FINDINGS AND DISCUSSIONS - The Alignment of Strategy and Performance: A Study on the Current

In accordance with the research purpose, questions and framework, this chapter has been divided into three main sections. The first section attempts to explain the alignment of the strategy of the Ministry of Health and Social Welfare (MOHSW) to the performance of Public Health Officers (PHOs) in the Gambia. The second section explores the existence of factors that support the performance of PHOs. The final section deals the current system of managing the performance of PHOs in the context of performance planning, performance execution, performance measurement and corrective action.

Alignment of Strategy and Performance

Alignment is the extent to which the job of the PHO corresponds to the requirements of the MOHSW as contained in the Health Policy (2011-2015). In this section, two aspects of alignment have been covered: the extent and effect of alignment which represent answers to the first two research questions from the findings. The various responsibilities of PHOs, the methods by which they knew those responsibilities, the availability of targets and their involvement in the setting of those targets as found out from the interviews are compared against those in the policy to know the extent of alignment. An overview of the documents reviewed is also given.

On the other hand, the effect of alignment is considered by looking at the impact of alignment, public image of the public health cadre and the performance level of PHOs from them and their supervisors’ perspectives. The section is intended to provide a description for the results of alignment on performance as was given in the research framework.

Extent of Alignment

The extent to which the job of PHOs aligns with strategy of MOSHW was investigated by finding out what the key responsibilities of the PHOs were. This

provided the researcher the basis against which the responsibilities of PHOs in the MOSHW’s strategy can be compared. The assignment of the responsibilities was found by asking how PHOs came to know that these were their key responsibilities.

This was done to find out whether these assignments were based on the strategy. On the other hand, for the performance of PHOs to be measured, it must be based on a standard. Based on the experience of the researcher, performance standards were set as targets which were usually in the form of a score of achievement on a specific objective. This was investigated because for all the areas of performance, there should be targets to be able to measure the extent of goal achievement. The availability of targets, the procedures pursued in the establishments of the said targets and their similarities with those contained in the strategy will greatly explain alignment.

Responsibilities.

According to the strategy as outlined in the Health Policy of the Ministry of Health and Social Welfare (2011-2015), the responsibilities of the PHOs span across five major categories as given below:

 Environmental health and safety

 Health education and promotion

 Expanded Program on Immunization (EPI)

 Disease control

 Reproductive and Child Health (RCH) (MOSHW, 2011)

On the other hand, the results revealed the existence of PHOs’ responsibilities spanning across various aspects of public health. Each of these responsibilities can be grouped under seven major categories:

 Administrative Responsibilities

 Disease control

 Health education and promotion

 Reproductive and Child Health (RCH) services

 Expanded Program on Immunization (EPI) services

 Registration of birth and deaths (see Appendix D)

Each of these areas will now be discussed with reference to the strategy of MOSHW.

Administrative responsibilities.

Under this category are those responsibilities which dealt with the day-to-day management of the public health office and the involvement of PHOs in the management of the health facility which was done with other members of staff of the facility. From the interviews, the following were identified:

 Administration (B3-05-R02C5)

 Data management (B3-02-RO2C5)

 Interdepartmental collaboration (B1-06-R02C6)

 Monitoring health laborers (B3-04-RO2C1, RCH B1-04-R02C2, B2-04-R02C1) Administration involved all activities related to the running of the public health office and involvement in decision making issues of the health facility in which the PHO operates. In addition to administration, PHOs collected and managed data on the activities they perform. Such activities included immunization, surveillance, environmental inspection, meat inspection and the registration of births and deaths.

Collaboration was required of PHOs in a variety of areas. This was because health had numerous stakeholders with whom PHOs worked. These may be governmental e.g. Area or Municipal Councils, Department of Livestock Services, Department of Water Resources; agencies e.g. National Nutrition Agency, National Environment Agency; or nongovernmental organizations e.g. Catholic Relief Services, UNICEF. PHOs were also responsible for the supervision of health laborers. This involved assigning health laborers their daily duties. Health laborers reported to PHOs on all issues related to their work. The main function of health laborers was to

maintain a clean environment in and around the health facility. They also supported the PHOs during their inspections.

Even though these activities (administration, collaboration, data management, and the issue of health laborers) are not specifically mentioned in the strategy, they were crucial for the effective implementation of virtually all aspects of the strategy.

Therefore, they can be considered as part of the strategy. However, the manner in which each of these activities should be executed needs to be specified and standards should be in place to serve as a guide during the execution of performance.

Disease control.

All public health activities that are directed towards the prevention and control of the spread of diseases whether they are communicable or non-communicable may be referred to as disease control. From the responses the following were recorded:

 Disease control and prevention

 Environment and food hygiene (inspections)

 Surveillance

 Vector control (see Appendix D)

Disease control and prevention as a responsibility in this context includes all the activities mentioned above. This was mentioned by respondents because a major function of PHOs was the prevention and control of diseases through interventions aimed at the reduction of morbidity and mortality. For environment and food hygiene, there were public health standards required for dwelling houses, shops, bakeries, food outlets and even whole communities. PHOs inspected these places to ensure compliance with such standards. However, the results indicate that those standards were learned through training or gained from experience and were not based on the strategy. For example some respondents indicated that:

These (responsibilities) were gained from the training institutions, were part of

their curricula, they are also gained through experience and also from the Public Health Act. …all that I do, I learnt from school except with the experience gained through practice. We have no terms of reference from the ministry but by definition of public health i.e., experience and demands of the work. (Bakary, Cherno, and Omar)

An important element of disease control is surveillance (public health surveillance). It refers to the continuous, systematic collection, analysis and interpretation of health-related data needed for the planning, implementation, and evaluation of public health practice. Such surveillance can:

 serve as an early warning system for impending public health emergencies;

 document the impact of an intervention, or track progress towards specified goals; and

 monitor and clarify the epidemiology of health problems, to allow priorities to be set and to inform public health policy and strategies (WHO, 2013).

Surveillance was done by PHOs sometimes with the assistance of other health workers e.g. nurses and laboratory assistants. However, as far as the experience of the researcher is concerned, this domain was in most instances limited to specific diseases of interest to the EPI Unit. Also, according to the strategy, surveillance is an integral part of EPI services.

A vector is any arthropod, insect, rodent or other animal of public health significance capable of harboring or transmitting the causative agents of human disease (e.g. malaria, plague) to humans. Under certain circumstances, insects or other arthropods that cause human discomfort or injury, but not disease, are sometimes referred to as vectors (Greater Los Angeles County Vector Control District [GLACVD], 2013). The control of these vectors is essential in disease control.

However, this activity was largely limited to mosquitoes for the prevention and

control of malaria. This may be wise considering malaria accounts for the greatest burden of diseases in The Gambia.

Another aspect of disease control in the Health Policy (2011- 2015) is environmental health and safety. The main objective in this domain is to reduce the frequency of environmental health and safety related diseases/conditions by 50% by 2015. The strategies formulated to achieve these are the enforcement of environmental health-related acts, institution of proper management of solid, gaseous and liquid wastes and the strengthening of the environmental units of key municipalities. The enforcement of environmental health-related acts and the institution of proper management of solid, gaseous and liquid wastes are key public health functions. However, even though enforcing the implementation of the various health-related acts e.g. the Public Health Act, the Food Act and National Environment Management Act (NEMA) was the responsibility of the PHOs, only one respondent (Bakary) mentioned it. This might be due to the fact that law enforcement was usually a component of other responsibilities in the domain of disease control and prevention.

The objectives of disease control according to the Health Policy (2011–2015) is to reduce the burden of communicable diseases to a level that they cease to be a public health problem and to promote healthy life styles, increase understanding on the prevention and management of non communicable diseases. The strategies to be employed to achieve these objectives are to strengthen disease surveillance and response capacity at all levels; provision of appropriate case management capacity at various levels of health care delivery system and community empowerment on disease prevention and control. The areas to be covered are malaria, tuberculosis, HIV/AIDS, sexually transmitted infections (STIs) (other than HIV/AIDS), diarrheal diseases, trachoma/eye diseases, respiratory tract infections, non- communicable diseases (NCDs) and mental health (see Appendix C). Each of these areas has specific

strategies to be implemented to realize the goals of the ministry. Evidence from the interviews indicated that PHOs were not familiar with the details of the strategies in each of the areas of disease control. Also, it was discovered that some areas e.g.

malaria and mental health had their own policies. The Mental Health Policy was not seen during the data collection while the malaria policy was found in only one region.

Health education and promotion.

Health education and promotion is a cross cutting aspect of public health which covers all areas of health. According to the Health Policy (2011-2015), the objective of health education and promotion is to raise awareness among the population through the provision of relevant health information that would promote, protect and improve health outcomes. To this end a health education and promotion policy would be developed and implemented. A mechanism to coordinate the use of correct and consistent health messages and to strengthen the capacity of service providers on information, communication and education and behavioral change communication were envisaged. The concept was referred to in the interviews as sensitizations, health sensitizations or health education and promotion (A3-RO1C5, B1-05-R02C4, B2-04-R02C3, B2-05-R02C2, B3-01-RO2C4, B3-04-RO2C2). At the time of the interviews, no policy on health education and promotion was found nor was there any indication of a mechanism to strengthen the capacity of service providers. Though all regional offices had a Health Education and Promotion Officer, the relationship between them and PHOs as regards health education and promotion was weak as regards communication that will help provide PHOs the necessary capacity outlined in the strategy.

Reproductive and child health (RCH).

RCH was mentioned by only two respondents as a key responsibility B1-04-R02C2, B2-04-R02C1). However this may be because RCH services were

considered by many PHOs as part of the EPI services which mainly had to do with immunization of pregnant women and children less than five years of age against vaccine preventable diseases. It also includes birth registration of children less than five years. However, according to the strategy the objectives of RCH services are to reduce mortality and morbidity related to but not limited to childhood, reproduction and the reproductive system across the country. The strategies of public health concern to attain these include the introduction and institutionalization of peri-natal reviews and audits; monitoring, evaluation, and research; and increasing awareness on sexual, reproductive and child health issues. The specifics of what exactly entails the duty of PHOs as regards RCH services are not stated in the policy. Even though, a RCH policy exists, it was neither available to the PHOs nor their supervisors except for one (Malafi) at the time of the data collection. Therefore, virtually no PHO knew about the RCH policy let alone its contents. Consequently, the performance of PHOs as far as RCH was concerned was based on their experiences of practice which was mainly immunization of pregnant women and children five years of age and registrations of births for such children. As a matter of fact, the immunizations of pregnant women and children less than five years of age are considered as EPI activities. However, even these activities were to be considered as part of RCH, they are far less than what concerns PHOs as far as the strategy of MOSHW was concerned.

Expanded program on immunization (EPI).

Nineteen respondents mentioned EPI as a key responsibility (see Appendix D).

EPI services include immunization of children less than five years of age and pregnant women, surveillance of vaccine preventable diseases and the conduct of other immunization programs such National Immunization Days (NIDs). The objective of EPI according to the Health Policy is to increase immunization coverage

to at least 90% for all antigens at national and regional levels and to ensure vaccine security for all vaccine preventable diseases. The strategies to be employed to attain the said objectives are to strengthen the effectiveness and efficiency of the EPI delivery system and improve surveillance mechanism for early detection and response to vaccine preventable disease outbreaks. The focal persons for EPI services were the RPHOs who were the supervisors of PHOs. From the interviews and the review of documents, communication between EPI and PHOs and RPHOs was constant and several documents were available to PHOs and their supervisors to monitor all EPI activities at both regional and facility level.

The health strategy does not specify the role of PHOs in the execution of EPI services. However, from the researcher’s experience EPI is an integral part of the PHOs’ job and the EPI unit has supported the PHOs maximally for the realization of their objectives.

Registration of birth and deaths.

PHOs were expected to register all births and deaths of people in The Gambia.

The registration of birth for children less than five years was integrated into the Reproductive and Child Health (RCH) program. Registrations of births for people above five years of age and all death registrations were done by PHOs but these were not part of RCH. As an important public health function, fifteen respondents mentioned it as a key responsibility (see Appendix D). However, this responsibility was not mentioned in the Health Policy (2011 – 2015) even though registrations form an integral part of public health responsibilities. This might be an oversight in the strategy.

Knowledge of responsibilities.

This dimension concerns the source from which the PHOs knew about their responsibilities. These included:

 school and practicum attachments

 colleagues

 from definition of public health

 the desk officer

 guidelines and timetables

 experience

 the ministry

 orientation by supervisor at RHT

 seniors (see Appendix D)

The schools concerned with the training of PHOs were the University of The Gambia and the School of Public Health, Gambia College. During their training, PHOs undergo practicum attachments in various institutions of public health interest and health facilities. As pointed out by an interviewee “I gained the knowledge of my responsibilities from the school and from experience, and also from practicum attachment. I got some from my supervisor too” (Isatou). Bailo also mentioned a similar statement saying “I was exposed to my responsibilities during attachments and when posted we found some things on the ground but there is no terms of reference.”

As indicated, the practice of some PHOs was almost entirely dependent upon what they were trained from these schools. This source constitutes the greatest source of communicating the responsibilities of PHOs. Also, in most cases no terms of reference (A2-R02C1, B1-05-R03C3) were provided forcing PHOs to rely almost entirely on the trainings received. Similarly, the RHTs to an extent provided some orientation to new PHOs upon their postings on some basic expectations of the field.

However, information provided during orientations may not be related to the health strategy but what the supervisor knew through practice and experience as mentioned by Malafi: “it is from the ministry, from a long time and we found it in the system”.

On the other hand, where desk officers were designated, they issued directives as to which PHO should be responsible for what. Other sources mentioned like colleagues, guidelines and seniors in addition to those mentioned earlier can prove to be very useful instruments in informing PHOs their responsibilities though few interviewees mentioned them. However, as the purpose of this question was to establish a link between the job of PHOs and the strategy of the MOSHW, the responses do not indicate that PHOs’ performance was based on the strategy.

Targets for public health responsibilities.

In other words, this aspect i.e. availability of targets explores the availability of standards the accomplishment of which will determine the level performance attained with respect to the various key responsibilities. Ten respondents said that targets were available (see Appendix D) while eight said targets were available for some especially EPI services but not all key responsibilities (see Appendix D). However, five of them said there were no targets for the key responsibilities (B1-05-R04C1, B2-01-R04C1, B2-02-R04C1, B3-01-R04C1, B3-04-R04C1).

As the involvement of the participants in target setting was important, it was enquired of respondents as to whether they knew how the targets for the key responsibilities were set. Ten respondents (see Appendix D) said they did not have targets for most of their key responsibilities and therefore could not explain how the targets were set while five mentioned RHT (or the ministry) in their responses (A1-R04C1, A2-R04C2, B1-04-R06C1, B1-06-R06C1, B2-04-R06C1). One supervisor explained this as:

Standard guidelines are developed; I developed them on my own. We don't actually consult the strategy, not only the strategies of the MOSHW but various other strategies of program units when assigning PHOs their duties. Further work needs to be done not only at this level but from the central level. (Omar)

Other respondents said that they were actually involved in working out the targets for the various EPI services through workshops (B3-03-R06C1, B3-05-R06C1, B3-06-R06C1, B3-07-R06C1). Paul mentioned “the EPI unit involves us in calculating targets for immunization by giving us the formula. We then calculate the target ourselves.” The EPI Unit has been very successful in the way it dealt with PHOs and their supervisors. From the researchers’ own experience, the EPI Unit

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