District health systems have been promoted as a way to provide responsive services that meet the needs of poor communities. However, failure to deliver quality services in low and middle income countries is not only due to financial constraints, but often insufficient leadership capacity among district managers. Due to the legacy of apartheid, many managers have insufficient expertise necessary for their role, and use top down approaches that discourage collective leadership and innovation. Combined with a huge patient burden due to the HIV & TB epidemics, the result is low staff motivation, high absenteeism, burnout, and sometimes physical abuse of patients by front line staff.
Since 2009, the National Department of Health has initiated wide ranging policies to revitalise PHC, and so has increased the demands placed on the district health system. Given the limited financial resources, and that salaries are nearly 70% of health care expenditure, senior decision-makers are asking what strategies will effectively strengthen the leadership capacity of PHC managers, and hence improve the performance of the health workforce.
While there is consensus on the importance of developing individual and collective leadership capacity, there is little agreement on what strategies are most effective to this end. Little of the available evidence is from low and middle income countries. Although the study of organisations and their development (OD) is a well-established discipline, collaboration between health researchers in low and middle income countries, and colleagues in the field of OD, has been lacking.
CHP is involved in a three year study known as the ‘Siyaqinisa’ (We strengthen together) District Learning site to support the Sedibeng District Management with an OD process involving researchers and colleagues to strengthen leadership capacity to improve staff engagement and team effectiveness.
In the first phase, researchers conducted a situational analysis to understand existing leadership practices. Together with the Sedibeng Team, the second phase is focusing on activities which include developing and facilitating workshops for teams of staff to develop individual capacity (i.e. increased self-awareness, enhanced interpersonal relationships, and change resilience) and collective leadership capacity (that enables participation, collective thinking, constructive conflict, reflexivity and alignment to performance outcomes). Some OD techniques are highlighted in the table below:
Table 1: Some OD techniques we will use in developing leadership capacity
The thinking environment
Focuses on increasing the quality of our attention to improve the quality of other people’s thinking, and hence our collective action;
Identifies what is working well, analyzing why it is working well and then doing more of it.
Exploring the uncertainties and questions that no one has answers to, so that the team or organization begins to think together;
The analysis of a system to identify strategies for improving day-to-day operations;
The work will be extended to other teams including corporate services staff, health programme managers, local area managers and clinic managers. Areas that have been identified as requiring development are:
a) collaboration between corporate services staff and health programmes managers to strengthen planning and implementation of service improvement activities;
b) collaboration between health programme managers to allow the provision of integrated care. Additional topics for task specific training are strengthening budget submissions to the province, and routine human resource practices.