LITERATURE REVIEW - The Alignment of Strategy and Performance: A Study on the Current

This chapter covers an overview of information about the Gambia with reference to the health sector and provides explanations on other concepts related to the study i.e. performance management, alignment, and performance management in public institutions.

Information about The Gambia

This section provides an overview of health-related information about The Gambia, the components of the health sector of The Gambia, the public health cadre and strategies of the MOHSW.

Health-related Data

The Gambia is located in Western Africa, bordering the North Atlantic Ocean and Senegal. The country is almost an enclave of Senegal and is the smallest country on the continent of Africa. It has an area of 11,295 sq km (10,000 sq km – land; 1,295 sq km - water). The country has a total population of 1,840,454 with a growth rate of 2.344%, a birth rate of 33.41 births per thousand population and a total fertility rate of 4.1 children born per woman (2012 estimate). The death rate was estimated in 2012 to be 7.5 deaths per thousand population. The maternal mortality rate is high with 400 deaths per hundred thousand live births (2008) and an infant mortality rate of 69.58 deaths per thousand live births (2012 est.). The estimated life expectancy in 2012 was 63.82 years [male: 61.52 years, female: 66.18 years]. Thecountry’s expenditure on health was 10.1% of GDP as of 2009 (Central Intelligence Agency [US], (2012).

The Health System

The Gambia’s health sector has a three-tier system comprising the primary, secondary and the tertiary levels. The primary level includes the village health services and community clinics. The secondary level includes minor and major health centers while the tertiary level is made up of hospitals and a teaching hospital. On the

other hand, the health sector is managed at two levels, the central and regional levels (AHWO, 2009). The central level is organized into the directorates of Health Services;

Planning and Information; Social Welfare, Food Standards and Quality (MOHSW, 2012); and Health Education and Promotion (from researcher’s experience).

The country is divided into six health regions each with a Regional Health Team (RHT) headed by a Regional Director. The RHTs have overall responsibility for the Primary and Secondary health care facilities as well as the staffs of such facilities within the respective regions. On the other hand, the hospitals and the teaching hospital have semiautonomous boards and are headed by Chief Executive Officers and a Chief Medical Director respectively. The recruitment, deployment, promotion, retention and management of the National Civil Service are the responsibility of the Personnel Management Office (PMO). It is through this unit that a number of policy decisions with respect to human resources in the health sector have been implemented to improve the motivation and retention of health workers especially in the rural areas (AHWO, 2009).

There are various health training institutions: the School of Community Health Nurses, the School of State Enrolled Nurses, the School of Nursing and Midwifery, School of Public Health, and the Faculty of Medicine and Allied Health Sciences at the University of The Gambia. These institutions annually produce professionals that feed the health system. They are all under the Ministry of Higher Education, Research, Science and Technology (MOHERST) except for the schools of Community Health Nurses and the State Enrolled Nurses which are under the MOHSW (MOHSW, 2010).

The Public Health Cadre

PHOs are trained at The Gambia College, School of Public Health for a three-year period to obtain a Higher National Diploma in public and environmental

health. After graduation, they are appointed as Assistant Public Health Officers (APHO). Depending on the length of service or further training, promotions are made to the positions of Public Health Officer, Senior Public Health Officer (SPHO), Principal Public Health Officer (PPHO) and finally Chief Public Health Officer (CPHO), the highest rank in the cadre. There are positions sometimes between these main ones e.g. deputy CPHO or other function-specific nomenclatures such as Senior Administrative Officer (SAO) or Regional Vector Control Officer (RVCO) (researcher’s experience).

The RHTs are under the Directorate of Health Services. This directorate is headed by a Director of Health Services. Major decisions (e.g. postings, relocation and applications for promotions) concerning PHOs and their supervisors are passed subject to the director’s approval. PHOs at the secondary level of healthcare delivery are supervised by Regional Public Health Officers (RPHO) (researcher’s experience).

Strategies of the MOHSW

All aspects of health may be of concern to PHOs, however, only those strategies which directly concern the job of PHOs were selected to help shape the focus of this research. From the researcher’s experience, these were areas for which PHOs were directly held responsible. These strategies as outlined in the Health Policy of the Ministry of Health and Social Welfare (2011-2015) were categorized under five main areas as given below. The detailed strategy is provided in Appendix C.

 Environmental health and safety

 Health education and promotion

 Expanded Program on Immunization (EPI)

 Disease control

 Reproductive and Child Health (MOHSW, 2011)

These areas comprised the major functions of PHOs’ serving at health facility

level in The Gambia. There were set goals and objectives by the ministry as regards these areas and strategies by which these goals could be realized. Therefore, performance of PHOs should be defined by these strategies in order to achieve the objectives and goals set. As such, all the responsibilities of the PHOs must be geared towards the achievement of the ministry’s goals and objectives in the specified manner.

Performance Management

This section provides an overview of the definition of performance management (PM), the characteristics of an ideal system and the purpose of implementing such a system.

Definition

According to Adler (2011), PM was exclusively referred to as management control, the process by which managers ensure resource availability and their effective and efficient use towards the realization of organizational objectives. A relatively recent description of the concept by him is the process by which managers influence other members of the organization to implement the organization’s strategy.

Kagioglou, Cooper and Aouad (2001) mentioned it as a closed loop control system which deploys policy and strategy, and obtains feedback from various levels in order to manage the performance of the system. Similarly, en Hartog, Boselie, and Paauwe (2004) described it as a process in which managers work with their employees to set objectives, measure and review results, and compensate performance in order to improve worker efficiency and influence business success. These descriptions are in line with Aguinis’ (2012, p.2) definition of PM as “a continuous process of identifying, measuring, and developing the performance of individuals and teams and aligning performance with the strategic goals of the organization”. These definitions indicate that PM is the process by which managers influence members of the organization by

working with them in setting objectives, measuring, reviewing, developing, compensating and aligning performance with the strategic goals of the organization to achieve organizational objectives through the effective and efficient use of resources.

There health system in The Gambia had two levels of management: Central and Regional. The Central Level comprised more or less of specialized units each responsible for a particular aspect(s) of the strategy. The Regional Level otherwise called RHTs comprised various professionals serving as focal persons of the various units. As a team, they were responsible for coordinating and supervising the activities of the secondary and primary level healthcare activities. Even though not all units were specifically represented, the structure thus exists for the implementation of an ideal PM system. Influencing the performance of workers at the primary and secondary levels to achieve the goals of the MOHSW would require the empowerment of the RHTs to enable them effectively supervise workers and the provision of such capacity and controls by which workers will perform effectively and efficiently. A PM system that is linked to a strategic plan establishes:

 objectives against which progress is measured,

 tracking inputs, outcomes, and efficiencies,

 benchmarking to set targets and make performance comparisons, and

 program evaluation to ensure effectiveness through performance measures and outcomes (Plant, 2009).

From the researcher’s experience, the Health Policy of the MOHSW was the document that specified the objectives of the ministry usually over a five year period.

All institutions under the ministry were expected to work towards the attainment of the objectives contained in the strategy. This could be done by ensuring that the performances of workers in these institutions were aligned to the strategy of the ministry and that such mechanisms were in place to monitor the progress of such

alignment and corrective measures instituted where deviations from the strategy were found. PHOs by virtue of their functions had a quota in all aspects of the strategy.

Ensuring that the performance of PHOs was aligned to the strategy of MOHSW would play a crucial part towards the attainment of the set goals and objectives of the ministry.

Characteristics of an Ideal System

A highly effective performance management system is one that is designed on and facilitates actions that give autonomy to individuals within their span of control;

reflect cause and effect relationships; empower and involve individuals; create a basis for discussion, and thus support decision making with respect to continuous improvement (Lebas, 1995). Such a system will clearly spell out the organization’s values and objectives, define individual objectives and connect them to the organizational objectives, review performance regularly, relate pay to performance and provide training and counseling (Armstrong & Baron, 2000). An ideal PM system should reflect organizational strategy which should be communicated and deployed through performance measurement. In that case, performance metrics would be shaped by the mission, vision, and strategy of the organization (Abu-Suleiman, 2006).

According to Aguinis (2012), in an ideal performance management system, evaluation should cover all employees on all major job responsibilities including performance spanning the entire review period and giving feedback on outcomes of evaluation.

The system must be acceptable and fair to all workers based on a standard by which performance is evaluated consistently across people and time.

For health workers in The Gambia, an ideal PM system would be one based on the strategy of the MOHSW. Their functions and the measurement of the outcomes of what they do should be based on what the ministry’s mission, vision and goals were.

This would enable the ministry realize its goals. It would also assist the supervisors to

monitor and measure the performance of workers based on concrete grounds.

Purpose of a PM System

According to Lebas (1995), PM precedes and follows performance measurement, in a virtuous spiral. It brings about the context for measurement. Brown (2005) mentioned that organizations introduce PM (and/or measurement) for any of the following purposes:

 to provide information on organizational effectiveness and efficiency and on employees’ effectiveness and efficiency;

 to improve organizational effectiveness and efficiency, employees’ effectiveness and efficiency, employees’ levels of motivation, the quality of employees’

training and development and to improve customer service;

 to link employees’ pay with perceptions of their performance and to raise levels of employee accountability;

 to align employees’ objectives with those of the organization as a whole and to focus employees’ attention on areas deemed to be of greatest priority and

 to facilitate the implementation of an organization’s mission and/or strategy.

It follows that the performance of employees needs to be managed to increase both employee and organizational efficiency and effectiveness. A PM system provides the media for the alignment of the organization’s strategy to the individual objectives of employees. This facilitates measurement of performance which is crucial to performance appraisal and providing information on the extent of goal achievement.

Thus, for public institutions to realize their visions, the performances of their employees must be managed. When an ideal PM system is implemented, definitions of jobs and criteria required to accomplish job requirements are clarified. Such a system enhances employee motivation, self esteem, engagement, commitment, competence, intention to stay in the organization, differentiates between good and

poor performers, and makes administrative actions more fair and appropriate (Aguinis, 2012).

The Concept of Alignment

According to Watkins (2007), alignment begins with the strategic goals and objectives of individuals, organizations, communities, and societies. It begins with these intentions because they define the expected results of any performance effort.

To create alignment throughout the organization and effectively communicate goals to the frontline, measurements systems must be cascaded down to all levels of the organization. Therefore, strategic objectives, which are specific to departments and connected to the public services they provide, must be aligned with the overall strategic goals of the organization (Plant & Douglas, 2006).

Semler, (1997, pp.27, 29) described alignment in the general sense as the extent to which the strategy, structure, and culture of the organization combine to create a synergistic whole that makes it possible to achieve the goals laid out in the organization's strategy. It is a state rather than an outcome. The strongest possible alignment will indicate the greatest probability of attaining the organization's strategic goals. He highlighted six aspects of alignment (process, reward system, values, norms, performance, and environment). These aspects are discussed under four main categories; cultural, environmental, structural, and performance aspects of alignment.

Environmental Aspect

The environmental aspect of alignment reflects the strategic fit between the demands of the external environment and the selected vision, goals, and tactics of the organization.

Cultural Aspect

The match between elements of strategy and organizational culture defines the next two aspects of alignment. Agreement between cultural values and the values

implicit in the strategy facilitates acceptance of the strategic goals by the organization’s members. Similarly, agreement between planned behavior (and tactics) and the cultural behavior and norms facilitate the direction of actual behaviors toward attainment of the strategic goals.

Structural (Process and Rewards)

Agreement between the goals of different levels of activity within the organizational structure describes the first structural aspect of alignment. The second structural aspect of alignment is the systematic agreement of reward systems with the strategic goals, values and tactics.

Performance Aspect (Ideal and Actual Behavior)

This aspect of alignment describes the agreement between the actual behavior of an organization's individuals and processes and the behavior that is required for attainment of the strategic goals. Alignment of this aspect is an indicator of the degree of operational goal-directed behavior demonstrated by organizational members and processes. This aspect serves as a corroborative check on the other four internal aspects of alignment. The focus of this research was mainly on the performance aspect of alignment. This covered agreement between the actual behavior of PHOs and the behavior that was required for the attainment of the strategic goals of MOHSW.

Various central level program units e.g. the Reproductive and Child Health (RCH), Expanded Program on Immunization (EPI), Environment, Health Education and Promotion Directorate each represented an implementation agency for the various items on the ministry’s strategy. These units in collaboration with the RHTs can offer an effective performance management mechanism through which the goals of the ministry can be realized.

Performance Management in Public Institutions

Plant and Douglas (2006, pp.44-45) created a model of performance management system in a local government setting as shown in figure 2.1 which is composed of three fundamental elements: macro-level, shown in the outer circle of the diagram; operational performance implementation and improvement, shown in the inner circle; and enabling conditions that support the whole system, shown in smaller circles.

Figure 2.1 The performance management system in local government. Adapted from

“The Performance Management Continuum in Municipal Government Organizations”

Each of the three levels is discussed below with reference to relevant literature.

The Macro-level

The macro-level includes institutional mandates, departmental strategic

objectives, budget, outcomes and impacts, assessments and decisions on future actions. The mandate is usually reflected in a strategic plan. High-level indicators are usually set that reflect key priorities affected by the various organizational programs.

The aspect of the macro-level considered in this research is the Heath Policy of the MOHSW (2011 – 2015) in which various goals, objectives, and strategies related to the job of PHOs are outlined. Though other categories of health workers apart from the PHOs might be affected by the policy, reference was made to the policy only to the extent by which it concerns the performance PHOs at health facility level.

Operational Performance Implementation and Improvement

The operational level consists of performance implementation and improvement which involves business plans and performance standards and measures; operational task performance; monitoring, measurement and assessment; and corrective action.

These components provide a framework for communicating organizational goals throughout the organization, assessing results of organizational activities, and taking corrective action. With reference to the elements under operational level of Plant and Douglas’s (2006) model, the following are the operational level elements considered for this research.

 Performance planning

 Performance execution/implementation

 Performance measurement

 Corrective action

Performance planning.

Planning from the management perspective refers to the selection of missions and objectives followed by the selection of strategies, policies, programs, and procedures for achieving them. It involves decision making and the selection of a course of action from among alternatives (Murk & Walls, 1998). An effective

business planning process helps departments establish annual business goals that are linked to the strategic plan and specifies resource requirements necessary to achieve those goals along with appropriate measures for assessing performance progress against goals (Plant, 2009). Classically, strategic planning entails the development of the mission, strategic objectives, and strategies of an organization followed by an articulation and implementation of operating plans and a control system (Yusuf &

Saffu, 2009). It entails two dimensions: planning content which refers to the ends of the planning process e.g. goals, mission statements, environmental information programs, and internal resources; and planning processes which focus on the means or methods by which the planning process is carried out e.g. commitment, system maturity, comprehensiveness, time horizon, and importance (Hoffman, 2007).

Planning enables all employees to know their accountabilities. Accountability requires three components: setting a performance standard for each program;

monitoring program performance against that standard; and applying sanctions when standards are not met (Grizzle & Pettijohn, 2002). Performance standards are the yardsticks designed to help people understand to what extent the objectives have been achieved and provide raters with information about what to look for to determine the level of performance that has been achieved (Aguinis, 2012). However, for most public services, no absolute standards of performance are available (Wholey & Hatry, 1992). Nonetheless, where standards (or targets) are available, measures have to be developed to measure them. Performance measures are viewed as indicators of the efficiency, effectiveness, and productivity of organizations. The development of performance measures is an important phase in developing a comprehensive strategic plan (Plant, 2009). Unfortunately, the health strategy lacks targets and measures for many public health responsibilities.

Performance execution/implementation.

Implementation is the system-wide action taken by firm members aimed at accomplishing formulated strategies and is important to firm performance because strategies do not add value unless properly implemented (Hahn & Powers, 2010).

Successful implementation is dependent on practitioners' micro-level decision making (Timperley & Robinson, 1997). Dobni and Luffman (2003) through their research and consultancy work found that the key challenge for management lies in the implementation of strategy and the key to successful implementation rests in the ability to guide and manage employee behaviors on a collective basis. Likewise, Long and Franklin (2004) indicated that internal and external factors that must support successful implementation include the number and nature of the actors involved, the nature of conflict over the policy in question, the expectations concerning the goals

在文檔中 The Alignment of Strategy and Performance: A Study on the Current (頁 21-39)