MANAGERS WHO LEAD - Msh
MANAGERS WHO LEADA Handbook for Improving Health ServicesCambridge, Massachusetts
Copyright 2005 Management Sciences for HealthAll rights reserved.Trainers and facilitators may photocopy the exercises, tools, guidelines, and instructionsfor participants without prior permission, for noncommercial use only. Any translation,adaptation, or commercial use of any part of this book in any form or medium requiresprior written permission from the publisher.The trademarks or service marks used in this book and CD-ROM, including Microsoft,Word, and PowerPoint, are the exclusive property of Microsoft Corporation. ManagersWho Lead is not a product of, nor is it endorsed by, Microsoft Corporation.Management Sciences for Health784 Memorial DriveCambridge, MA 02139-4613 USATel.: 617.250.9500Fax: 617.250.9090Web site: www.msh.orgISBN 0-913723-95-9Interior design and composition: Jenna DixonIndexer: Barbara K. TimmonsProofreader: Ceallaigh ReddyFunding for this publication was provided by the Office of Population andReproductive Health, Bureau for Global Health, US Agency for InternationalDevelopment, under the terms of the Management and Leadership Program,award number HRN-A-00-00-00014-00. The opinions expressed herein are thoseof the authors and do not necessarily reflect the views of USAID.Printed in the United States of America on acid-free paper by Quebecor Worldwith vegetable-oil-based ink. The paper used in this publication meets the minimum requirements of theAmerican National Standard for Information Sciences—Permanence of Paperfor Printed Library Materials, ANSI Z39.48-1992.Library of Congress Cataloging-in-Publication DataManagers who lead : a handbook for improving health services.p.cm.Includes bibliographical references and index.ISBN 0-913723-95-9 (alk. paper)1. Health facilities—Administration—Handbooks, manuals, etc.2. Leadership—Handbooks, manuals, etc. 3. Health services administration—Handbooks, manuals, etc. I. Management Sciences for Health (Firm)RA 971.M3463 2005362.1’068—dc221 2 3 4 5 6 7 8 9200504795905 06 07 08 09
authorscontributorsJoan Bragar GalerAnn S. BuxbaumSylvia VriesendorpLourdes De la PezaAlison EllisJoseph DwyerMichael J. HalleditorsSallie Craig HuberJanice MillerSarah JohnsonClaire BahamonRiitta-Liisa Kolehmainen-AitkenBarbara K. TimmonsNicole B. LubitzCary PerryGregory RodwaySteve SapirieKaren SherkBarry D. Smithinternational review boardAbdo Hassan AlswasyConsultant for Obstetrics and GynecologyKom Ombo Central HospitalKom Ombo Aswan, EgyptLuis Eduardo de Menezes LimaDeputy Secretary for EducationState of CearáFortaleza, BrazilTimothee GandahoExecutive DirectorPartners in Population and DevelopmentDhaka, BangladeshZoonadi Joseph NgwenyaCountry Programme ManagerSouthern African AIDS TrustLusaka, ZambiaClare Gibson-GiraudLeadership Coach and FacilitatorPerformance Plus CoachingBordeaux, FranceLourdes QuintanillaSenior Consultant and PartnerCali-DesSaltillo, MexicoAtanu MajumdarUNICEF ConsultantKolkata, IndiaFenosoa RatsimanetrimananaExecutive SecretaryNational AIDS CouncilAntananarivo, MadagascarMorsy MansourLeadership Development ConsultantCairo, EgyptIrna SenekalHealth Diploma CoordinatorFort Hare Institute forGovernmentBisho, South Africa
To the memory ofDr. Pape Syr Diagnethe late Executive Directorof the Centre for African Family Studiesin Nairobi, KenyaDr. Pape Syr Diagne was a visionary and passionate leadercommitted to improving reproductive health.His greatest legacy is the young men and womenwhom he inspired to follow in his footsteps.
ContentsFigures viTables viCountry examplesviForeword viiAcknowledgments ixIntroduction xichapter 1chapter 2chapter 3chapter 4chapter 5chapter 6Leading and managing to achieve results 1Leading teams to face challenges 21Improving work climate to strengthen performance 51Moving up the leadership ladder 81Reorienting roles in the health system 115Leading change for better health 149toolkitResources to support managers who lead 173Annotated bibliographyIndex 285271
vimanagers who ading and Managing for Results Model 8Leading and Managing Framework 12Integrated Leading and Managing Process 14The Challenge Model 23Factors to consider in scanning the environment 30Sample action plan worksheet 41Rewards of a positive work climate 52Causes and effects of work climate 54From stage to balcony: A change in perspective 83Shifting the health system to serve local needs 117Sectors of the health system 118Leading and Managing for Results Model 151tablestable 1table 2table 3table 4table 5table 6table 7table 8table 9table 10table 11table 12table 13table 14table 15table 16table 17Leader shifts 3Leadership competencies 16Becoming a manager who leads 17Sample action plan format 41Learning about your staff 56Shift from reactive to proactive language 64Distinguishing commitment from compliance 69Key leading and managing practices for the first-level manager 89Key leading and managing practices for the second-level manager 95Key leading and managing practices for the third-level manager 102Key leading and managing practices for the top-level manager 109Roles that support effective local health services 119Shifts in focus at the district level 121Shifts in focus at the central level 130Shifts in focus at the middle level 139Distinguishing between routine and complex 151Key factors in leading organizational change 154country examplesImproving capacity to respond to a challenge—Example from Guinea 15Leading with a vision to achieve results—Example from Egypt 43Improving work relationships, group climate, and performance—Examplefrom Senegal 76Stimulating political will for local health initiatives—Selected countryexamples 126Reorganizing a Ministry of Health to support new roles—Example fromNicaragua 136Improving morale and resource flows through district outreach—Examplefrom South Africa 142Scaling up changes in the way health managers work—Selected countryexamples 166
ForewordEarly in my career I provided primary health care in a village in UpperEgypt. My own family came from this area and I was deeply concernedabout the health of the people there. Working in this remote area without support from anyone, I learned how hard it is for a young physician on hisown to face the health challenges of an underdeveloped, underserved region.This is the front line of health services around the developing world: healthworkers in rural as well as urban areas. They badly need good managers andsupervisors who can enable them to succeed in protecting their communitiesfrom the dangers of poor health.Years later, as Coordinator of Population Projects in Upper Egypt, I foundmyself responsible for these same rural health units. I struggled to give themthe support I knew they so badly needed. The district team managers andsupervisors tried to find a way to improve the quality of services and theservice results. But no matter how much clinical training we provided forservice providers, or training in planning and data analysis for central andlocal managers, there were only small improvements in service quality andresults.I began to feel that there was a missing piece in the health system. Therewas something that created a gap between knowledge and skills on one hand,and people’s behaviors and attitudes on the other. Even when health workersknew what was right, they didn’t practice it consistently. People knew aboutinfection control, but they didn’t practice it. People knew about the importance of counseling, but they didn’t apply what they knew. What was missingwas something inside their hearts, something that ignites the fire inside allwho want to truly contribute or make a difference. What was missing wascommitment. 2005 Management Sciences for Healthvii
viiimanagers who leadThe question became: “How can we inspire this commitment in everyhealth service team and team member?” This is the question that health managers around the world are asking.How can we take our limited resources and give the best of ourselves toensure the quality we want our people to have? How can we not be stopped inthe face of inadequate systems and limited resources? How can we motivateour staff to be creative in overcoming obstacles, when there are so many?I believe that when people are committed they can produce incredible results.Even if the systems are poor, with commitment they will find ways to continuously improve them.Now you can see a change in Aswan in Upper Egypt. This week I visiteda rural health unit, much like any in the developing world. I found the manager there, a young female physician, Iman. She is a quiet person, and beforeshe was posted to this unit she was afraid that she would not be able to leada health unit team. She said she thought that leaders had to have loud voicesand yell at other people to make them afraid in order to get things done.But Iman has developed her leadership skills with coaching from her district managers. With the support of her team and of managers in other healthunits, she is learning how to lead. She now knows that a good manager is successful not because people are afraid, but because she helps them find ways toovercome the obstacles. Her power as a leader comes from allowing her teamto explore new ideas without fear. By trusting their ability, she is supportingthem to produce results.This book contains much of what these health workers in Aswan are learning. I recommend that you read and use the materials in it to develop yourself,your health team, and your organization to serve better those most in need.Whether you work in Haiti, South Africa, or India, you can focus on the missing piece in most health systems—how to lead—to change people’s attitudesand behaviors. This book is written for those who dream of a better future.Morsy Mansour, MDCairo, Egypt 2005 Management Sciences for Health
AcknowledgmentsThis handbook is based on 20 years of experience in working with healthprofessionals around the world in the public, private, and nonprofitsectors to strengthen the performance of health organizations andimprove people’s health. Initially the work focused on improving the management of health programs. Under the Management and Leadership (M&L)Program, funded by the US Agency for International Development (USAID),Management Sciences for Health has focused in recent years on developingthe management and leadership capabilities of managers—at all levels of thehealth system—to achieve significant improvements in health services andhealth outcomes.Building on our earlier work in management, the handbook crystallizesour collective experience with our partners in applying leadership and management concepts and best practices. The book provides a link between twobodies of experience. On the one side are the renowned leadership thinkers and researchers whose ideas and approaches inform our work. On theother are the managers on the front lines of health care who must use theseapproaches every day to achieve results. In this handbook, we have taken thebest thinking in management and leadership and applied it to the challengesthat health managers face.This handbook was written by an interdependent team of authors and editors who worked together on all aspects of writing, editing, and producingthe book. Each member brought a wealth of experience in management andleadership, and together the team members synthesized MSH’s collectiveexperience and that of our partners around the world. We are proud to haveproduced a result that no one person could have done alone and to have experienced the power of teamwork. 2005 Management Sciences for Healthix
xmanagers who leadWe have also benefited from the broad experience and critical thinkingof health professionals around the world who work at different levels of thehealth system—in urban and rural settings and in the public and privatesectors. We are indebted to the many health managers who imparted theirexperience and shared their challenges and successes with us. The countryexamples in this book are a testimony to their commitment to finding newways to approach difficult challenges and to leading their health programsnow and into the future.We would particularly like to thank the members of the InternationalReview Board for their detailed reviews and willingness to share their knowledge and experience in leading and managing health programs. We alsoextend our thanks to John Grove of the Centers for Disease Control andPrevention in Zambia, Benjamin Lozare of the Center for CommunicationPrograms at Johns Hopkins University Bloomberg School of Public Health,and Marc Luoma of the Training Resources Group, Inc., for their technicalreviews and insightful comments.We are indebted to the many MSH staff who carefully reviewed and commented on early drafts of the handbook and to the staff of the M&L Program,who contributed to the handbook through their daily work with our partnerorganizations around the world. Their input based on real experience wasinvaluable and greatly improved and sharpened the content of this book. Wewould also like to thank Ceallaigh Reddy, Kristyn Stem, and Sherry Cotacofor their assistance in the production and distribution of this publication, andRuby Thind and Alex Bermudez for producing the accompanying CD-ROM.Joseph Dwyer, Director of the M&L Program at Management Sciences forHealth, provided leadership, guidance, and steadfast support in the effort todistill the best of our experience for this handbook.Finally, we thank Susan Wright, USAID Cognizant Technical Officer forthe M&L Program, for her commitment to, and encouragement and supportof, this handbook. We are also grateful to Barbara Addy of USAID for providing guidance and lending her experience to the handbook. We greatly appreciate the continued investment of USAID in improving the management andleadership capacity of health programs so that managers of public, private,and nonprofit organizations around the world can realize their vision of highquality, accessible, and sustainable health services for all. 2005 Management Sciences for Health
Introduction“We aren’t creating leaders—we are uncovering people’s leadershipcapabilities and providing a path for them to put their capabilities intopractice.”— j o se p h d w y e rm a n a ge m e n t s c i e nc e s f o r h e a lt hManagers Who Lead was inspired by the work of managers aroundthe world who are on the front lines of health care—those who aremaking real improvements in health under the most difficult circumstances. This handbook is a tribute to their work. It could not have beenwritten without the knowledge gained from their experience.All over the world, health managers and providers face the challengesof producing results in an increasingly complex health care environment.Health sector reform, changing donor priorities, shifting client needs, andnew technologies require that managers at all levels take on responsibilitiespreviously held by people at higher levels.Moreover, the drain on health systems due to the AIDS pandemic and newand emerging diseases has accelerated the need to learn new ways of leadingand managing to achieve results. Through improved leadership, management,and teamwork, managers in public, private, and nongovernmental organizations can face these challenges with more confidence and lead their teams toeffect significant changes in health.Managers Who Lead is designed to help all managers tap into their naturalabilities to lead others to reach for and achieve results. It is for managers whowant to learn how to create a shared vision of a better future and mobilizeindividuals, teams, and entire organizations to make a difference. The handbook does not separate leaders from managers. It is for managers who lead,at any level. This approach is based on the belief that improvements in healthcare are made by managers who lead and manage well.The approach in this handbook is based on these fundamental principles:nFocus on health outcomes. Good management and leadershipresult in measurable improvements in health services and outcomes. 2005 Management Sciences for Healthxi
xiimanagers who leadOnly by focusing on real organizational challenges can managersdevelop their ability to lead.Good leadership and managementcan, and must, be practiced at every level of an organization. Working with their teams, managers at all levels—from health posts tonational institutions—can confront challenges and achieve results. Practice leadership at all levels. You can learn to lead. Leadership practices improve through aprocess of facing challenges and receiving feedback and support. Byusing this process, managers develop the leadership abilities of theirstaff. Leadership is learned over time. Becoming a manager who leadsis a process that takes place over time. This process works best whenit is owned by the organization and takes on critical organizationalchallenges. Sustain progress through management systems. Gains made inhealth outcomes can be sustained only by integrating leadership andmanagement practices into an organization’s routine systems andprocesses.Now more than ever, effective leadership, with good management, is critical for health organizations. This handbook provides managers with practicalguidelines and approaches for leading teams to identify and find solutions fortheir challenges. Staff at any level of the health system can use these conceptsto improve their ability to lead and manage well. We invite you to invest indeveloping managers who lead at all levels of your organization.how this handbook is organizedThe handbook includes six chapters, a toolkit, an annotated bibliography,and a CD-ROM with additional resources. Each chapter presents key issuesfacing managers today, practical advice on applying leadership and management practices to address health care challenges, questions for reflection, andreal-life examples that illustrate the role of leadership and management inimproving health.Chapter l: Leading and managing to achieve results. Discusses therelationship between strong leadership and management, and the resultingimprovements in health services and outcomes. It introduces the Leadingand Managing Framework: the basic practices that enable work groups andorganizations to face challenges and achieve results. Experience with applying this framework to develop managers who lead forms the backbone ofthis handbook. This chapter also discusses the “leader shifts,” or changes inmindset, that managers need to make in order to learn and embrace new 2005 Management Sciences for Health
Introductionxiiiapproaches to leading and managing their teams that will result in significantimprovements in health.Chapter 2: Leading teams to face challenges. Presents the ChallengeModel, a process that helps managers work with their teams to deal withone challenge at a time to overcome obstacles in order to achieve results. TheChallenge Model provides a systematic approach to creating a shared visionof the future and helping teams identify a challenge and a desired, measurableresult. The process leads them to assess factors in the external and internalenvironments related to their desired result, and plan and implement priority actions to address the root causes of their obstacles. Teams can apply thisprocess repeatedly to tackle each new challenge.Chapter 3: Improving work climate to strengthen performance. Analyzes the critical factors in the work environment that support or detract frommotivation and high performance. The chapter identifies the rewards of apositive work climate and helps managers recognize their role in influencingthe work climate and, thus, the motivation and performance of their staff. Thechapter also provides a tool for assessing the work climate of a work groupand developing a plan for improving it.Chapter 4: Moving up the leadersh
Cambridge, MA 02139-4613 USA Web site: www.msh.org ISBN 0-913723-95-9 Interior design and composition: Jenna Dixon . Bureau for Global Health, US Agency for International Development, under the terms of the Management and Leadership Program, award number HRN-A-00-00-00014-00. Th e opinions expressed here
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