management functions, action plan, evaluation of health services

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CHAPTER IV
HEALTH MANAGEMENT
Objectives :
1. Define management.
2. Identify the main management functions
3. Enumerate the planning functions
4. Identify the levels of planning
5. Define the components of situation analysis in a community.
Definition of management: group of activities done for reaching goals. It is
a science and art that needs experience. Management is getting things
effectively done to achieve desired objectives through proper planning,
efficient implementation, and evaluation to assess achievements and identify
the needs for re-planning. Management is thus a dynamic process.
Management is not only for projects or large business but it can be applied
in daily life for every one. The art of management is how to do tasks
successfully in the right way, within your available resources and in its fixed
time.
"Needs lead to invention" it is true statement also for management science.
An individual can do his daily tasks, prioritize these tasks, change time
schedule in doing it, i.e. he is free in how, when, why to do things providing
that he will do what should he done. If the same job is distributed on two or
more individuals, there must be rules for doing that job to prevent
duplication, lack of responsibility, waste of resources. These rules are the
bases of management. So management is rules (functions) that control
execution of work (or job) to reach goals (aims) properly (with zero mistake)
with maximal use of available resources in the least time.
Aim of health management:
To reach goals easily (getting things done) with least resources, effort and
time
The goals in the medical field are: to promote health, prevent health
problems, control problems (mortality and morbidity) and rehabilitation of
handicaps.
So management in the medical field is used to reach promotion of health,
prevention and control of diseases in a proper way, with minimal resources,
effort and time.
Scopes of H. management: in scientific research, thesis, projects, program,
experiment, medical services (hospital, health units, clinics) to add something
new (new technique or treatment) or to improve something already present in
these areas and needs improvement management techniques.

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Management functions:
1- Where are we now? = situational analysis = what is the background of
the health problem (or subject under study). To study and understand the
nature, distribution, importance and contributing factors related to that
problem (or research point) you are interested in. Collect data from all
previous studies in that subject. Do field study ask about the needs of the
people (customers) who will benefit from that research. Do SWOT
analysis to assess strengths, weak points, opportunities and threats that
can help or complicate your research. Think in the whole situation to
formulate problem statement .i.e. to choose certain aspect (or point) in the
problem to be solved (or improved).
Example: suppose we want to increase the sales of a factory. First of all we
should study well market needs, competitive factories products, the resources
of the factory (man power, budget, tools and instruments) work shifts,
problems of workers, availability of materials in market (local or imported)
system of work, all steps before production. This situational analysis revealed
that to increase sales we must retrain workers, increase incentives.
Example: if we do situational analysis to solve parasitic diseases problem we
should collect data about the prevalence of these infections, who are infected,
how, where, and why. Study life cycles of the parasites, study host and the
environment that helps the presence of the infection (ecology). From this
situational analysis we know the most prevalent parasite in the area, factors
that facilitate infection.
Situational analysis for community health includes:
1. Political and administrative rules
2. Demographic features 3. Economic resources
4. Social stratification and relations
5. Leadership pattern and its influence.
6. Community organizations and their functions and activities
7. Cultural facets or traditions
8. Health, nutrition, and sanitation levels 9.Education levels
The sources of information are various: from records, books, previous
researches, surveys (focus group, in depth interview), census, internet,
experts etc.
2- What can we do? formulation of the vision, mission, goals, objectives.
Vision is a broad scope for the importance of the selected problem. Mission
is the goals we dream to achieve. Goals are broad statements of what we
are going to accomplish. Objectives must be measurable, specific,
attainable, applicable, reliable and time limited statements that define what
we are going to achieve. Example: to decrease infant mortality is a goal.

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To decrease post neonatal mortality rate from 25 to 15 per 1000 in Egypt at
the year 2010 is an objective.
3- How can we reach these objectives? By planning.(or preparation) Plan is
the details of answers to how, who, where, when, which etc.the objectives
can be reached. In other words what are the activities that must be done, how
to execute, who will do what, what are the available resources (man, money,
materials, time). Planning is to think well before doing. In the planning stage
we can prioritize objectives if we have no enough time, money or equipment.
Priority setting is not easy. There must be objective criteria to be respected
for selection. The prime objective should be SMART as we previously
mentioned and it must be acceptable by consumer, should serve large sector
of them, satisfy their needs. Priority should be within policy, ethics and law.
It should be effective for health (do an improvement) and cope with the
available resources and at the same time can cope with obstacles.
Types of plans:short plan for 1 to 5 years.Long plan is for more than 5 years.
(1) Allocation plan: (or strategic plan) to prepare objectives, setting
priority, preparing resources as man power, money, materials,
determine time needed etc.
(2) Action plan deals with assignment of hierarchy of employee, the
relation between teams, co-ordination, supervision methods, how to
do monitoring and evaluation.
Levels of population based planning:
• Ministry of Health and Population (MOHP) is concerned with the
planning at the country level.
• Health Directorate is concerned with planning at the governorate level.
• Health District is concerned with planning at the district level.
• Community based planning: Concerned with planning for the
catchments area at the health unit level (as field training of students).
4- How to activate the plan? Implementation (execution, to do, to act, to
perform): to make plan real. Can be preceded by pilot test, to test the success
of the plan before actual performance of the whole plan. Through this pilot
we can detect obstacles or defects in the plan to be repaired. Every member
sharing in the plan should perform his task properly, within stated time, with
the available resources. Supervision: is to make sure that the staff perform
their duties effectively. It means that a supervisor helps and guides the staff
and trains them as necessary in such a way that they become more competent
and keep the standard of work.
Objectives of supervision:
-To maintain the expected quantity and quality of a health team work.
-To assess the performance of team members.

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-To identify some causes of work deficiency, e.g. insufficiency of resources,
lack of training, lack of motivation of employees, personal problems, unclear
job descriptions......
-To help resolve dispute among team members.
-To help with personal problems.
-To train (On-the-job training)
Supervision methods: Observation checklist, record and reports review
5- Do I reach my stated objectives? Do I succeed to solve the problem? =
Evaluation: is to assess effectiveness of the plan objectives. Evaluation can
be done all through processes or at the end of the program or at mid and end
etc. It can be done by calculating indicators, opinion of experts, customer
opinion, on job owner opinion (workers). Evaluation should not be
subjective. All aspects should be evaluated (plan, time, effort, performance,
cost/benefit).
Evaluation process should answer: is that work succeeded? Can it be
repeated? Who evaluates? How to evaluate? When? What to evaluate?
Failure can be positive if we reach to its causes in order not to get through
those faults again. The perfect is the plan the better will be the outcome.
Success is not the end, but sustainability of success is needed.
Management cycle can be summarized in the following steps:
Situation analysis
evaluate(check) Plan
Do(perform,implement)
Therefore planning function includes:
1. Situation analysis.
2. Problem identification and priority setting.
3. Objective setting.
4. Selection of alternative solutions/interventions.
5. Planning for resources.
6. Planning for monitoring and evaluation.
7. Planning for sustainability.
Criteria for selecting priority problems on community basis
1-The extent of the problem (prevalence, incidence rates).

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2- Seriousness of the problem which has four main components:
* Urgency: Some problems require a rapid response in order to prevent the
spread of the problem or death e.g. contaminated food, or radioactive waste.
* Severity: This is measured by immediate effects e.g. high mortality rates,
or late sequels in the form of complications or handicapping conditions.
* Economic costs should include the costs of medical expenses, public
services and prevention programs to the community.
* Impact on others: communicable disease control remains an important
priority; however, other problems include water and air pollution, passive
smoking, ..etc.
3-Effect on economy and productivity, and other socio-economic
implications.
4-Availability of cheap feasible technologies for prevention and control
5-Single, or multi-sectoral approach, and the feasibility of implementation
and monitoring of the program.
6-Time required for achieving visible results.
At the end of this step it should be clear what are the priority problems to
be dealt with first, among who, and where.
QUALITY MANAGEMENT
Objectives:
1- Define quality
2- Explain the criteria of quality in health care
3- Describe quality improvement cycle
Definition of quality: Quality is the degree of adherence to pre-established
criteria or standards.Is to do the right thing right at the first time in the planed
time.
Criteria of quality in health care:
1- Appropriateness: refers to the balance between user's needs and the
capacity of the system from the technical and materialistic aspects. (It is
equivalent to functional accessibility).
2- Accessibility: Four elements are important
2-1. Physical accessibility which means that the service is located within
reach of individuals walking or by using transport.
2-2.Financial / economic accessibility is the affordability of the cost of
service.
2-3.Cultural accessibility is the acceptability of the service by the clients.
2-4.Functional accessibility means that the right kind of care is available to
those who need it whenever they need it.

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3- Effectiveness: refers to the degree to which care is provided in correct
manner to achieve the desired outcome or how successful it was to meet
the desired objectives and the patient needs.
Effectiveness can be measured for community health programs; in this
case it estimates success in decreasing morbidity and mortality, coverage
of all health services i.e. prevention and control.
4- Equity: refers to fairness in dealing with the clients.
5- Efficiency: refers to the best use of resources to minimize cost and
achieve cost containment.
6- Support to health care providers at all levels they need economic and
social support to motivate good work.
7- Acceptability: A health care system should be acceptable and
attractive to its users.
8- Continuity: is the harmony and integrity of delivery of care at
different levels. Clients are provided with comprehensive, integrated
care, without interruption. Health care is ongoing at the levels of first
contact with health services (PHCC), referral service, follow up is
another aspect of continuity, which necessitates better record-keeping
and information regarding the patient or services.
9- Respect and Caring: The degree to which patients are involved in the
decision and the provider’s reaction to the patient needs and
expectations.
10-Competency: The degree to which practitioner adheres to professional
standards of care and practice. It refers to skills and actual
performance of health providers
11- Safety: ensures minimizing risks of injury and harmful side effects to
health services delivery to patients and also to health provider. i.e
patient (free of infection) should not be infected because of admission
to hospital. Also physicians should not get infection from patients.
Steps for quality improvement
1. Develop a plan with SMART objectives for improvement of service
2. Set standards which include:
• practice guidelines
• administrative procedure, clear rules and regulations
• Specifications, distribution of responsibilities.
• performance standards in relation to time and resources
3. Communicate standards for the workers.
4. Monitoring of implementation; continuous supervision.
5. Identify problems, analyze each problem to identify its root causes (by
Fish-bone diagram) and put priorities to these problems to be solved
6. Choosing a team to solve the problem

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7. Develop solutions and actions for quality improvement.
8. Implement and evaluate the quality improvement efforts.
9. If succeeded repeat the cycle again in another area.
Example: one of the objectives of surgical departments is to prevent post
operative infection. All surgery departments have rules and standards for the
performance of surgeons and nurses in pre operative, intra operative and in
yard after surgery. Infection rate of certain department was 25% (high). This
is a problem to be improved. Analysis of the problem revealed that the staff
does not follow the rules for proper sterilization. The head of department
puts an objective to decrease the infection rate to 0% within 6 months.
Distribute responsibilities on all the department team. All the needed
resources were available (disposable gloves, sterilization techniques,
antiseptic solutions etc). He disseminates the new standards on all staff, hang
regulatory rules every where in the department. Staff begins to follow the
strict rules for performance. He supervises their action in the operative room,
nurse's behavior in sterilization of instruments etc. One of the staff is
responsible for detection and recording of infection. Analysis of records
reveled that there was still 5% post operative infection rate. This solution
succeeds in decreasing the infection rate but does not reach the objective. He
chooses a team for analysis of cause of failure to reach 0% infection rate.
They analyze all possible causes and find that the antiseptic measures done
for patient skin before operation is still deficient. They put new standard
technique, disseminate it to nurses, apply it, supervised and calculate the
infection rate again. The infection rate reaches 0% , they recommend this
technique to be applied in all surgical departments. (If infection is still
present, try other solution by analysis of all processes to find any defect,
suggest an improvement, plan for it, act, evaluate and so on).
TOTAL QUALITY MANAGEMENT TQM
• Total quality management is a way of strict management of
business/service's processes and at every stage to ensure complete customer
satisfaction, internally and externally, the first time and every time.
• TQM focuses on preventive measures, not detection of problems and
correction i.e. proactive rather than reactive actions.
• TQM is to ensure quality standards from the beginning and in every step
(planning, implementation, supervision, output). Put possibility of any thing
that can occur and causes failure of reaching the standards, change in plan to
prevent this threat.
Example: to make TQM of teaching in the faculty of medicine we should
select students by quality standards, study contents of curricula of different
subjects carefully, correct to verify pre stated objectives according to national
or international standards, select staff carefully, define responsibility to every

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one in the teaching process. Supply of place, materials and resources needed
in the teaching process. Continuous supervision and assessment for teaching
process and evaluation by final exam result, student satisfaction, student
standard in relation to similar medical schools.
HEALTH ECONOMICS
Objectives :
1. Define the major aspects of health economics
2. Describe financing mechanisms
3. Understand cost-effectiveness analysis
• Economics is the study of how people and society choose to employ
resources, usually scarce / limited resources. Economics analyze the
costs and benefits.
• Health economics is the application of economic principles to the
health field. It is an important component of health management.
Major aspects of Health Economics
I- Financing Health Care: There are many methods for Financing Health
Services as:
1.Governmental financing. The government resources come from tax
resources (income tax and indirect taxes). The percentage allocated to the
health sector varies from one country to the other.
2.User fees (user’s out of pocket charges).
3.Health insurance: is based on the concept of risk-sharing / cost-sharing. It
involves three parties:
• The insurer
• The health care provider, paid by the insurer
• The patient who usually pays a premium and co-payment for each
service received
Separation of finance from service delivery is a new strategy in Health
Reform in Egypt
4. Non-governmental organization (NGO's) and the donations.
Criteria of evaluation of the financing system
Equity: People should be able to utilize health care when they are in need to
do so. Equity in finance: According to ability to pay (poor pays minimum fee
and rich shares by larger fees).
Equity in delivery of health care: Health care distributed equally on all areas
according to the need of population, rather than their ability to pay.

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Efficiency: A measure of how well resources are used to produce the desired
results. It relates inputs to outputs of the health service. Is the health service I
got proportional to what I pay?
Sustainability: A health service is sustainable when operated by an
organizational system with long term ability to mobilize and allocate
sufficient resources despite changes in the outside environment
Quality: Quality of care is the extent to which actual care is conforming with
preset criteria or standards for good care.
II- Cost Analysis: Classification of cost by inputs:
• Category I = Fixed cost
This category covers salaries and wages.
• Category II = Direct cost
This category covers operational cost including drugs, supplies, rents,
petrol for vehicles, maintenance, water, electricity.............
• Category III = Capital cost
This category covers durable assets with a life more than one year. It
includes buildings ( owned not rented), and equipment.
In some countries there is category IV used for payment of loans or
liabilities.
III-Cost-Effectiveness: Effectiveness is a measure of the extent to which
objectives are achieved. Cost-effectiveness analysis (CEA) is an analytical
tool to help decision makers, assess and compare the costs and effectiveness
of alternative ways of achieving an objective. It is a technique to identify the
most effective use of limited resources. CEA is also used in evaluation of the
interventions. The results of CEA are used for re-planning. Example: the
most cost effective line of treatment of gastroenteritis and dehydration is the
oral therapy by rehydration salts. It is cheap and at the same time effective.
Some of the indicators used to measure the effectiveness of health
improvement in relation to cost
• Morbidity reduction: decreased incidence or prevalence of disease
• The number of days with disability prevented: if the treatment can
decrease or prevent any number of days with disability or impairment.
• Mortality reduction which can be quantified as the number of averted
deaths; can be adjusted to measure the potential years of life gained.
• DALYs for a disease are the sum of the years of life lost (YLL) due to
premature mortality in a population and the years lost due to disability
(YLD) for cases of certain health condition.
IV-Cost containment:
• Cost containment refers to the "measures taken to reduce the rate of
growth of expenditure".

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Causes of rise of health care spending
- Demographic changes producing populations that are older on average.
-A changing pattern of disease towards chronic illness.
-Advances in medical technology and highly sophisticated equipment.
-Rising public and professional expectations connected with technological
advances.
-Increased utilization of curative health services rather than self or
community care.
- Higher wages and salaries.
-Higher cost for drugs and supplies.
-Lack of cost-conscious behavior by providers.
-Insurance coverage introducing a third party in the health financing system
(over-utilization & increased cost).
-Inefficiency and inadequate management of resources. Overstuffing,health
workers are badly deployed and supervised, hospital beds are underutilized.
Examples of the public health activities that are highly cost-effective:
• Immunization : in the first year of life would have the highest cost-
effectiveness of any health measure available in the world today.
• School-based health services, screening and immunization.
• Health information for family planning and nutrition.
• Program to reduce tobacco & alcohol consumption.
• Regulatory action and limited public investments to improve
household environment.
• Health education for Aids prevention.
• Primary health care is cost effective than building five star hospital.
• Using head helmets to prevent complications of accidents.
Measures for decreasing costs:
1.Identify the most cost-effective actions and re-orient the resources towards
them.
2.Training of managers at all levels: Policy level, top / middle management
and health care providers on rules of health economics.
3. More appropriate technology in the more costly services and rationalized
use of expensive technology as MRI, CT scan.
4.Rationalized use of drugs.
5.The health insurance systems need to be reformed for better use of
resources.