Health services use introduction in Kenya.

1. Elements of health services
management
MS. BETSY CHERIRO

2. What are elements of a Health system?
 Elements encompasse the:
- population the system serves, as well as
- the supply or delivery of services,
- interventions and
- activities intended to promote health and wider value.
 Elements are the WHO framework that describes health systems in terms of six core
components or “building blocks”:
- service delivery,
- health workforce,
- health information systems,
- access to essential medicines,
- financing, and
- leadership/governance

4. What is a health system?
 Health systems can be defined either by what they seek can be understood as: to do and achieve, or
by the elements of which they are comprised.
 Defining goal of health systems is generally seen as health improvement – achieved not only through
the provision of curative and preventive health services but treated also through the protection and
promotion of public, emergency preparedness and intersectoral action financing for the system
(Mackintosh & Koivusalo, 2005)
 Wider goal includes: equity, or fairness, in the distribution of health and the costs of financing the
health system as well as protection, some of for households from the catastrophic costs associated
with disease
 Responsiveness to the expectations of the population; and the promotion of respect for the dignity
of persons (World Health Organization, 2007)

5. Critical roles of the population
 Patients with health needs requiring care
 Consumers with expectations of how they will be treated
 Taxpayers who provide the main source of financing for the system
 Citizens who may have access to health care as a right
 Co-producers of health through their health seeking and health promoting
behaviors

6. What is Health service management (HSM)?
 HSM is the field relating to leadership, management, and administration of public health systems, health care systems, hospitals,
and hospital networks in both metropolitan and rural areas
a. Who is a HS Manager?
 An administrator or health professional with special training and skills in management who is concerned with the planning and
provision of health services and with managing performance.
 Doctors, nurses, and others may fill such posts, sometimes combining them with professional appointments
b. What are the roles of HS Manager?
 Varied and integrated, depends upon the area worked in: main roles:
 Human Resource Management
 Operational Management
 Financial Management
 Project Management (increasingly
c. The evolving role of the HS Manager
 Closer working relationship between managers and clinicians
 Clinicians as Managers and various clinician manager roles
 Focus on accountability and outcome

7. Specific roles of HS Manager
 Human Resource Management
• Personal development of staff, rostering including staff mix, annual and sick leave
management, skills maintenance and up-skilling of staff and staff development
 Operational Management
• Operational activity meets required National Safety Standards
• Clinical governance, quality assurance
• Meeting Key Performance Indicators (KPIs)
• Managing and dealing with issues on a daily basis
 Financial Management
• Delivery of services within budget constraints, managing and ordering stocks, financial
planning for the given year.
 Project Management (increasingly prevalent)
• Health reform activities involving considerable project and change management

8. Source of management knowledge
 Learning by doing
 Hearing or reading local accounts
 Studying approaches or theory
 Attending management development workshops or course
 Attending seminars and conferences (networking)
 Judgement
 Experience (first and second hand)
 Knowledge of self
 Basic and expertise skills

9. Challenges in health services Management
 Managing change – health reform a growing field
 Managing information
 Dealing with financial and resource constraints
 Evaluation
 Corporate planning
 Human Resource Management
 Conflict Resolution
 Staff development
 Technical advances

10. Clinician versus Manager
Clinician Manager
Tasks Agreed procedure understood by all Ambiguous, fragmented, unpredictable
Role Clear, level of authority understood Often increase in responsibility (budget) but decrease
in authority
Relationships Involves small groups of like minded
individuals
Need to establish and maintain a large network in
order to get job done – Politics and power games
Orientation
and priorities
Patient orientation with quality of care
focus
Multiple and conflicting, economics, relationships
Decision
processes
Systematic and rational, based on the
assumption that there is one best way and
there is a solution
Ad hoc, incremental, intuitive and political, multiple
agendas
Skills Professional practice, specialisation in
specific skills
Negotiation, politics, entrepreneurial skills, managing
people who do not agree with you

11. Kenya Health care System
 Health sector comprises the public system, with major players including:
 MOH and parastatal organizations, and
 The private sector, which includes private for-profit, NGO, and FBO facilities.
 Health services are provided through a network of over 4,700 health facilities countrywide, with the
public sector system accounting for about 51 percent of these facilities.
 Public health system consists of the following levels of health facilities: national referral hospitals,
County Referral Hospitals, Sub County hospitals, health centers, and dispensaries.
 National referral hospitals are at the apex of the health care system, providing sophisticated diagnostic,
therapeutic, and rehabilitative services. The two national referral hospitals are Kenyatta National Hospital
in Nairobi and Moi Referral and Teaching Hospital in Eldoret.
 The equivalent private referral hospitals are Nairobi Hospital and Aga Khan Hospital in Nairobi.

12. Ct’ Health care system
 Kenya health system is structured in a stepwise manner and gaps are filled by private and church run units
 County hospitals act as referral hospitals to their Sub-County hospitals.
 They also provide very specialized care. Act as intermediary between national central level and the
districts.
 Oversee the implementation of health policy at the County level, maintain quality standards, and
coordinate and control all County health activities. Similar private hospitals at the provincial level include
Aga Khan Hospitals in Kisumu and Mombasa.
 County hospitals concentrate on the delivery of health care services and generate their own expenditure
plans and budget requirements based on guidelines from headquarters through the provinces.

13. Ct’ health system
 Network of health centers provides many of the ambulatory health services. Health centers
generally offer preventive and curative services, mostly adapted to local needs.
 Dispensaries are meant to be the system’s first line of contact with patients, but in some
areas, health centers or even hospitals are effectively the first points of contact. Dispensaries
provide wider coverage for preventive health measures, which is a primary goal of the health
policy.
 The government health service is supplemented by privately owned and operated hospitals
and clinics and faith based organizations' hospitals and clinics, which together provide
between 30 and 40 percent of the hospital beds in Kenya.

14. Devolved Health system
 Health policy Project (HPP) 2012, supported the ministries of health to implement the Road Map to Devolution.
 Merge the two ministries of health- In September and October 2012, HPP partnered with MOMS and MOPHS on
two consultation events to develop a common understanding of the structures, opportunities, and challenges of
devolution for health sector actors.
 Health managers recognized the need to better prepare for these significant systemic changes by proposing
definitions for national and county-level functions.
 Reviewed the role of hospital management boards
 County politicians with limited experience-controlled resources with no systems to administer- invested county
resources in infrastructure improvements, i.e. constructing new health facilities within counties.
 In partnership with the MOH, HPP sought to help county health management teams (CHMTs) allocate resources to
ensure that priority services would not be neglected in the rush to build facilities. Along with the MOH and the
World Health Organization, HPP organized strategic planning workshops
 Devolution is a political process. Future of Kenya’s health system relies on negotiation among stakeholders that can
operate in this new political environment.

15. Strategy of Decentralized Healthcare
 Kenya Health Policy 2014 – 2030 provides guidance to the health sector in terms of identifying and outlining the
requisite activities in achieving the government’s health goals. The policy is aligned to Constitution of Kenya and global
health commitments.
Under the devolved system, healthcare facilities are organized as follows:
 Level 1: Community health services. This level comprises all community-based demand creation activities, that is, the
identification of cases that need to be managed at higher levels of care, as defined by the health sector.
 Level 2: Primary care services. There are the dispensaries, health centers and maternity homes for both public and
private providers.
 Level 3: County referral services: These are hospitals operating in and managed by a given county and consist of the
former level four and district hospitals in the county and include public and private facilities.
 Level 4: National referral services: This level comprises facilities that provide highly specialized services and includes all
tertiary referral facilities.
 In essence, the decentralized system has consolidated service areas into 4 main categories for ease of governance and
responsibility. These responsibilities are shared between the national government and county governments.

16. Health system-Governance
 Kenya Health Policy 2014-2030 provides an institutional framework structure that specifies the new institutional and
management arrangements required under the decentralized system.
 The policy acknowledges need for new governance and management arrangements at national and county levels of
government and outlines governance objectives. Key objectives for governance systems at the county levels:
 The ability to delivery efficient, cost-effective and equitable health services to the population
 The further decentralization of health service delivery, administration and management to the community level
 Ability to initiate and sustain stakeholder participation and accountability in health service delivery, administration and
management
 The ability to maintain operational autonomy
 The ability to maintain efficient and cost-effective monitoring, evaluation, reviewing and reporting systems
 The implementation of Smooth transition from current to proposed devolved arrangements
 The existence of complementarity of efforts and interventions between the national and county healthcare systems

17. Health care financing
 Primary sources of funding for healthcare are:
 The public. Government allocations-national budget comprise 30% of the total yearly expenditure in healthcare in the
country. Main source of funding for about 80% of the population receiving services from the public sector.
 Private (consumers). Largest contributor of total healthcare funds spent in the country at 35.9% of the total expenses.
Funds serve about 20% of the population-able to access private healthcare services. Mostly funded through company or
employee insurance schemes. These funds are thus not available for the newly decentralized units.
 Donors. These include funds to fight high burden diseases such as HIV, malaria and Tuberculosis. These funds directly
supplement public sector funds and contributes about 30% of the total healthcare expenditure in the country.
 The health service delivery function was formally transferred to counties on August 9, 2013, and one-third of
the total devolved budget of KSh 210 Billion ($2 Billion) was earmarked for health in the 2013/2014 budget
following the transfer.
 The budget for 2015/6 imposed severe restrictions. KSh 43 billion was allocated to the maternity budget, as in
the previous year. Funding for the Kenyatta National Hospital-reduced from 9.3 to 8.8 KSh billion. KEMRI
reduced to KSh 1.7 billion from KSh 1.9 billion and the national Aids Control Council was cut to KSh 600
million from KSh 900 million and the slum health programme to KSh 700 million from KSh 1 billion

18. Coordination of Health Services
NATIONAL COUNTY SUB COUNTY
-Health policy
-Regulation
-National referral
health facilities
-Capacity building
and technical
assistance to counties
-County health facilities and pharmacies
- Ambulance services
-Promotion of primary healthcare
-Licensing and control of undertakings that sell
food to the public
-Veterinary services
-Refuse removal, refuse dumps and solid waste
disposal
Health Facilities

19. NATIONAL REFERRAL SERVICES
Comprises of:
 All tertiary (level 6) referral hospitals,
 National reference laboratories and services,
 Government owned entities, Blood transfusion services, Research and training institutions
providing highly specialized services. These include:
(1) General specialization
(2) Discipline specialization, and
(3) Geographical/regional specialization.
 Focus is on: Highly specialized healthcare, for area/region of specialization, Training and
research services on issues of cross-county importance

20. County Referral Health Services
 Level 4 (primary) and level 5 (secondary) hospitals and services in the county: forms the County
Health System together with those managed by non-state actors.
Provides:
 Comprehensive in patient diagnostic, medical, surgical, Habilitative and rehabilitative care,
including reproductive health services; -Specialized outpatient services; and
 Facilitate, and manage both vertical and horizontal referrals.

21. Primary Care Services
 Comprise all dispensaries (level 2) and health centres (level 3), including those managed by non-state
actors.
They provide:
 Disease prevention and health promotion services;
 Linkage to community units
 Basic outpatient diagnostic, medical surgical & rehabilitative services;
 Ambulatory services
 Inpatient services for emergency clients awaiting referral, clients for observation, and normal delivery
services

22. Community Health Services
Comprise community units (level 1) in the County.
 Facilitate individuals, households and communities to embrace appropriate healthy
behaviors;
 -Provide agreed health service;
 -Recognize signs and symptoms of conditions requiring referral

23. Hospitals
 Hospitals complement and amplify the effectiveness of many health system, providing
continuous availability of services for acute and complex conditions.
 Concentrate scarce resources within well-planned referral networks to respond efficiently
to population health needs.
 They are an essential element of Universal Health Coverage (UHC) and will be critical to
meeting the Sustainable Development Goals (SDG).
 Hospitals are also an essential part of health system development.

24. Ct’ Hospital
 Currently, external pressures, health systems shortcomings and hospital sector
deficiencies are driving a new vision for hospitals in many parts of the world i.e. key role
to play to support are essential in a well-functioning referral network.
- other healthcare providers and
- for community outreach and
- home-based services;
 Hospitals matter to people and often mark central points in their lives.
 They also matter to health systems by being instrumental for care coordination and
integration.
 They often provide a setting for education of doctors, nurses and other health-care
professionals and are a critical base for clinical research.

26. National Hospitals
There are five national hospitals in Kenya, namely:
 Moi Teaching and Referral hospital
 The National Spinal Injury and Referral Hospital
 Kenyatta National Hospital
 Mathare National Teaching and Referral Hospital
 Kenyatta University Teaching and Referral Hospital
 Headed by a Chief Executive Officer (CEO)

27. National level responsibilities
 Health policy
 Financing
 National referral hospitals
 Quality assurance and standards
 Health information, communication and technology
 National public health laboratories
 Public-private partnerships
 Monitoring and evaluation
 Planning and budgeting for national health services
 Services provided by Kenya Medical Supplies Agency (KEMSA), National Hospital Insurance Fund (NHIF), Kenya
Medical Training College (KMTC) and Kenya Medical Research Institute (KEMRI)
 Ports, borders and trans-boundary areas
 Major disease control (malaria, TB, leprosy)

28. County Hospital
 Kenya has 47 counties, each with a county hospital which is the referral point for the district hospitals.
 These are regional centers which provide specialized care including intensive care and life support and
specialist consultations.
 It is the policy of many hospitals that those who do not pay their bills are not allowed to leave and may be
prevented from doing so by armed guards.
 This policy was found to be illegal in September 2015 by the High Court but was still widespread in
October 2018, when the court again ruled that this “is not one of the acceptable avenues (for hospitals) to
recover debt”

29. County level responsibilities
 Ambulance services.
 Promotion of primary health care.
 Licensing and regulation of entities that sell food to the public.
 Disease surveillance and response.
 Veterinary services (excluding regulation of veterinary professionals).
 Cemeteries, funeral homes, crematoria, refuse dumps, solid waste disposal.
 Drug Rehabilitation services.
 Disaster management.
 Public health and sanitation.

30. Sub-County hospitals, Nursing Home
Sub-County hospitals
 Each sub county formally district in the country has a sub county or district hospital which is the
coordinating and referral center for the smaller units.
 They usually have the resources to provide comprehensive medical and surgical services. They are managed
by medical superintendents.
 These are similar to health centers with addition of a surgery unit for Caesarean section and other
procedures.
 Many are managed by clinical officers. A good number have a medical officer and a wider range of surgical
services.
Nursing Home
 These are owned privately by individuals or churches and offer services roughly similar to those available at a
sub-district or district hospital. They are also believed to provide better medical services compared to public
hospitals.

31. Health centers
 All government health centers have a Clinical officer as the in-charge and provide comprehensive
primary care.
 Because of their heavy focus on preventive care such as childhood vaccination, rather than curative
services, County Government and most mission, as well as many private health centers, do not have
clinical officers but instead have a nurse as the in-charge.
 Health centers are medium-sized units which cater for a population of about 80,000 people.
 A typical health center is staffed by: At least one Clinical Officer, Nurses, Health administration officer,
Medical technologist, Pharmaceutical technologist, Housekeeper and Supporting staff
 All the health center staff report to the clinical officer in-charge except the public health officers and
technicians who are deployed to a geographical area rather than to a health unit and report to the
district public health officer even though they may have an office at the health center.

32. Ct’ HC
 The health center has the following departments:
 Administration block where patients register and all correspondence and resources are managed.
 Outpatient consultation rooms where patients are seen and examined by clinical officers.
 In-patient (wards)-very sick patients can be admitted. wards are divided into male, female and pediatric with newborn units.
 Laboratory where diagnostic tests are done. The following tests: blood slides for malaria parasites, sputum AFB, urinalysis, full
haemogram, stool O/C, blood sugar, Elisa and CD4 counts in comprehensive care centers for HIV/AIDS patients.
 Pharmacy
 Minor theatre where minor surgical procedures are done, e.g., circumcicion, stitching wounds and manual vacuum aspiration.
 Maternity
 Maternal and Child Health
 Kitchen and catering
 Student hostels for rural health training centres where students go to get rural experience.

33. Dispensaries
 Government runs dispensaries across the country and are the lowest point of
contact with the public.
 Run and managed by enrolled and registered nurses who are supervised by the
nursing officer at the respective health centre.
 Provide outpatient services for simple ailments such as common cold and flu,
uncomplicated malaria and skin conditions.
 Those patients who cannot be managed by the nurse are referred to the health
centres.

34. Private Clinics
 Most private clinics in the community are run by nurses.
 In 2011 there were 65,000 nurses on their council's register.
 A smaller number of private clinics, mostly in the urban areas, are run by clinical
officers and doctors who numbered 8,600 and 7,100 respectively in 2011.
 These figures include those who have died or left the profession hence the actual
number of workers is lower

35. Public Health care

36. What is PHC?
 Primary health care is one of the best tools in achieving the world committed in making health for all a reality.
 Through the Declaration of Astana, countries have reaffirmed the importance of PHC.
 Global consensus becoming nothing more than a pipe dream unless countries can turn the four commitments into action on
the ground.
 PHC has been neglected in many countries in favor of a disease-specific approach. This is often due to:
- a combination of lack of political will,
- under investment, and
- common misperceptions of the role and benefits of PHC. Political will has advanced greatly with the adoption of the Declaration of Astana.
 It’s proven that health systems with a PHC-based foundation result in:
- improved clinical outcomes,
- increased efficiency,
- better quality of care and
- enhanced patient satisfaction.

38. Ten essential services of Public Health

39. Ten essential PH services
 Assess and monitor population health status, factors that influence health, and
community needs and assets
 Investigate, diagnose, and address health problems and hazards affecting the
population
 Communicate effectively to inform and educate people about health, factors that
influence it, and how to improve it
 Strengthen, support, and mobilize communities and partnerships to improve
health
 Create, champion, and implement policies, plans, and laws that impact health

40. Ct’ ten PH services
 Utilize legal and regulatory actions designed to improve and protect the public’s health
 Assure an effective system that enables equitable access to the individual services and
care needed to be healthy
 Build and support a diverse and skilled public health workforce
 Improve and innovate public health functions through ongoing evaluation, research,
and continuous quality improvement
 Build and maintain a strong organizational infrastructure for public health

41. Primary health care
 Fundamental premise of primary health care;
- All people, everywhere, deserve the right care, right in their community.
 Primary health care (PHC) addresses the majority of a person’s health needs
throughout their lifetime.
 Includes: physical, mental and social well-being and it is people-centred rather
than disease-centred.
 PHC is a whole-of-society approach, includes: health promotion, disease
prevention, treatment, rehabilitation and palliative care.

42. Ct’ PHC
A primary health care approach includes three components:
 Meeting people’s health needs throughout their lives;
 Addressing the broader determinants of health through multisectoral policy and
action; and
 Empowering individuals, families and communities to take charge of their own
health.
 In the community- PHC addresses individual and family health needs, also the
broader issue of public health and the needs of defined populations.

43. Ct’ PHC
 Principles of PHC- first outlined in- Declaration of Alma-Ata in 1978, a seminal
milestone in global health.
 Forty years later, global leaders ratified the Declaration of Astana at the Global
Conference on Primary Health Care which took place in Astana, Kazakhstan in
October 2018.
 PHC- is about how best to provide health care and services to everyone,
everywhere, and most efficient & effective way to achieve health for all.
 Countries must increase spending on primary health care by 1% of GDP to close
coverage gaps
 Primary health care is care for all at all ages. All people, everywhere, deserve the
right care, right in their community.

44. CT’PHC
 Primary health care can meet 90% of a person’s health needs throughout their
lifetime
 Primary health care encompasses a broad spectrum of areas and activities,
including (but not limited to):
 Rehabilitation, health workforce, mental health, digital health, sexual and
reproductive health, and quality, among others.
 To assist countries and health professionals to understand how each of these areas
is implicated in primary health care, WHO has produced the Technical Series on
Primary Health Care.

45. Misconceptions - PHC
1. PHC only provides “basic” care, when, in fact, PHC provides essential care that can cover the
majority of a person’s health needs throughout their lives.
2. PHC is about maternal and child health – PHC is about health at all ages. PHC involves
prevention, health promotion, treatment, rehabilitation, and palliation.
3. PHC is “cheap” health care for the poor. Because PHC is based in the community, it is
frequently the only health care available to poor or marginalized communities, who may not
have access to a hospital.
 PHC focuses on the person rather than the disease, it is an approach that moves away from
overspecialization.
 In PHC, the goal is to work through multidisciplinary teams with strong referral systems to
secondary and tertiary care when needed.

46. Aspects of PHC
 PHC also goes beyond providing health care services to individuals.
 It is a whole-of-society approach that seeks to address the broader determinants of health:
- Community-level disease-prevention efforts, and
- Empower individuals, families and communities to get involved in their own health.
 In 2018, world leaders committed to advancing PHC. However, moving from political commitment to
reality will require efforts on the part of all stakeholders:
– governments, health care providers, civil society, and the public.
 "Primary health care” is an overall approach which encompasses the three aspects of:
- Multisectoral policy and action to address the broader determinants of health;
- Empowering individuals, families and communities; and
- Meeting people’s essential health needs throughout their lives. “Primary care” is a subset of PHC and
refers to essential, first-contact care provided in a community setting.

47. Importance of PHC
 It is the foundation of a strong health system.
 It leads to more equitable health across the community and leads to greater patient and
health worker satisfaction.
 A PHC approach is about meeting the majority of people’s health needs through services
provided directly in the community where they live.
 A PHC approach means working with multidisciplinary teams – doctors, nurses, caregivers,
therapists, and others – to treat the person rather than the disease.
 Providing health care services throughout a person’s life, PHC allows people to develop
long-term partnerships with their care providers.
 Health care providers can address treatment needs, also prevention, health promotion,
rehabilitation and palliation services

48. Assessing, measuring and improving PHC
 Existing indicators have been adapted to regional realities to create the PHCMI (Primary
Health Care Measurement and Improvement) initiative, - enables countries- region to
evaluate existing health systems and approaches.
 PHCPI, the Primary Health Care Performance Initiative, through its Vital Signs Profiles,
also provides a great deal of data to assist countries in evaluation and decision-making.
 Once the data is available, and the decisions are made, it is time for implementation.
 WHO has, with the support of partners, created the PHC Operational Framework which
outlines a number of PHC levers which countries can use to guide the move to a PHC
model.

49. Measuring PHC vital signs
 Crucially, each Vital Signs Profile acts like a unique fingerprint.
 By pulling data together from diverse sources and distilling this information in an accessible way, the Vital Signs
Profile helps leaders visualize and act on the main strengths and weaknesses of primary health care in their health
system.
 First generation Vital Signs Profile measures across four main pillars:
1. Financing- There is no global target for spending on primary health care (PHC). However, we know that
infrastructure, providers, and other critical resources for PHC remain underfunded in countries around the world
- More government investment in primary health care is greatly needed, alongside more detailed data to better
understand who is bearing the cost, where funds are coming from and how funds are being spent.
2. Capacity- The “capacity” of a Primary Health Care system refers to the foundational properties of the system that
enable it to deliver high quality primary health care (PHC)
- Robust data collection on health system capacity is possible and necessary. By leveraging a mix of qualitative and
quantitative data, country leaders have the best opportunity to uncover gaps that impact how a health system is
functioning and act to improve primary health care.

50. Ct’ Measuring VS
3. Performance- Performance pillar of the VSP gets at the heart of this issue by assessing how well primary health
care (PHC) is performing in terms of three mutually-reinforcing domains: Access, Quality, and Service Coverage.
Three domains of PHC performance:
 Access: People’s ability to get the primary health care they need when they need it, regardless of where they
live or how much money they have.
Quality: PHC services that meet necessary standards for comprehensiveness of care, continuity of care,
person-centeredness, provider availability and competence, and safety practices.
Service Coverage: The proportion of the population that is receiving the range of essential services they need,
including for infectious diseases, maternal and child health, and non-communicable diseases. These
interventions are selected from the UHC Service Coverage index, and the vast majority can be delivered
through strong primary health care.
- There is substantial room for improvement across access, quality and coverage of primary health care services;
and quality remains the most under-measured dimension of primary health care performance, even after
innovative efforts to fill data gaps through local sources.,

51. Ct’ Measuring VS
4. Equity- We can’t say a health system is functioning well if it’s not functioning well
for all people, especially a country’s most vulnerable communities.
The VSPs leverage data related to three common sources of health disparities –
wealth, level of education and the rural and urban divide – to assess three critical
dimensions of equity: access, coverage and outcomes. To demonstrate equitable
service delivery grounded in primary health care (PHC), a country must perform well
on all three dimensions.
- Equity is a fundamental goal of primary health care. By comprehensively
assessing the extent of disparities in access, coverage and outcomes within a
health system, countries can pinpoint who is being left behind and progress
further on their unique path to Health for All

52. Management
function of
medical
practitioners.
22.10.2021

53. What is a medical profession?
 Medical professional is a practising medic, or the representative of practising medics, in the
top management team (TMT) or (medical director)
 An executive manager who was formerly a medic or has some form of medical training is not
a medical professional

54. Comparing Doctors and managers
Doctors
 Decision making in the interest of
individuals
 Accountable to profession (peers)
 Decision led by professional norms and
rules
 Normative and autonomous decisions
Managers
 Decision making in the interest of the
organization
 Accountable to multiple stakeholders
 Decisions led by organizational goals
 Group decisions, political environment,
bargaining, compromise

55. Should clinicians be top managers?
 Doctors seem to attribute reduced resources, and the reduced medical
performance they imply, to weak medical representation in the TMT
 Medical director plays an important part in balancing medical and financial performance.
 It is perceived wisdom among medics that the medical director’s position should be strong and on an equal footing
with the commercial director.
 Clinicians believe that relegating their representative to a subordinate role would entail financial considerations
taking precedence in decision making, leading to cost-cutting and consequent detrimental effects on medical
performance.
 Placing the medical director in a subordinate position may in fact lead to increased resources and superior medical
performance, because medical and financial performance are strategic complementarities
 Doctors have a high commitment to professional values and a relatively low commitment to managerial values.
 Some evidence shows that medics who acquire some management competence
tend to use it not primarily to help balance the goals of the firm but rather to secure their
professional autonomy and reinforce the nexus between managerial and professional power

56. Challenges in medical professional as managers
 First, firms operate within significant institutional constraints that change frequently as part of a sensitive
political process. This puts severe limitations on effective management.
 Second, medical personnel, doctors and nurses, see their role first and foremost as carers. They have
significant autonomy and focus on and are led by professional norms and values, a characteristic that can
lead to the formation of “tribes” (Shortell, 1991) and a “clash of cultures“ (Abernethy and Stoelwinder,
1995) with management.
 Third, while health care organisations, like most other organisations, are assessed on key dimensions of
financial performance and quality of service, these variables, in contrast to traditional economics, are not
linked through price differentiation.
 Standardisation of services for compensation purposes means that it is rarely possible to demand higher
prices for better service. Management’s main lever to increase margins is
to cut costs, often with a detrimental effect on quality.

57. Ct’ challenges
 Healthcare professionals-fall into camps with little interaction: physicians and nurses on one side and
managers and administrators on the other.
 It is tempting to bridge this gap by including representatives of both groups in the TMT.
 A key advantage of a diverse TMT like this is that it provides access to different sources of
information.
 This diverse knowledge has to be effectively employed in the decision making process if it is going to
have any effect on organizational performance.
 Lack of communication and understanding between the two camps can be a significant barrier to
capturing the performance-enhancing potential of diversity
 The greater the degree of physician involvement in the governance of a hospital, the greater the
degree of clinical involvement in quality management processes.
 Board participation by medical staff enhances operational performance.
 Medics’ role conflict in the budgeting process is reduced if the process is clearly and transparently
linked to organizational goals. It is easier to communicate such a link if a medic is represented in the
TMT.

58. Organizational factors for quality outcomes
i. Involvement of the medical staff president with the hospital governing board,
ii. Overall physician participation in hospital decision making,
iii. Frequency of medical staff committee meetings and
iv. Percentage of active staff physicians on contract are positively associated with
higher quality-of-care outcomes.

59. Two frameworks of integrated decision making
i. Managers and medics on an equal footing; or
 This first model maintains the traditional autonomy model of professional organisations. ”One policy is to
establish a chief medical officer at the vice president level who works with the management staff on an
ongoing basis regarding medical matters but who can also participate in other management functions
 Executive in charge of clinical quality and safety should be a physician”
i. Medics in a subordinate role.
 The second decision framework integrates the medical professional in a more hierarchical way, as
illustrated in Eeckloo et al. (2004), with reference to the situation in Belgium: “(...),each hospital has a
general manager (CEO), who is appointed by the hospital board and is directly and exclusively responsible
to it.
 His/her tasks include day-to-day management of the hospital. The CEO co-operates closely with those
responsible for the medical, nursing, paramedical, administrative and technical departments. Together they
constitute the executive management.“ There is a single decision maker in this model but the medical
profession has a clear voice.

60. Journey is almost…