The purpose of this research was to investigate the alignment of the public health goals and strategies of the Ministry of Health and Social Welfare (MOSHW) to the performance of Public Health Officers (PHO) in the Gambia. This chapter covers the conclusions and suggestions for the government, the ministry of health, the program units, the RHTs, the public health cadre, and human resource professionals based on the findings of the research.
Conclusions
The objectives of this research were to find out the extent and effect of alignment of the job of PHOs to the public health strategies of the MOSHW, the existence of the necessary support for PHOs to carry out their responsibilities and the current system of managing the performance of PHOs. Thus, the results of the research are based on the aforementioned objectives.
The Alignment of PHOs’ Job to the Strategies of MOSHW
There were variations between the contents of the strategy of the MOSHW and the responsibilities of PHOs as well as the contents of the Health Policy-related documents. There was no systematic procedure of performance planning for PHOs where their duties and responsibilities would be designed based on the strategy. The requirements of the field which entailed the job of PHOs were usually gained from what they learned from trainings institutions for public health. Performance standards in the form of targets were set for some aspects of the strategy and were uniform for all regions. However, these targets were neither comprehensive nor were they explicit with regards to the behaviors required to achieve them. Also, in many instances, the strategy does not specify the areas of responsibility for which the PHOs were accountable. However, the strategy has subsidiaries which are detailed extensions on almost all the five areas e.g. EPI Policy, RCH Policy, Malaria Control Policy, and the
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proposed Environmental Health Policy. Also there were documents which provided guidelines on the implementation of the various aspects of the strategy e.g. National Environment Management Act, Food Act and the Public Health Act. As such, even though the strategy of the MOSHW did not provide comprehensive details for the implementation of its contents, these documents provided details which PHOs and their supervisors could make reference to.
The Effect of Alignment on the Performance of PHOs
PHOs were doing extremely well in terms of the execution of their duties and responsibilities. This was because by and large most health facilities had only one or two PHOs who had to do all the responsibilities required of a PHO. Implementation of the public health aspect of the strategy of the ministry is tantamount to implementing several strategies within a strategy. Thus, it would be difficult if not impossible for any public health office to fully live up to the challenges of accomplishing the goals enshrined in the strategy. As a result, some PHOs were of the view that they really fell short of the demands of their offices. Another dimension to the problem was the lack of using the strategy as a reference for all public health functions. Therefore, it would not be expected for the goals of the ministry to be achieved when performance was not wholly based on it and directed towards the realization of its objectives. These might provide an explanation for why the image of PHOs was dwindling in the public domain because the people served were not impressed. There was a void in the way most people view PHOs in their duty of enforcing the various public health-related laws i.e., PHOs strive to be seen as advocates of healthy behaviors and lifestyles in people while people consider them as law enforcers who force people to change. This trend may change if the proper mechanisms were in place to serve as a guide to PHOs in dealing with the communities they serve. This is because most public health activities entail dealing
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with people. When trust is lost in the community it would be terribly hard if not impossible for public health goals to be realized.
The Existence of Necessary Support for PHOs’ Performance
PHOs need support to execute their functions. Though there was some form of support, various aspects still lacked the necessary support. Supports in terms of both environmental and personal factors were minimal. However, personal factors were found to be more available than the environmental factors. The personal factors were knowledge, capacity and motives, while the environmental factors were resources, incentives and data. Tools required for the implementation of the strategy especially those of monitoring and evaluation where found to be lacking or inconsistent with the strategy. Therefore, the results of performance on aspects which lacked adequate tools to be monitored could not be genuinely determined.
The Current System of Managing the Performance of PHOs
The performance management system of PHOs was found to be lacking in the ideal characteristics. With regards to planning for performance, PHOs as well as their supervisors were not engaged in performance planning. PHOs’ responsibilities were for the most part learned from the training institutions or gathered through experience.
Most of the responsibilities apart from EPI had no targets or standards. Therefore, the functions of the PHOs were executed not based on the ministry’s strategy.
Communication which should form the basis on which the performance management system should thrive was rare in some cases and not usually based on a predetermined criteria or standard. Similarly, measures or methods that were used to measure performance were largely not available and where available, were not linked to the strategy of the ministry. In the same vein, supervision was found to be weak in terms of how RPHOs monitor and evaluate the performance of the PHOs. In some of the regions, monthly meetings were held to serve as forums for PHOs to give reports on
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their performance. Those reports were then compared against each other to know the best performers. However, because there were no standards, those comparisons gave very minimal insight about the adequacy of performance. Also, apart from the EPI services, most other activities were recorded by PHOs in a Daily Activities’ books.
Those books were not standardized and each public health office had its own format and what was to be recorded therein was the prerogative of the PHO (the office).
Measurements and judgments based on such records would be inconsistent and might not appropriately portray the results of performance. Outcomes of such evaluations may therefore not be fair.
Suggestions
In this section, suggestions and recommendations are made for the government, the Ministry of Health and Social Welfare (MOSHW), The Regional Health Teams (RHTs), the Gambia Association of Public Health Officers (GAPHO), and researchers based on the findings of the research.
For the Government
Research related to performance management in health is scarce. Most of the research in this area is concentrated on the for-profit sector. For The Gambia and many other developing countries, human resource professionals in public sector jobs especially those in the health sector should engage in more human resource-related researches and make appropriate recommendations to improve the performance of employees. In this regard, governments should invest in research on human resource issues and in the training of more people in the field of Human Resource Development.
For The Ministry of Health (The Units)
The recommendations for the ministry include those for the units because the units are considered part of the central level which constitutes the highest level in the
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hierarchy of the ministry. Recommendations here include planning, specificity in assigning public health responsibilities, providing necessary support and collaboration.
Planning.
Planning for PHOs must involve key stakeholders such as the RHTs, the central level units, the School of Public Health, the Department of Public Health of the University of The Gambia, collaborators with health e.g., nongovernmental organizations, and most especially PHOs at health facility level. This will enable the PHOs to identify themselves with those responsibilities in the planning of which they were involved. Also, all aspects of the strategy and their modes of implementation should be key components of the curricula of institutions responsible for training PHOs. These aspects should also be the main targets when the public health students go on practicum attachments. Such measures should be instituted to ensure that all aspects of the strategy are intensively covered by students on attachment.
Specificity in assignments.
The ministry should do more to assign a PHO to handle the execution of each dimension of the strategy e.g. a PHO for EPI, a PHO for health education and promotion, a PHO for disease control, etc. This is because several dimensions have strategies of their own which are such that it can take at least a PHO to effectively implement one.
Provision of necessary support.
In collaboration with the ministry, the units should ensure the availability of the necessary support to enable PHOs implement the functions under the unit’s domain.
They should also ensure that such tools are in place to provide PHOs the required information on what is expected of performance. Tools to constantly monitor and evaluate performance and the creation of channels to facilitate communication
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between stakeholders should be ensured. PHOs as well as the RPHOs or the unit’s focal person in the region should be involved when planning for performance or designing any tool related to performance.
Increased collaboration.
The collaboration between the various program units and the regional offices should be made stronger. Each aspect of the strategy should have a focal person at the regional offices who in collaboration with the RPHO will work towards the implementation of the units’ strategies by the various PHOs. The necessary support for that implementation must also be made available to the regional officers as well as the PHOs.
For the RHTs
RHTs should ensure that all resources which PHOs need to perform are available.
For this, they should liaise with the program units to ensure that the required resources are within reach at the time they are needed. Up-to-date data on PHOs’
performance and the extent of goal attainment should always be available at the RHTs.
This can be achieved through regular performance monitoring and evaluation and the provision of feedback to both the units and PHOs. Information from such evaluations should be used to constantly check whether performance goals are achieved and to provide corrective actions in case of any deviations. Therefore, an important role of the regional offices should be to ensure the availability of all supervisory tools and the use of these tools to constantly supervise PHOs’ performance.
For the Gambia Association of Public Officers (GAPHO)
The recommendations for GAPHO as an association to which public health professionals, juniors and seniors alike subscribe include the reviewing and updating of public health documents and the provision of support for the PHOs at health facility level.
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Review and update public health documents.
The association should review and update the outdated and inconsistent documents or operational tools still being used by PHOs and standardize them across all regions. More should also be done to develop other documents and tools that will enable PHOs to perform every bit of their jobs with ease. Detailed guidelines about all performance dimensions in addition to a job description should be developed in collaboration with all stakeholders and sent to the ministry for approval. These activities can be done by none better than public health professionals.
Support PHOs at facility level.
The association has enough professionals with the skills and expertise to equip PHOs at facility level with the technical requirements of their jobs to be able to live up to the public health challenges of the twenty-first century. PHOs at facility level have the most extensive influence on changing the image of the cadre. Therefore, public health professionals anywhere in The Gambia should fulfill their commitments to the association in order to provide support to facility-level PHOs to enable them execute their functions effectively.
For Researchers
The recommendations for researchers are to conduct research on the various sub-strategies affiliated to the main strategy of MOSHW and research on other categories of health professionals.
Research on sub-strategies.
This research focused on the alignment of MOSHW’s strategy to the performance of PHOs. However, the performance dimensions in the strategy have their own sub-strategies the adoptions of which are necessary for effective implementation and achievement of strategic objectives. Therefore, further research is needed to find out how the performance of PHOs are aligned to those various
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sub-strategies e.g. the alignment of PHOs’ performance to the EPI strategy, to the RCH strategy, etc.
Research on other categories of health professionals.
For the fact that not all categories of PHOs are included, research is needed to find out about how the performance PHOs elsewhere in the MOSHW is managed.
Similarly, research on performance management as well as relevant human resource issues of other cadres of health professionals e.g. State Registered Nurses, Community Health Nurses and Pharmacists should be conducted so as to come up with recommendations for performance improvement and increased motivation.
Limitations
The availability of sub-strategies as found out from the review of documents which stemmed from the main strategy of MOSHW on which this research has been based has made the results of this research wanting in wholly explaining alignment of each component of the ministry’s strategy. Therefore, it may be necessary to conduct individual studies on alignment of each dimension of the strategy based on their respective sub-strategies to be able to find out the full extent of alignment of the performance of PHOs to the strategy of MOSHW.
This research found out about alignment by investigating how the planning, implementation and measurement of performance was done based on the strategy of the MOSHW. To know the full extent of alignment, all the specific tasks and duties of PHOs need to be known and compared against those of the strategy. Similarly, the effect of alignment as regards public image about PHOs was investigated from the perspectives of interviewees and not from the people affected by the PHOs’ services.
Therefore, this research may not fully portray the whole picture of the effect of alignment of the performance of PHOs to the strategy of MOSHW.
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