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

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(1)The Alignment of Strategy and Performance: A Study on the Current Performance Management System of the Public Health Cadre in The Gambia. by. Alhaji Jabbi. A Thesis Submitted to the Graduate Faculty in Partial Fulfillment of the Requirements for the Degree of MASTER OF BUSINESS ADMINISTRATION Major: International Human Resource Development. Advisor: Chih-Chien Steven Lai, Ph. D. National Taiwan Normal University Taipei, Taiwan June, 2013.

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(5) ACKNOWLEDGEMENT The most perfect thanks and praises to The Almighty Allah for granting me the privilege and opportunity to undergo this master’s program sound and healthy. I wish to place on record my appreciation to the International Cooperation and Development Fund (TaiwanICDF) for granting me the scholarship and for all the support I have received during the training. My heartfelt gratitude goes to my advisor, Dr Lai for successfully taking me through this research and for his encouragement through the most difficult times to enable me complete the research process. To the members of my defense committee Dr Chang and Dr Pai-Po Lee, a big thank you for the valuable suggestions and contributions which helped me accomplish the objectives of this research. I am thankful to my classmates and all my friends for the moral support and their advices. I am greatly indebted to Mr. Edward Liu whose insights tremendously helped shape this research. Finally, I am grateful to my family for their endurance and patience for the long separation from them. Thank you very much..

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(7) ABSTRACT With the increasing demands on health professionals as a result of the changing trends in health and health needs of populations, managing the performance of the available professionals is a necessity. Availability of highly trained public health professionals at the right place and time will not translate into meaningful public health outcomes if their performance is not managed. An important aspect of performance management is the alignment of organizational strategy to performance. The Health Policy (2011-2015) of the MOHSW outlined numerous strategies of public health concern which require the concerted efforts of all actors for their implementation. This research investigated the alignment of the public health strategies of the Ministry of Health and Social Welfare to the job of public health officers in The Gambia by examining the current system of managing their performance. A qualitative approach was used to collect data from public health officers and their supervisors from three of the six health regions of the Gambia. Relevant documents of the Ministry were also reviewed to gain more understanding of the performance management system. The results indicate that the performance of public health officers was not aligned to the strategy of MOHSW due to performance being largely based on knowledge gained from training or from experience through practice. Similarly, the manner their performance was managed was not ideal due to it not being based on defined standards and for the lack of the necessary tools required for an ideal system. Keywords:. alignment, performance, strategy, public health. I.

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(9) TABLE OF CONTENTS ACKNOWLEDGEMENT ABSTRACT .................................................................................................................. I TABLE OF CONTENTS .......................................................................................... III LIST OF TABLES....................................................................................................... V LIST OF FIGURES ................................................................................................. VII CHAPTER I INTRODUCTION ............................................................................. 1 Background of the Study....................................................................................................... 1 Significance of the Study ...................................................................................................... 2 Purpose of the Study ............................................................................................................. 3 Research Questions ............................................................................................................... 4 Delimitations ......................................................................................................................... 4 Definition of Terms ............................................................................................................... 4. CHAPTER II LITERATURE REVIEW ................................................................ 7 Information about The Gambia ............................................................................................. 7 Performance Management .................................................................................................. 10 The Concept of Alignment .................................................................................................. 14 Performance Management in Public Institutions ................................................................ 16. CHAPTER III RESEARCH METHODS ............................................................. 25 Research Framework........................................................................................................... 25 Research Approach ............................................................................................................. 27 Data Collection Techniques and Tools ................................................................................ 27 Sampling Process ................................................................................................................ 31 Participants of the Study ..................................................................................................... 32 Research Procedure ............................................................................................................. 33 Data Analysis ...................................................................................................................... 35 Quality of the Research ....................................................................................................... 38 Consent and Ethical Approval ............................................................................................. 39 III.

(10) CHAPTER IV FINDINGS AND DISCUSSIONS ................................................ 41 Alignment of Strategy and Performance ............................................................................. 41 Support for Performance ..................................................................................................... 59 The Current System of Managing the Performance of PHOs ............................................. 61 Discussions.......................................................................................................................... 70. CHAPTER V CONCLUSIONS AND SUGGESTIONS ...................................... 75 Conclusions ......................................................................................................................... 75 Suggestions ......................................................................................................................... 78 Limitations .......................................................................................................................... 82. REFERENCES ........................................................................................................... 83 APPENDIX A: DATA COLLECTION TOOLS ................................................... 89 APPENDIX B: LETTERS ..................................................................................... 99 APPENDIX C: STRATEGY OF MOHSW......................................................... 101 APPENDIX D: CODING PROCESS .................................................................. 105. IV.

(11) LIST OF TABLES Table 2.1 Behavior Engineering Model ....................................................................... 23 Table 3.1 Profile of Participants................................................................................... 33 Table 4.1 Checklists of Documents Reviewed ............................................................ 53 Table 4.2 Descriptive Statistics for Enabling Conditions for Performance ................. 60. V.

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(13) LIST OF FIGURES Figure 2.1 The performance management system in local government. ..................... 16 Figure 3.1 Research framework ................................................................................... 26 Figure 3.2 Research procedure .................................................................................... 35 Figure 3.3 Example of the coding procedure of RPHOs’ responses ........................... 36 Figure 3.4 Example of the coding procedure of PHOs’ responses .............................. 37. VII.

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(15) CHAPTER I INTRODUCTION In this chapter the author looks at the background of the study, significance and purpose of the study, research questions, and delimitations. The chapter concludes with the definition of terms.. Background of the Study Health workers form the foundation of health service delivery. Their numbers, skills and commitment are critical for the delivery of good health care (Serneels, Montalvo, Petterson, Lievens & Butera, 2010).. According to WHO (2009), a host of. contextual issues including the health workforce need to be considered before effective solutions can be designed. At all levels of government, effective, performance-oriented program management is needed, that is management that focuses on program quality and on the results achieved through the use public resources (Wholey & Hatry, 1992). Managing the performance of Public Health Officers (PHOs) in The Gambia is vital to achieving high quality of health service delivery through the execution of the public health component of the strategic goals of Ministry of Health. This can be realized by ensuring the alignment of the strategy to the performance of PHOs. Organizational alignment is the degree to which the design, strategy, and culture of an organization are working in harmony to achieve the desired goals. Alignment brings about efficiency in organizations while misalignment leads to inefficiency in organizational efforts toward goal achievement (Semler, 1997). This research focused on the alignment of the public health aspect of the strategies of Ministry of Health and Social Welfare (MOHSW) and the performance of PHOs in The Gambia. The Ministry has highlighted the existence of a disparity in the demand by the population and quality of services at different levels of health care. A coordinated monitoring and evaluation system to measure performance, plan for improvements and ensure 1.

(16) accountability were lacking (Ministry of Health and Social Welfare [MOHSW], 2011). This indicates the existence of a deficiency in the performance management system at various levels of health service delivery. However, there was a scarcity of research in the academic literature on performance management in health especially in The Gambia. Most of the studies with regards to the field of human resources (HR) were devoted to areas like motivation and job satisfaction. As for The Gambia, no researches had been found in the area of performance management of PHOs. Therefore, it was crucial to examine the system of managing the performance of PHOs by examining how their jobs were aligned to the strategy of the MOHSW. It was expected that the findings of this research would provide information that might help improve the performance of PHOs and narrow the research gap that existed in the area of human resources in the health sector as far as performance management is concerned.. Significance of the Study According to Semler (1997), the creation of high performance work systems depends on the ability to align properly the elements of the organization that must work in synergy. Assessing alignment, even in a qualitative way, can enable organizations reach this goal. In The Gambia, PHOs are posted after graduation to various health facilities or stations. Without a clear outline of areas of responsibility, expected results, and the availability of mechanisms to measure the extent to which the expected results are realized based on the goals of MOHSW, it would be difficult if not impossible to know the contributions of PHOs to the strategic objectives. This may cause loss of sense of direction and lower productivity. Therefore, it was crucial to find out how the job of PHOs was aligned to the strategies of MOHSW to come up with findings which would help improve their performance. PHOs were supervised by Regional Public Health Officers (RPHO) based on 2.

(17) qualifications and experiences RPHOs accumulated during substantial lengths of service. The functions of RPHOs were similar in the sense that they supervise the performance of PHOs. Additionally, the public health cadre in The Gambia was composed of experienced and highly trained professionals through which the country registered a lot of success stories. An investigation into the current system of managing the performance of this cadre was crucial to providing information that will assist both supervisors and supervisees in the effective execution of their duties and responsibilities. There had been limited studies conducted on the area of human resources in health sector of The Gambia. This research shall therefore contribute to the knowledge gap which existed with regard to the area of human resources management and development. Moreover, the findings of this research shall assist the Ministry of Health and Social Welfare (MOHSW) in the design of policies aimed at improving the quality of health service delivery and health promotion. Furthermore, the results of this research can provide a basis for conducting further studies in other sectors of the ministry.. Purpose of the Study Using a qualitative approach, this research was intended to contribute in narrowing the knowledge gap that existed in The Gambia’s health sector’s human resources situation through the study of the current system of managing the performance of PHOs by examining the alignment of their performance to the strategies of the MOHSW in the Gambia. The findings of this research can be used to help shape the execution of the strategic intents of the various institutions in health and of other departments in The Gambia’s public sector. As such, this research sought to find out: 1. The extent of alignment of the job of PHOs to the strategies of the MOHSW. 3.

(18) 2. The effect of alignment of the job of PHOs and the strategies on the performance of PHOs. 3. The existence of the necessary support for PHOs to carry out their responsibilities. 4. The current system of managing the performance of PHOs.. Research Questions This study investigated the alignment of the strategies of the MOHSW and the performance of PHOs. Thus, based on the purpose of the study, the research questions were: 1. To what extent does the job of PHOs align with the strategies of the MOHSW? 2. What is the effect of alignment of job and strategy on the performance of PHOs? 3. Is the necessary support available for PHOs to carry out their responsibilities? 4. What is the current system of managing the performance of PHOs?. Delimitations There were various categories of PHOs in the health sector of The Gambia. However, this research focused on only PHOs who serve at health facility level. PHOs who served elsewhere in the MOHSW were not included in this study nor did it include PHOs who served in the private sector. Similarly, health workers outside the public health cadre were outside the scope of this study. There were six health regions in The Gambia. Three regions out of a total of six were selected for the conduct of this study. Within these selected regions, not all PHOs had the chance to be selected as participants. Also, RPHOs (i.e. supervisors of PHOs) included in this study were only those from the regions selected.. Definition of Terms Cadre A small group of people specially trained for a particular purpose or profession 4.

(19) (Oxford Dictionaries, 2012), e.g. a cadre of public health officers, community health nurses, etc. In this study unless otherwise indicated, the public health cadre is used specifically to mean public health officers working at health facility level in The Gambia.. Public Health Officers In this study the term Public Health Officers (PHO) denote Public Health Officers who work at health facility level under the Ministry of Health and Social Welfare (MOHSW) in The Gambia.. Alignment While there are various aspects of alignment, for the purpose of this study, the performance aspect of alignment was investigated. According to Semler (1997), the performance 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. In this study, alignment refers to the agreement between the work that Public Health Officers were doing at health facility level and the behavior that was required for the attainment of the strategic goals of the MOHSW as outlined in the Health Policy of the Ministry of Health and Social Welfare (2011-2015). The study did not take into account the agreement between processes and the behavior required for attainment of the strategic goals.. Strategy Strategy as a plan is some sort of consciously intended course of action, a guide (or set of guidelines) to deal with a situation (Mintzberg, 1987, p.11). It is the framework of choices that determines the nature and direction of an organization (Brache & Bodley-Scott, 2007, p.59). Strategy in this research shall mean the objectives, goals and strategies of the MOHSW which concerns the work of PHOs as contained in the Health Policy (2011- 2015) of MOHSW of The Gambia. 5.

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(21) CHAPTER II LITERATURE REVIEW 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]. The country’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 7.

(22) 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 8.

(23) 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 9.

(24) 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 10.

(25) 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 11.

(26) 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 12.

(27) 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 13.

(28) 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 14.

(29) 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.. 15.

(30) 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” by T. Plant and J. Douglas, 2006, Performance Improvement, 45(1), p.44. Copyright 2006 by the International Society for Performance Improvement.. Each of the three levels is discussed below with reference to relevant literature.. The Macro-level The macro-level includes institutional mandates, departmental strategic 16.

(31) 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 17.

(32) 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.. 18.

(33) 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 and outcomes of the policy, the tractability of the problem and the ability of the statute to structure implementation. The authors highlighted that the involvement of stakeholders inside and outside the implementing unit strengthens the policy in a variety of ways: it enhances responsiveness, focuses resources on key concerns of those the organization serves, and improves the likelihood of successful implementation because it enables stakeholders to identify themselves with the policy or program. According to Aguinis (2012), in the execution of performance, both subordinates and their supervisors have a commitment towards goal achievement. Subordinates should strive to produce results, constantly solicit performance feedback and coaching from their supervisors, provide supervisors with regular updates on progress towards goal achievement and prepare for periodic reviews of performance. On the other hand, supervisors should observe and document performance daily; update and revise objectives, standards, and key responsibilities; provide feedback on progress; coach; 19.

(34) provide resources and opportunities to subordinates to participate in developmental activities and reinforce behaviors to remedy performance problems. Performance measurement. Performance measurement is the process of quantifying the efficiency and effectiveness of action and determining how successful organizations or individuals have been in attaining their objectives and/or strategies (Neely, Gregory & Platts, 1995; Kagioglou, Cooper & Aouad, 2001). According Neely et al. (2000), a performance measurement system comprises design, implementation, measurement and maintenance within the context of people, processes and infrastructure influenced by the organization’s culture. The implementation of strategy can be supported and facilitated by strategy-aligned performance measurement (Pongatichat & Johnston, 2008). For designing, developing, and implementing successful measurement systems and metrics, the following checklist can be useful: . Communicate to staff what will be measured and how it will be measured.. . Communicate to staff the individual contribution of its sets of metrics.. . Communicate to the entire organization the current performance level as a. baseline. . Provide historical documentation of organizational performance.. . Align business activities with organizational goals and objectives.. . Provide information and resources needed to set goals based on current. performance. . Provide information needed to identify performance problems and risks.. . Provide a means of determining if performance improvement interventions are. successful and have the desired impact on organizational performance.. . Provide a depiction of the organization’s internal components, the external. entities with which it interacts, and the internal and external interfaces. 20.

(35) . Standardize and formalize the way organizational performance information is. collected and reported in order to increase assessment accuracy and consistency. . Provide information required for strategic, capital investment, and other. decisions (Jensen & Sage, 2000, pp.40-41; Rodriguez, 2008, p.20). For the purpose of this research, performance measurement will be examined in the light of monitoring and evaluation. Dal Poz, Gupta, Quain, & Soucat (2009, p.4) defined monitoring as “the ongoing process of collecting and using standardized information to assess progress towards objectives, resource usage and achievement of outcomes and impacts. It usually involves assessment against agreed performance indicators and targets.” On the other hand, they defined evaluation as “the systematic and objective assessment of an ongoing or completed initiative, its design, implementation and results. The aim is to determine the relevance and fulfilment of objectives, efficiency, effectiveness, impact and sustainability.” According to them information gained form effective monitoring and reporting together with evaluation information should provide decision-makers and stakeholders the knowledge needed to identify whether the implementation and outcomes of a project, program or policy initiative are realized according to expectations and to manage the initiative on an ongoing basis. Health programs require continuous monitoring and evaluation and on a more frequent basis so as to detect errors or defects in performance as soon as they occur for corrective actions to be promptly taken as errors in health can be very costly. The intent of performance measures is to provide reliable and valid information on performance. These measures are used for the purposes of evaluating, controlling, budgeting, motivating, promoting, celebrating, learning, and improving. To use performance measures to achieve any of these purposes the manager needs some kind of standard with which the measure can be compared (Behn, 2003). These 21.

(36) standards with respect to the health strategy are the targets set for the various components of the strategy. To determine the use of a specific metric to measure performance against those targets, the program units within MOHSW as well as the Regional Health Teams (RHTs) may have to envisage performance measurement during the planning process and ensure that metrics designed cover all dimensions of performance. Corrective action. Human Performance Technology (HPT) involves performance analysis, cause analysis, and intervention analysis. Performance analysis involves comparison of desired performance to actual performance to identify performance gaps. Cause analysis identifies the specific factors contributing to a performance gap. Intervention analysis or corrective action, involves the selection, design, development, and implementation of interventions (Massey, Montoya-Weiss & ODriscoll, 2005). If the true cause of the performance gap is accurately identified, then the solution should be an appropriate intervention (Hughes, 2004). There is the need to recognize timely, proactive management when the organization is monitoring its operations and taking corrective action as soon as problems are noticed (Plant and Douglas, 2006).. Enabling Conditions for Performance Enabling conditions are elements that must be present in the organizational environment before a performance management model will produce any significant benefits (Plant & Douglas 2006, pp.44-45). The elements given in Plant and Douglas’ PM continuum (see figure 2.1) are similar to those given in the Behavior Engineering Model (BEM) (see table 2.1). BEM is a model developed by Thomas Gilbert (1978) that evaluates the environmental influences and the individual influences that can cause a gap in performance (Russell, 2010). This research adopted the elements as given. in. the. BEM.. According. to. the 22. model. areas. where. causes. of.

(37) performance deficiencies might be found are data, instruments, incentives, knowledge, capacity, and motives. It helps managers find out the causes of human competence or incompetence, and stressed that ineffective management of any of the elements could cause incompetence (Chyung, 2005). The model separates performance problems into the person and the environment levels. The person level consists of performance supporting factors within the individual while the environment level consists of performance supporting factors within the work environment. The BEM further classifies these levels into three categories of factors that influence performance: information, instrumentation, and motivation (Marker, 2007). The BEM is illustrated below in Table 2.1. Table 2.1 Behavior Engineering Model. Environmental supports Person’s. repertory. Information. Instrumentation. Motivation. 1. Data. 2. Instruments. 3. Incentives. 5. Capacity. 6. Motives. of 4. Knowledge. behavior Note: Adapted from “Behavior Engineering Model, From Taylors’ Scientific Management to Gilbert’s Behavior Engineering Model,” by S.Y.Y. Chyung. 2005, Performance Improvement, 44(1), p.25. Copyright 1999–2013 by John Wiley & Sons, Inc. In the environment, informational variables are expectations, feedback, and guidance on how to perform well; instrumentation variables are tools and resources; and motivational variables are monetary and nonmonetary incentives. In the individual, informational variables are knowledge and skills; instrumentation variables are physical and psychological capacities; and motivational variables are the 23.

(38) match between people's motives and the situation (Sugrue, 2004). The enabling conditions for performance support the increased involvement of staff and strengthen the system’s ability to remove barriers that produce frustration and limit the productivity of staff. The establishment of these conditions will assist the organization to be positioned to drive performance improvement and also support the full development of all organizational levels, from the macro-level to the operational level (Plant and Douglas, 2006). Also, the availability of these conditions was necessary in the sense that when they were lacking, even if there was perfect alignment of strategy and behavior of performers, the desired results would not be generated. For example, it was a duty of PHOs to go for outreach immunization services, if vaccines, needles and syringes were available but there was no vehicle for transportation of PHOs to the service delivery site, the duty would be impossible to execute.. 24.

(39) CHAPTER III RESEARCH METHODS In this chapter, the procedure and techniques used for the conduct of this research are explained. These include the research framework, research approach, data collection techniques and tools, sampling process, participants of the study, research procedure, data analysis, quality of the research and ethical approval.. Research Framework The framework of this research has been adapted from the work of Plant and Douglas (2006) on the performance management continuum in municipal government organizations. It explains performance management as a continuous process from the formulation of organizational strategy based on the mission of the organization through implementation to the results. Using this framework, this research examines the performance management system of PHOs by investigating how the performances of PHOs working at health facility level were aligned to the strategy of the Ministry of Health and Social Welfare (MOHSW). The strategic component of the framework refers to the aspects of the strategy of MOHSW as contained in the Health Policy (2011-2015) which were related to the responsibilities of PHOs. This was used as a reference to compare the responsibilities of PHOs against its contents. The operational performance implementation and improvement component of the framework which comprised planning, implementation, measurement and corrective action provided the main basis against which the research questions were designed. Thus, the alignment of performance and strategy was investigated by examining whether planning, implementation and measurement were done based on the strategy. Also, this component helped to explain the current system of managing the performance of PHOs. The enabling conditions for performance (the performance enhancers) i.e., environmental support and personal factors have been adapted from Chyung (2005, 25.

(40) p.25), human performance technology based on Gilbert’s (1978) behavior engineering model. Under the environmental supports, ‘resources’ instead of ‘instruments’ has been maintained as in Plant and Douglas’s (2006) model. However, these factors in both the Behavior Engineering Model and Plant and Douglas’s (2006) performance management continuum were similar. It was considered necessary to include the factors in this study because their availability was crucial for performance to take place. Figure 3.1 shows the framework of the research.. Strategy of MOSHW. Environmental supports Resources. Operational performance implementation and improvement Corrective action. Planning. Measurement. Execution. Incentives Data. Personal factors Knowledge Capacity. Results. Motives. Figure 3.1 Research framework. 26.

(41) Research Approach The research was conducted using a qualitative approach. This was because the opinions and experiences of PHOs as regards the relationship between their work and strategies of MOHSW were explored. According to Myers (2008), qualitative research methods are designed to help researchers understand people and what they say and do enabling a researcher to see and understand the context within which decisions and actions take place. Also, according to Mertens (2005) the nature of the research question may determine the choice of using qualitative research. He mentioned that the types of research questions for which qualitative methods would be appropriate can be when the focus of the research is on the process, implementation, or development of a program or its participants. In accordance with these views, this research was done on the performance management system of the public health cadre by investigating how aligned was the performance of PHOs to the strategy of MOHSW. In order to achieve this, information was generated through interviews of the PHOs and their respective supervisors in the regions. Documents that were required by PHOs for the execution of their duties were also reviewed for their consistency with the operational requirements and the strategy of the MOHSW. The availability of the enabling conditions for performance was assessed using a questionnaire to help the researcher gain more understanding about alignment.. Data Collection Techniques and Tools This is a qualitative research in which three procedures were used for collecting the data: personal interviews, document review and a questionnaire. The design of data collection tools went through peer review and expert review. The peers who helped in the review consisted of public health officers some of whom were practicing in the field while some were students pursuing various health-related graduate programs in Taiwan. Others were colleagues who were pursuing their masters in 27.

(42) human resource development and had familiarity with the field on which this research was being conducted i.e. performance management. The experts who undertook the review process were senior public health officers who had gathered vast experiences in public health practice and had participated in numerous healthcare researches. Data collection was done by the researcher.. Personal Interviews The questions were in two sets because the respondents were PHOs and RPHOs. Even though most of the questions were similar, there were some differences as some questions were not applicable to a group in some cases. The first set was for the supervisors of PHOs (i.e., RPHOs) while the second set was for the PHOs. The questions in both sets were designed to answer the research questions. Questions designed for the investigation of the level of alignment investigated the responsibilities of the PHOs, how they were communicated and what were the targets for those responsibilities. Questions which dealt with the effects of alignment investigated the impact of alignment on the performance of PHOs from the perspectives of PHOs and their supervisors. The question on the support available to PHOs to carry out their responsibilities was included in only the RPHO questions because there was a questionnaire on this dimension for PHOs. All the questions together helped answer the last research question i.e. performance management. The design of both sets of questions went through peer review and expert review. When the questions were designed originally, they were peer reviewed by colleagues in both the fields of public health and human resource development. In both sets, the sequences of the questions had been altered to allow for logical sequencing. In the RPHOs’ questions, Question 1 had been adjusted to key responsibilities instead of responsibilities. The listing of support available for each responsibility had been omitted for Question 3 to only mentioning whether necessary support was available 28.

(43) for the sake of simplicity. This question had been moved from 3 to 5 in the final version. Question 4 had been deleted completely by the expert panel because they advised that a checklist would be more appropriate for that purpose. The questions about the availability of targets and how they were set i.e., Questions 3 and 4 were included only in the final version of the expert review panel. The final version also added how and why to some questions and deleted some statements like ‘check for evidence’ from the previous versions. Appendix A shows the full procedure of the review of RPHOs’ questions. For the PHOs’ questions, the experts suggested to ask for experience in the first question because this was vital to ascertaining their eligibility for participation. For this set too, the question concerning public health documents i.e., Question 3 was deleted both in the peer review and expert review. The question on explaining how targets were set i.e., Question 6 was added to the expert review version so as to have detailed information about PHOs’ knowledge concerning performance planning. In this set too, the questions why and how were added to some questions e.g., Questions 8, 9, and 15. The original version of PHOs’ questions was only 12, but the peer review and expert review versions had 15 and 16 questions respectively. The full procedure of the review of PHOs’ questions is shown in Appendix A. Each interview lasted between 30 – 45 minutes. All the interview questions and the purpose of each and for which category it was intended are shown in Appendix A.. Document Review Documents of the MOHSW related to the job of PHOs were reviewed. These included job descriptions, monthly health facility returns, public health monthly and quarterly returns, reporting tools, abatement notice books, fresh food certificates, condemnation certificate, seizure certificates, the Public Health Act, the Food Act, National Environment Management Act (NEMA). These documents were reviewed 29.

(44) subject to their availability at the Regional Health Team (RHT). They were checked for their availability in the regions, standardization across users and consistence with the strategies of the MOHSW. Standardization was checked to find out whether the same tool was being used by all PHOs in a given region. The documents were checked for consistence to know whether they were in line with legal and operational requirements. Based on the advice and support of the experts who helped review the tools a checklist was developed. The checklist contains most of the documents currently used by PHOs to execute their functions, see Appendix A.. Questionnaire To help the researcher gain more understanding about the availability of factors that supported performance, a questionnaire was developed with reference to Cox, Blake, and Philibert’s (2006) work: valuing the Gilbert model: an exploratory study, with the assistance of classmates in the field of human resource development as well as colleagues in the field of public health. After it was pretested, it was found to be complicated and was not easy for most PHOs to fully comprehend. Therefore, comments from the pretest were incorporated by the expert review panel with reference to the updated behavior engineering model of Lemanski, Wisniewski, and Benson (2011): tales from the field - reaching the quality benchmark - case study and Gilbert’s (1978) work: human competence - engineering worthy performance.. It. was ensured that it captured the six dimensions of Gilbert’s Model and simplified further to enable respondents understand it better. Most of the items on the original questionnaire were either deleted or modified to suit the public health cadre. The original and final versions of the questionnaire are both shown in Appendix A. The questionnaire was used only to help the researcher understand the study subjects better. 30.

(45) Sampling Process There are six health regions in The Gambia. The selection of the three regions from the six was done using random sampling. In a random sample the nature of the population is defined and all members have an equal chance of selection (Marshall, 1996). This was done by writing the names of the six regions on separate pieces of paper which were rolled and balloted. Three pieces were selected at random in succession after thoroughly shuffling. These turned out to be Upper River Region (URR), Central River Region (CRR) and West Coast Region (WCR). Restricting the research to only three regions was dictated by similarity in PHO functions across regions and resource limitations in conducting a nationwide survey. After the selection of the regions, the supervisors of PHOs (RPHOs) in each of the selected regions then automatically qualified to participate by virtue of they being the supervisors of PHOs in those region. Of the three regions selected Six PHOs were selected from URR and CRR each and eight PHOs were selected from Western Region which had the highest number of PHOs. However, the decision with respect to the number of PHOs to be selected from each region was discretionary. The selection of health facilities from which the PHOs were to be selected was also done through random sampling by balloting just as in the selection of the regions. Thereafter, PHOs were selected through purposive sampling. According to Kelly and Richard (2000), purposive sampling is designed to enhance understandings of selected individuals or groups' experiences or for developing theories and concepts by selecting “information rich” participants that provide the greatest insight into the research question. As it was required of participants to have an in-depth understanding of the public health functions to be able to answer the questions, only those PHOs who had served for at least one year in the field were interviewed at the selected health facilities. 31.

(46) Participants of the Study The sample size of this research was 20 PHOs at public health facilities and their respective supervisors (RPHOs) from each of the three selected health regions. These health regions vary greatly in size and other demographics. They all have urban and semi-urban towns in which PHOs work. The work content of PHOs may be different with some devoting more time on one activity than others and vice versa. However, in general terms, their functions are similar regardless of location. PHOs at health facility level who had served for at least one year in the field were eligible to participate. One year was used as a criteria because from consultation with senior practitioners at facility level and some senior public health officers at both central and regional level, this duration was considered long enough for any PHO to engage in all public health activities. However, public health students on their practicum attachments and PHOs who had just graduated from the School of Public Health or the University of The Gambia awaiting appointment and postings even if they have previous work experience were not eligible to participate. After the selection of the regions, the RPHOs of the selected regions became eligible to participate by virtue of their positions because each region had only one RPHO. RPHOs in all regions had accumulated much experience in the field of public health due to their lengths of service in the public health field. The genders and ages of participants as well as their respective regions are withheld as these may reveal their identity. Similarly, the names given here are not real and do not represent any of the respondents. This was done because the interviewees were promised the anonymousness of the research. Their experiences range from one to eight years and fourteen to twenty two years for PHOs and RPHOs respectively. The experiences of the PHOs and the RPHOs are displayed in the table below.. 32.

(47) Table 3.1 Profile of Participants PHOs. PHOs. RPHOs. Name. Experience. Name. Experience. Name. Experience. Pa. 1 year. Mariama. 3 years. Bakary. 22 years. Modou. 1 year. Bailo. 3 years. Omar. 14 years. Isatou. 1 year. Musa. 3 years. Malafi. 20 years. Ensa. 2 years. Sarjo. 3 years. Dawda. 2 years. Haja. 3 years. Elizabeth. 2 years. Paul. 3 years. Yankuba. 2 years. Ousman. 4 years. Mamadi. 2 years. Basir. 5 years. Cherno. 2 years. Sira. 5 years. Fatou. 2 years. Kawsu. 8 years. Research Procedure The topic for this research came about after doing the performance management course at the faculty of International Human Resource Development where this Masters Program is being pursued and as a result of the researcher’s own experience as a public health officer. After the identification of the research topic, literature was reviewed and the conceptual framework was developed. Due to the scarcity of literature specific to the area of this research, the methodology was largely shaped through consultations and reviews by peers and experts both in the field of public health and human resources development. This same procedure was pursued in the design of the data collection tools. The interview questions and the questionnaire were initially developed by the researcher in consultation with peers under the direction of the thesis advisor. After the design, both were further reviewed by experts. They were 33.

(48) then pretested and modified accordingly. These processes where somewhat reiterative in nature. For instance, the questionnaire, though reviewed by both peers and experts, they were pretested and brought back to the experts for the final modification. This was the case for the interview questions too. Thereafter, data was collected by the researcher through interviews, the questionnaires were administered and the documents reviewed. All the collected data from the interviews were transcribed and coded for subsequent analysis while results from the questionnaires were analyzed using SPSS statistical software version 20. The results from the document review were tabulated. Thereafter, the results of all the aforementioned were interpreted based on the research questions to come up with the findings. The findings were then analyzed to draw the conclusions. Based on the conclusions, recommendations were made. The procedure adopted for the conduct of this research is shown in the Figure 3.2.. 34.

(49) Determine topic. 1.. Review relevant literature. Develop framework. Determine methods. 2. 3. 4.. Develop instruments. Design checklist/ questions/questionnaire Peer & Expert review of questions/questionnaire Pretest questions/questionnaire Modify questions/questionnaire. 5. Collect data. Analyze data. 1. 2.. Conduct interviews Review documents. 3. 4.. Administer questionnaire Record data. Transcribe/Code. Generate results. Draw conclusions. Interpret/Reflect. Propose suggestions Figure 3.2 Research procedure. Data Analysis The data analysis procedure for the interview results can be described as had been done using the following steps: 1.. Transcription of responses. 2.. Reading and rereading the transcripts. 3.. Segmenting and coding the data. 4.. Comparing , categorizing and inducing. 5.. Identifying relationships and answering the research questions. The researcher conducted all the interviews face-to-face and transcribed all the responses verbatim. The transcripts were read and reread several times to enable the 35.

(50) researcher gain an understanding of patterns of similar ideas in the responses. The transcripts were then imported into MaxQDA 10 to summarize the data for further analysis and interpretation. MaxQDA 10 is a qualitative software program for managing qualitative analysis (Blake, Kohler, Culler, Hawley, & Rask, 2012).The software provided a medium for organizing the data and retrieving particular data segments for comparison and subsequent analysis. Similar data segments were grouped under the same concepts (referred to as codes in the software) which were then assigned code numbers (codes in this research). The codes were grouped into appropriate concepts. These concepts were further grouped under categories which were then categorized under themes upon which the analyses are based. This process facilitated the use of the themes to answer the various research questions as all the themes were based on the research questions. Memos were also created to explain the meanings of the categories and the assignment of codes. Figures 3.3 and 3.4 show the coding processes of RPHOs and PHOs respectively.. Code. Response. Concepts. A3-R07C1. I analyze the information on the checklists and from Analysis what I observe and make a report; these information are shared with PHOs during in-service meetings i.e. feedback and appropriate actions are taken. A3 –R07 C1 Concept 1 Response 2 of question 7 RPHO in region 3 Figure 3.3 Example of the coding procedure of RPHOs’ responses. 36.

(51) Code. Response. Concepts. B3-01-R02C1. My responsibilities include. B3-01-R02C2. inspection (food and premises), birth and death. B3-01-R02C3. registration, disease surveillance and health. B3-01-R02C4. education. immunization,. C1. Immunization C2. Environment and food hygiene C3. Registrations. B3-01-R02C5. C4. Surveillance C5. Health education & promotion. B3 -01-R02 C1 Concept 1 Response 2 of question 2 Respondent 1 of region 3 PHO in region 3 Figure 3.4 Example of the coding procedure of PHOs’ responses The responses of the supervisors and PHOs were coded together because both sets of questions were similar except for a few minor differences in their application as they pertain to the two groups. However, the codes for supervisors start with A1, A2 and A3 while those of PHOs start with B1, B2 and B3 for the three different regions respectively. The analysis of the documents reviewed was done during the review process. Documents were checked for availability in the particular RHT; standardization across the regions; and consistency with the legal and operational requirements of public health. These dimensions were checked against a checklist which was marked accordingly. The responses to the questionnaire concerning the enabling conditions for 37.

(52) performance were analyzed using SPSS version 20 statistical software to generate the descriptive statistics. The mean, minimum and maximum scores were generated to examine which necessary conditions for performance had the highest and lowest means as well as the minimum and maximum scores. This was done so as to be able to compare the extent of availability of environmental support factors against personal support factors. The results helped the researcher gauge the overall support available for PHOs to perform.. Quality of the Research The interview questions were developed with reference to the review of literature on the various components of the research framework. In order to increase reliability, the questions were discussed several times with the thesis advisor and reviewed by several colleagues in the field of public health as well as human resource development to ensure the relevance of the questions to the research purpose. The committee for the proposal defense also made valuable suggestions with regards to the tools used for the data collection during the defense. Their suggestions were noted and corrections were accordingly made. These enabled the researcher to make adjustments to fit the health sector of The Gambia and to ensure that the research questions were adequately answered. The questions were pretested on PHOs in some selected facilities. Some experts in the field of public health (senior and principal public health officers) both at central and regional levels were consulted to review the questions for comments and advice. Their comments on the questions enabled the researcher in consultation with the thesis advisor to make appropriate adjustments for the data collection exercise. The different adjustments to the questions in each stage of the review are shown in Appendix A. To improve the validity of the research, triangulation was used. In triangulation, researchers make use of multiple and different sources, methods, investigators, and 38.

(53) theories to provide corroborating evidence (Creswell, 2007, p.208). Data as well as between-method triangulation techniques were used to collect the data. According to Flick (2002) data triangulation refers to the use of different sources of data to collect data while between-method triangulation refers to the use of different methods of data collection. Data triangulation was done by collecting data from PHOs and their supervisors as well as reviewing documents related to public health. Documents were reviewed with the aid of a checklist. The checklist was developed based on the advice of the expert review panel and they assisted tremendously in providing the necessary information required for the checklist. On the other hand, between-method triangulation was carried out through interviews and the use of a questionnaire.. Consent and Ethical Approval Ethical clearance to conduct the study was sought from the Director of Health Services formally seeking his consent and permission for the conduct of this research. Before starting the data collection exercise, the Regional Health Teams (RHTs) concerned were notified about the procedure of the research. Also, approval was sought from the RHTs for the PHOs to take part in the study. The informed consent of respondents was sought before the administration of the questionnaires. To ensure the privacy of the respondents, the survey was strictly anonymous and participants’ responses were kept confidential. Participation was voluntary. Participants were also informed that they could refuse or discontinue participation at any time during the interview.. 39.

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(55) CHAPTER IV FINDINGS AND DISCUSSIONS 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 41.

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