Mr. Moffat Nakedi, of the Ministry of Health in Botswana, contributed useful ideas to this study. Health workers according to the type of health sector and involvement in planning 161 Table 4.33: Respondents of health workers according to the opinion of the extent to which remuneration is equal 162.
CHAPTER ONE
PUBLIC SECTOR HEALTH POLICY IN BOTSWANA: OVERVIEW
- Introduction
- Background to provision of national health services
- Botswana Ministry of Health Departments: Headquarters a) Department of Clinical Services
- Vision 2016
- Challenge posed by HIV/AIDS Scourge
- Government approach to public sector policy
- Botswana position on public-private partnership (PPP) with specific reference to health service provision
- Context of efficiency and effectiveness with regard to models of public/private mixes
- General public sector management challenges
- Current Botswana health policy
- Performance Improvement Initiatives in Botswana
- Total Quality Management
- Work Improvement Teams
- Performance Management System (PMS)
The workshop participants noted that the public sector in Africa was at the center of the individual countries' development. In Botswana, the majority of public service employees leave employment through resignations.
Performance Reviews 5. Procedures for Sustaining
Through PMS, government capacity had to be increased at the various organizational levels of the government service. The Performance Management System Manual for the Botswana Public Service (2001:2) describes the Performance Management System as 'the approach adopted by the Botswana Public Service to achieve the objectives of the National Development Plans (NDP) and Vision 2016.' The PMS approach was explained in the manual as consistent with the performance improvement methodology of 'Plan-Do-Study-Act (PDSA)', whereby the outputs of PMS correspond to the PDSA.
Annual Performance Plans 1. Strategic Plan
Performance reviews, to be conducted quarterly, were intended to serve as an objective assessment for employees, and the process was to be accompanied by a performance-based pay system in which individual achievements were rewarded. PMS was seen as facilitating the ability to improve individual and organizational performance systematically.
Measurement Charts Plan
- Performance Based Reward System (PBRS)
- Relationship of the performance improvement initiatives
PBRS was introduced in the Botswana public service in the year 2000 to provide a link between the Performance Management System (PMS) and individual pursuit of performance based on objectives set annually. The relationship of the performance improvement initiatives is complementary as it aims to improve the effectiveness and efficiency of health service delivery.
TQM a
PBRS
- Linkage of performance improvement initiatives to the Vision 2016
- Health service delivery challenges in Botswana
- Significance of evidence-based health policy and practice in Botswana
- Introduction to the statement of the problem
- Statement of the problem
- Three-fold hypothesis: To what extent is it unique to Botswana?
- Broad objective
- Specific objectives
- Research questions
- Relationship of broad objective to the hypotheses
- Chapter summary
The main interest of the study focused on the process of introducing and implementing performance improvement initiatives in the health sector of Botswana. To evaluate performance improvement initiatives introduced to improve the quality of health service delivery in the Botswana health sector.
CHAPTER TWO
- Effectiveness, efficiency and productivity
- Effectiveness
- Efficiency
- Productivity
- Relationship between efficiency, effectiveness and productivity
- Empowerment
- Variations of Power
- Employee empowerment
- Patient empowerment
- Equity
- Equity in relation to health service employees
- Equity in relation to health care consumers
- Problem of deciding on morally relevant values
- Importance of organisational performance in health sector
- Worldwide managerial reform based on efficiency, effectiveness, empowerment and employment equity
- Efficiency and effectiveness
- Employment equity
- Employee empowerment
- Effect of vested interests on the management of health services
- Health governance
- Value of the research
- Literature review
- Introduction
- Comment on the health services management research traditions
- Chapter summary
In South Africa, Philip (2004) observed that the country is one of the most inequitable societies in the world in terms of distribution of health resources. Andreychuk (2007:23) stated that the overall conclusion of the committee was that employment equity is not yet a reality in the Canadian federal public service and that "the government is not moving fast enough and the situation needs to be corrected." The values of different stakeholders may conflict, so design may require compromise.
The value of the research lies in the fact that healthcare is generally understood as a foundation without which activities in other social sectors cannot be fully implemented. The importance of leadership in implementing performance improvement strategies is confirmed by Healthcare Financial Management (2004:2), which states that “leaders must facilitate the path to performance improvement…” The results of studies reported by Rawlins et al. , Suh, et al, and Furth have similarities in that they emphasized the importance of the role of management, although they focused on different managerial aspects. Sanchez et al (2005) conducted a descriptive study of the implementation of the EFQM excellence model in a Basque health service in Spain.
The methodology used was an examination of 'the health, performance frameworks, indicator quality and management documents...' (Arah 2003:3). In Australia, effectiveness was viewed as accommodating “the domains of quality, appropriateness, accessibility and timeliness” (Arah 2003:11).
CHAPTER THREE
RESEARCH DESIGN AND METHODOLOGY
- Introduction
- Methodological approach
- Areas of focus and study variables
- Data collection techniques
- Primary sources of data .1 Interviews
- Sampling
- Determination of sample size for health institutions
- Selection of the random start in each stratum
- List of hospitals selected for inclusion in the study
- Selection of respondents (staff)
- Purpose of selecting the stakeholders at the policy, implementation and consumer levels
- Selection of respondents among policy makers
The only controls were limited to subject selection, data collection and analysis. The areas of focus explored were guided by the objectives of the study. Questionnaires were personally delivered to the secretaries of policy makers in the ministry.
The selection of hospitals to be included in the study was done via Stratified Random Sampling. To facilitate the selection of government hospitals to be included in the study, a random number table was used. Five percent (5%) of the total number of patients in each hospital were systematically selected to be interviewed.
TMT)
- Selection of respondents among health workers
- Sample distribution of health sector performance improvement initiatives policy implementers by institution and professional stratum
- Selection of respondents (patients)
- Reasons for choosing stratified random sampling
- Plan for analysis and interpretation
- Introduction
- Brief comparison of computer-assisted qualitative data analysis software (CAQDAS)
- Ethical considerations
- Strengths and weaknesses of research design and methodology
- Limitations of the study
- Chapter summary
Stratified random sampling made it easier to understand the subgroups or strata in the population. To facilitate the analysis, a description of the informants has been made in the data processing as well as in the reporting of the findings. The interpretation of the data aimed to make the data more coherent while remaining truthful.
The selection of the hospitals for inclusion in the study was by stratified random sampling. The weakness of the methodology used in the study is the difficulty in generalizing the conclusions of the findings to a larger setting due to the smaller samples used, as they can be considered unrepresentative. The methodology adopted minimized bias in the selection of the respondents and health facilities for inclusion in the study.
CHAPTER FOUR 4. PRESENTATION OF RESULTS
Introduction
The overall response rates for senior management, health professionals, patients and community members are indicated in Table 4.1. Apparently it was not possible to obtain all the questionnaires from the senior management in the Ministry of Health due to their busy schedules. It was also not possible to conduct all 13 targeted Focus Group discussions due to logistical problems.
The selection of staff for questionnaires and interviews was made on the basis of a sample of staff using a staff list established on the day of the visit, with the help of supervisors, in each institution to ensure that those selected were on duty. The fact that all those sampled were on duty on the days the investigator visited the hospitals contributed to the high response rate.
Data presentation on policy makers
Top management participates in the decisions about policy adoption and passes it on to the coordinators who link it directly to the implementers, in this case the healthcare workers in hospitals. The Clinical Services house the medical and nursing staff, who are the main implementers of healthcare policy. The department includes pharmaceutical services, which are one of many medical support services that participated in the assessment of the performance improvement initiatives (PIIs) in this study.
The policy makers were assessed for the length of their services in relation to the PIIs launched so far to improve performance within the line ministries. The respondents also confirmed that the PIIs known to them have a monitoring mechanism which is used to review the exercise from time to time.
Effectiveness of PIIs towards delivery of quality health services
The respondents identified the weaknesses of the PIIs as weak monitoring and evaluation mechanisms, unclear setting of objectives, poor staff training on the implementation of the PIIs and a lack of resources to follow up their implementation.
Empowerment of implementers by policy makers
Internal equity in relation to health workers (initiative implementers)
As noted in table 4.10, three (3) of the respondents were of the opinion that the implementers were poorly paid.
Findings on assessment of PIIs among health worker implementers
- Demographic Data
- Health workers knowledge and awareness of PIIs
Of the 13 hospitals, 10 (77%) were government health facilities serving the public, while the rest were privately owned. Of the 65 health workers selected for the study, 54 (83%) were public service workers and 38 (59%) were stationed in urban localities. The majority of health workers (31%) were in the 30 to 39 age group, followed by the younger generation at just over a quarter (26%) of the sample.
4 doctors who manage some institutions, 2 pharmacists and 1 laboratory technician were also selected for interviews in this study. The majority of healthcare professionals surveyed (83) were aware of the PBRS policy used to improve workplace performance in the public sector, while those in the private sector used a variety of other initiatives. A greater proportion (83) of health workers were civil servants who were aware of PBRS as a performance improvement initiative.
Distribution of health worker respondents by source of PIIs knowledge (n=65)
- Knowledge of monitoring and evaluation mechanisms for PIIs
- Assessment of PIIs effectiveness from the point of view of implementer respondents
- Efficiency of health service delivery through PIIs
- Empowerment of health workers for service delivery
- Equity in rewarding of health workers
Over half (54%) of healthcare workers surveyed believed that the quality of healthcare provided at their healthcare facilities had improved over the years. About a quarter (25%) attributed the lack of improvement in the quality of health services to poor payment of workers and poor working conditions. The majority of health workers surveyed suggested more effective training for implementers (31%), which should be supported by regular follow-up plans (23%) in both the private and public health sectors.
The assessment of health professionals by type of health sector shows that both the public and private health sectors mentioned the need for more effective PII training to increase their usefulness (private = 27%, public = 32%). All (65) healthcare professionals surveyed were formally evaluated four times each year to assess their achievement of set goals. More than half (55%) of the health workers included in this study were not involved in health service planning.
Health worker respondents by satisfaction with remuneration (n=65)
- Performance improvement initiatives assessment through interviews
Almost three-quarters (74%) of the total study sample expressed frustration with low wages (31%), poor service (18.5%) and working conditions (10.8%), and poor working conditions (14%) as the main ones. reasons for unfairly rewarding their work. It was found that 7.7% of the respondents, on the other hand, enjoyed good working conditions, and 6% were satisfied with the amount of their pay. Healthcare professionals have a common feeling of dissatisfaction with their pay packages in both the public and private healthcare sectors.
Patients
Effectiveness and efficiency
Factors patients disliked in health services received
Main health sector negative attributes identified by staff
Perceptions of patients on level of community satisfaction with health services
Patients were answering the question: "Is your community satisfied with the way they are treated by health workers when they visit health facilities to seek treatment?" Seventy-three percent (73%) of public patients gave a positive assessment of services, while all 16 patients who had access to private health sector services gave a positive assessment.
Perceptions of patients regarding community satisfaction with health services
Patients' rating of health services provided according to type of hospitals
Empowerment
Measures taken by patients to deal with institutional problems by age group
- Equity
- Performance Improvement Initiatives Assessment through Focus Group Discussion: Community Members
- Deborah Retief Memorial Hospital (DRMH)
- Gantsi Primary Hospital
- Maun Hospital
- Orapa Mine Hospital
- Princess Marina Hospital
- Sekgoma Memorial Hospital
- Chapter summary
Hospital good condition of functional facilities 9 out of 12 Availability of essential medicines and logistics 9 out of 12 Availability of essential manpower 7 out of 12 Expected comprehensive service package 5 out of 12. Hospital good condition of functional facilities 9 out of 10 Availability of essential medicines and logistics 8 out of 10 Availability of essential manpower 3 out of 10 Expected comprehensive package of services 5 out of 10. Hospital good condition of functional facilities 9 out of 10 Availability of essential medicines and logistics 9 out of 10 Availability of essential manpower 4 out of 10 Expected expanded package of services 5 out of 10 * Static.
Community involvement in health service planning 1 out of 10 Community connection to health service delivery. financing. Hospital's Good Condition of Functional Facilities 7 out of 8 Availability of Essential Medicines and Logistics 7 out of 8 Availability of Essential Manpower 7 out of 8 Expected Comprehensive Service Package 6 out of 8 Hospital's Good Condition of Functional Facilities 7 out of 8 Availability of Essential Medicines and logistics 5 out of 8 Availability of essential labor 6 out of 8 Expected comprehensive service package 6 out of 8 * Improvement.
CHAPTER FIVE
5 CRITICAL ANALYSIS OF THE RESEARCH PROCESS
Introduction
