academics or managers, in conducting qualitative research in this sector. The article presents the methodological issues addressed by a team of researchers engaged on a project about manager learning and development in an NHS Trust, and highlights concerns about ethical issues that emerged from the research process. The study had involved a series of interviews with senior managers and clinical staff, doctors, nurses and therapists, and it addressed issues surrounding change within the organization, the impact on individuals' jobs, and the resultant learning and development required and undertaken. The article emphasizes that engaging in reflection on the research process is valuable and suggests that it should become a mainstream part of such research. It concludes that there is an important role of qualitative management research in the health sector and that for it to be acceptable and valued, it must be operationally sensitive, ethically robust and methodologically rigorous.     

Setting the stage for a business case for leadership diversity in healthcare: history, research, and leverage

Leveraging diversity to successfully influence business operations is a business imperative for many healthcare organizations as they look to leadership to help manage a new era of culturally competent, patient-centered care that reduces health and healthcare disparities. This article presents the foundation for a business case in leadership diversity within healthcare organizations and describes the need for research on managerial solutions to health and healthcare disparities. It provides a discussion of clinical, policy, and management implications that will help support a business case for improving the diversity of leadership in healthcare organizations as a way to reduce health and healthcare disparities. Historical contexts introduce aspects of the business case for leveraging leadership diversity based on a desire for a culturally competent care organization. Little research exists on the impact that the role of leadership plays in addressing health disparities from a healthcare management perspective. This article provides practitioners and researchers with a rationale to invest in leadership diversity. It discusses three strategies that will help set the stage for a business case. First, provide empirical evidence of the link between diversity and performance. Second, link investments in diversity to financial outcomes and organizational metrics of success. Third, make organizational leadership responsible for cultural competence as a performance measure. In order to address health and healthcare disparities, collaborations between researchers and practitioners are necessary to effectively implement these strategies.     

Designing adverse event prevention programs using quality management methods: the case of falls in hospital.

OBJECTIVE: From a public health perspective, the effectiveness of any prevention program depends on integrated medical and managerial strategies. In this way, quality management methods drawn from organization and business management can help design prevention programs. The aim of this study was to analyze the potential value of these methods in the specific context of preventing falls in hospital. SETTING: Medical and Rehabilitation Care Unit of Saint-Maurice National Hospital (France). DESIGN: In phase 1, two surveys assessed the context in which falls occurred. The first survey (1995) quantified adverse events during a 1-year period (n = 564) and the second (1996-1997) documented the reasons for falls (n = 53). In phase 2, a set of recommendations to prevent falls was elaborated and implemented throughout the hospital. RESULTS: The fall frequency in this unit was 18.3% in 1995. Analysis showed organizational causes in 35 (66%) of the 53 documented falls; 24 of them were associated with individual factors. Even though the two categories of causes are interdependent, their distinction enables specific recommendations. The proposed organizational management changes recommended do not aim to achieve an illusory objective of 'zero falls', but are designed to reduce the number of avoidable falls and to limit the negative consequences of unavoidable falls. CONCLUSION: Quality improvement methods shed new light on how to prevent falls. An unexploited potential for prevention lies in organization and management of care for hospitalized patients.     

Shifting to Value-Based Principles in Sickness Insurance: Challenges in Changing Roles and Culture

Purpose Management principles in insurance agencies influence how benefits are administered, and how return to work processes for clients are managed and supported. This study analyses a change in managerial principles within the Swedish Sickness Insurance Agency, and how this has influenced the role of insurance officials in relation to discretion and accountability, and their relationship to clients. Methods The study is based on a qualitative approach comprising 57 interviews with officials and managers in four insurance offices. Results The reforms have led to a change in how public and professional accountability is defined, where the focus is shifted from routines and performance measurements toward professional discretion and the quality of encounters. However, the results show how these changes are interpreted differently across different layers of the organization, where New Public Management principles prevail in how line managers give feedback on and reward the work of officials. Conclusions The study illustrates how the introduction of new principles to promote officials’ discretion does not easily bypass longstanding management strategies, in this case managing accountability through top-down performance measures. The study points out the importance for public organizations to reconcile new organizational principles with the current organizational culture and how this is manifested through managerial styles, which may be resistant to change. Promoting client-oriented and value-driven approaches in client work hence needs to acknowledge the importance of organizational culture, and to secure that changes are reflected in organizational procedures and routines.     

South African Red Cross Flying Doctors Service quality and safety in the rural and remote South African environment

CONTEXT: The South African Red Cross Air Mercy Service and its Flying Doctors Service provides health care to far flung and disadvantaged communities in South Africa. PURPOSE: The purpose of this article is to highlight the importance and effectiveness of the service in providing health care to a range of people who have poor or no access to certain health services in South Africa. METHODS: Data and information was collected from records and statistical data of our service. Data was evaluated and compiled into a report highlighting the achievements of this organisation from its infancy to the present day. FINDINGS: The Flying Doctor and Health Outreach Programme has made a difference in improving health care by providing specialist services, transport of patients and training of medical personnel in outlying areas of South Africa that have poor access to health care. Emergency Air Ambulance and Rescue Services have proven to be supportive in providing rapid advanced life support and rescue services to patients in emergency situations. Many lives have been saved through this service. CONCLUSION: The South African Red Cross Air Mercy Service plays a crucial role in delivering specialised health care to disadvantaged communities in South Africa.     

The process of managerial control in quality improvement initiatives

The fundamental intent of strategic management is to position an organization with in its market to exploit organizational competencies and strengths to gain competitive advantage. Competitive advantage may be achieved through such strategies as low cost, high quality, or unique services or products. For health care organizations accredited by the Joint Commission on Accreditation of Healthcare Organizations, continually improving both processes and outcomes of organizational performance--quality improvement--in all operational areas of the organization is a mandated strategy. Defining and measuring quality and controlling the quality improvement strategy remain problematic. The article discusses the nature and processes of managerial control, some potential measures of quality, and related information needs.     

The global financial crisis: experiences of and implications for community-based organizations providing health and social services in South Africa

The global financial crisis that began in 2008 with the collapse of the US real estate bubble is considered the worst economic turmoil since the Great Depression in the 1930s. While the crisis has negatively impacted the global economy and the flow of aid to Sub-Saharan African countries, little is known about the implications of the crisis for community-based organizations (CBOs) providing health-related services in marginalized communities. We conducted qualitative interviews with managers of 14 CBOs providing health and social services to marginalized communities in South Africa about their experiences of the crisis. CBOs reported experiencing a marked decrease in funding received from both international and local donors as a result of the global financial crisis. At the same time, they experienced difficulties in securing new funding. Organizations addressed the funding problems by conducting organizational restructuring and implementing austerity measures that led to the retrenchment of staff, reduction in benefits and incentives for staff and volunteers, reduction in the number of communities served and rationing of services provided to these communities. These measures had negative psychological impacts on paid staff and volunteers and contributed to absenteeism and attrition among volunteers, and some of the organizations eventually closed down. Our findings show that the global financial crisis has far-reaching implications for health, social and developmental services delivery and ravaging impacts on the economy of marginalized communities. Policy-makers should explore mechanisms for protecting CBOs from the effects of economic shocks to guarantee the provision of critical services to marginalized communities.     

‘They can’t report abuse,they can’t move out. They are at the mercy of these men’: exploring connections between intimate partner violence,gender and HIV in South African clinical settings

This qualitative study captured South African female health provider perspectives of intimate partner violence in female patients, gender norms and consequences for patients’ health. Findings indicated female patients’ health behaviours were predicated on sociocultural norms of submission to men’s authority and economic dependence on their partners. Respondents described how men’s preferences and health decision-making in clinics affected their patients’ health. Adverse gender norms and gender inequalities affected women’s opportunities to be healthy, contributing to HIV risk and undermining effective HIV management in this context. Some providers, seeking to deliver a standard of quality healthcare to their female patients, demonstrated a willingness to challenge patriarchal gender relations. Findings enhance understanding of how socially-sanctioned gender norms, intimate partner violence and HIV are synergistic, also reaffirming the need for integrated HIV-intimate partner violence responses in multi-sector national strategic plans. Health providers’ intimate knowledge of the lived experiences of female patients with intimate partner violence and/or HIV deepens understanding of how adverse gender norms generate health risks for women in ways that may inform policy and clinical practice in South Africa and other high-HIV prevalence settings.     

Building departmental influence in health care organizations

This article has outlined several steps to follow in assessing and building department influence at the top management levels of health care organizations. Identifying and contributing to resolving the organization's key areas of uncertainty are strategies that have improved the influence of many departments in recent years. Individual strategies, such as developing one's expertise and sharing that expertise with other departments and top management (an example of the "involvement" technique), also are being used daily by effective department managers. Decentralized management, which entails the assignment of greater responsibilities to middle managers, is increasingly popular in health care organizations. This trend will no doubt facilitate the building of departmental influence in organizational decision making. However, the steps outlined in this article can be implemented whether or not top management endorses a decentralized management style. In a critical sense, departmental influence is too important to be left to top management. It is up to department managers to exert their influence for the good of their employees, the organization as a whole, and their own careers.     

On being comfortable with being uncomfortable: centering an Africanist vision in our gateway to global health.

African identity must be central to research on African health and development. This article focuses on three primary themes for advancing a different vision for understanding health issues in Africa. The first is the need to deconstruct conventional assumptions and theories that have been used to frame public health problems and solutions in Africa. The second is to insist that identity be central to how we frame issues of health and behavior in general and in Africa in particular. The third is the importance of the notion of "social cultural infrastructure" in defining African ways of knowing to guide public health research and intervention in Africa. Finally, the metaphor of the "African gate" is used to illuminate these themes while drawing on examples from an HIV- and AIDS-related stigma research in South Africa and its implications for addressing the critical global public-health issues of today.     

South African Academic Health--the future challenge

In South Africa, significant changes in Academic Health have taken place since the first democratic elections in 1994. Academic Health came from a separated academic hospital, departmental-based curriculum and research focussed on achievement, and an abundance of money, to a position of integrated service delivery with specific reference to primary health care, separation of service levels, a new integrated curriculum, research focussed according to the need and contract research, and financial constraints with limited budgets. The management of this change is a task challenging the manager in all fields of Academic Health. Leaders need to know their environment and organisation to be able to manage change. Academic Health centres are experiencing major changes as a result of the effects of managed care, reduced rate and growing expenditure on health services. In addition to restructuring of the clinical services, Academic Health centres are being challenged to sustain their academic mission and priorities in the face of resource constraints. In order to tackle these challenges, institutions need physicians in administrative positions at all levels who can provide leadership and thoughtful managerial initiatives. The future challenge for managers focuses on service delivery, research, health education and training, Academic Health management, professionalism and financial management.