PBRS
1.16 Introduction to the statement of the problem
Assumptions about conditions necessary for successful implementation of performance improvement initiatives need to be realistic. The new initiatives needed to be matched with the specific conditions of the health institutions in Botswana in order to attune the initiatives to the environmental reality or culture of the institutions so as to enhance the chances of success. The introduction of the initiatives was not an end in itself but a means to an end which was to improve customer satisfaction, a mission achievable through the generation of creative ideas, not mere replication of best practices. It was borne in mind in this study that the creation of much activity, such as the establishment of various teams in institutional departments or units, with respect to the new initiatives, was not necessarily an indicator of successful implementation. The value added by the initiatives to the work output counted more than the mere process of introducing the initiatives.
The study assessed evidence that suggested the failure by health service managements in the health sector to think critically about the requisite conditions for effective implementation of performance improvement initiatives. Such assessment of unrealistic expectations regarding the initiatives shed light on institutional decisions taken to either continue with initiatives or lose interest in them, after some period of intense introductory activity. The literature indicates that in instances where particular initiatives are deemed to have fallen short of meeting expectations the problem does not always lie in faults inherent to the initiatives themselves but in the institutions embracing initiatives without a rigorous interrogation of the environment in which they were to be applied. In such cases, a cycle of implementing different initiatives would begin anew, making the attempts at introducing subsequent improvements more difficult. The results of such short-comings are cynicism in the employees, a loss of management credibility and, overall, a wasted effort and resources.
In identifying the main problem hindering the successful implementation of performance improvement initiatives in the Botswana health service, the investigator has benefited from having worked in the country‟s public health sector in a managerial capacity over a ten year period since 1999. The investigator‟s role in the Ministry of Health Headquarters was to coordinate administrative and personnel management functions as well as liaising with health partners of the Ministry, such as donor organisations. Besides information gleaned informally, the investigator is aware of documentation that abounds on customer satisfaction surveys to indicate that there is a culture of indifference amongst health sector employees, more notably in the public health sector. The Botswana President, Festus Mogae, (cited in Hope, Sr., 2000) stated in a 1993 introductory speech to the Performance Management System (PMS) initiative, that there was inadequate strategic management by managers in Government Ministries and Departments. The political leadership through the Office of the President was instrumental in the 1990s in introducing management initiatives or strategies that were meant to improve productivity at the work-place. In the public sector, such initiatives included Total Quality Management (TQM), Work Improvement Teams (WITS) and PMS. In spite of these initiatives, there has not been much evidence to suggest an improvement in productivity compared to the period before their introduction. Hope, Sr.
(2000) observed that despite the reforms, some public service institutions still perform poorly.
1.16.2 Statement of the problem
This research will assess the perceptions that selected respondents in the health sector have about the extent to which performance improvement initiatives are effectively and efficiently implemented in the provision of health services in Botswana. A significant amount of resources are expended in the Botswana health sector to address national health needs with the aim of improving the health status of the nation. Part of this expenditure includes the implementation of performance improvement initiatives.
During NDP 8 (1997-2003), for example, expenditure on the health sector represented 10.3% of the government‟s total expenditure on development (WHO Country Cooperation Strategy: Botswana - 2003- 2007). It is, however, not clear the extent to which more resource allocation translates into quality health care. A Government of Botswana Customer Satisfaction Survey for the Public Service (2005) revealed that the Ministry of Health recorded the second lowest overall satisfaction rating in the public service.
The impact on health indicators depends on numerous factors such as the efficiency and effectiveness with which health programmes are implemented. It is, therefore, necessary to ascertain within the Botswana context the major hindrances to the effective implementation of performance improvement initiatives in the health sector.
There is concern in various quarters about the low level of productivity in the Botswana public service in general and the health sector in particular. This has negative implications for the efficiency and effectiveness with which services and goods are produced in the health sector. Molale (2006), at a seminar at which the performance of the public service was discussed, noted in his capacity as the Permanent Secretary to the President, that some of the challenges that the political leadership was facing included poor delivery of public services, poor implementation of projects and programmes, low productivity and poor work performance in general. He also stated that Government was having to deal with public accusations of its perceived insensitivity to public demands, needs and aspirations coupled with lack of accountability and discipline in the provision of services.
Chirairo (2008), following a survey conducted by EOH Consulting and Credmark EDC, observes that the public, private and parastatal sectors in Botswana were facing challenges of implementing change for the improvement of performance and service delivery. He noted that performance reforms introduced by the Government followed a realisation that unless there was an improvement in service delivery, Government departments and the private sector would continually face challenges in fulfilling their mandates.
Specifically, service delivery challenges in the public service were said to be characterised by a slow responsiveness to customer needs, low productivity levels, poor work ethic, inadequate and irregular performance reviews, and rewarding inappropriate behaviours. The Consultants concluded that it was necessary that a culture change programme be defined and implemented in order to entrench high performance and service.
Marobela (2008) states that reforms to improve productivity were justified on the premise of poor performance by public sector workers with managers ever engaged in efforts to change workers attitudes and perceptions about the quality of their work. There was still much room for the improvement of productivity then, long after the 2002 productivity week in Francistown, the second city of Botswana, whose theme was „efficiency and effectiveness: the smart choice to customer satisfaction.‟ The NDP9 (2004-2009) stated that one of the challenges faced by the government was the as yet unmet public expectation for more improved services since the introduction of PMS.
Official statements made at various national work-related awards have indicated that productivity improvement, which is critical to the realisation of the Vision 2016 ideals, has continued to be elusive over the years. There has been general acknowledgement that much remains to be done in productivity improvement, hence, customer service has been compromised. It is notable that although a number of performance improvement initiatives have been introduced in the Botswana public sector, the health
service organisations included, what is not clear is the extent to which there is an uptake of the initiatives by the health staff and the way in which they contribute to productivity in the public health sector.
The study process involved an assessment of the evidential base for sustaining the three-fold hypothesis which emerges from the assumptions based on the implications of the statement of the problem in section 1.16.2 that is;
i) performance improvement initiatives were imposed in a top-down manner in the Botswana health sector with the noble belief that they were valuable in contributing towards the achievement of the goals of Vision 2016;
ii) there is limited knowledge on the part of the health workers at the operational level regarding the usefulness of the performance improvement initiatives and this contributes to their low uptake of the initiatives in the Botswana health sector
iii) the frequency of complaints by health services consumers is a reflection of the poor quality of health services provided in the health sector in Botswana.
The assumptions, defined by Abdellah and Levine (1986:122) as „statements whose correctness or validity is taken for granted‟ were instrumental in shaping the course of this study.
The study assessed the quality of evidence at the two levels of health sector policy formulation, implementation and evaluation, cross-cutting four key quality indicators of efficiency, effectiveness, empowerment and equity. The empirical study assessed the perception of these concepts or indicators held by staff and by patients in the health sector. This constituted the model for the research. The main focus of the study was on understanding the experiences of respondents in the study in their context or natural setting. It was necessary to define three closely related terms, that is, productivity, efficiency, and effectiveness as well as the context of the terms „empowerment‟ and „equity‟ in this study. The main interest of the study centred on the process of introducing and implementing performance improvement initiatives in the Botswana health sector.
1.16.3 Three-fold hypothesis: To what extent is it unique to Botswana?
Socio-economic development in African countries, which attained their national independence in the late 1950s and 1960s, had depended on the effectiveness of the public sector in the different countries to succeed. Writers such as Garnham and Haque, (cited in Ayee, 2005) state, however, that generally the public sector was not able to perform its function effectively due, amongst other reasons, to its indifference towards public needs and demands.
The literature indicates that most of the strategies undertaken by African states to improve the performance of their public services have not been able to achieve desired results due to constraints of a political, historical, economic, institutional and cultural nature. Following studies in Sub-Saharan Africa, Kuada (2003) notes that scholars have emphasised the importance of context, especially the cultural context, to the behaviour of managers and administrators in the public sector. He noted that indications are that development is constrained rather than supported by the social structures and relationships within the traditional societies. From a cultural perspective, studies of the behaviour of African managers showed a lack of the generally accepted principles of good management with evidence of wanton indifference to organisational performance, poor strategic management and unsatisfactory productivity levels. The economic success of Botswana, which has been singled out as one of the most remarkable in Africa, has been criticised in some circles as having been beneficial to a few elites at the expense of the majority.
Unfavourable government policies, poor management practices and negative employee attitudes all combine to support the view of an African continent with a public sector that has a culture of poor implementation of performance improvement initiatives. The framework for the hypotheses in this study is, therefore, not unique to Botswana even though it is nuanced by the specific cultural features of the Batswana.