SCHOOL OF PUBLIC HEALTHCOLLEGE OF HEALTH SCIENCESUNIVERSITY OF GHANA, LEGON ASSESSMENT OF STRATEGIC MANAGEMENT PRACTICE OF MALARIA CONTROL IN THE DANGME WEST DISTRICT, GHANA THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PHILOSOPHY (MPhil) HEALTH, POLICY,PLANNING, AND MANAGEMENT DEGREE ADELAIDE MARIA ANSAH OFEI ID. 10213368 Co-Supervisors: Submitted: September 2007 Dr. F. K. Wurapa Prof. E. A. Afari Dr. R. K. O. Asante University of Ghana http://ugspace.ug.edu.gh ii DECLARATION I certify that this thesis has not already been submitted for any degree and is not being submitted as part of candidature for any other degree. I also certify that the thesis has been written by me and that any help that I have received in preparing this thesis; and all sources used, have been duly acknowledged in this thesis. ………………………………………. Adelaide Maria Ansah Ofei ………………………………………….. Dr. Frederick K. Wurapa …………………………………………. Prof. Edwin A. Afari …………………………………………… Dr. Rexford O. K. Asante University of Ghana http://ugspace.ug.edu.gh iii DEDICATION This work is dedicated to the memory of my dear late husband, Dr. Kwadwo Ansah Ofei, my children, Selma, Yaw Titi, Kwadwo Ansah and Kwaku Quartey for their support and encouragement. It is also dedicated to my mother, Madam Faustina Haizel Commeh and my sisters, Mrs. Magdalene Abude and Ms. Verona Dadson, whose tireless efforts gave me the courage to complete this work. University of Ghana http://ugspace.ug.edu.gh iv ACKNOWLEDGEMENTS The thesis could not have been completed without the help and guidance of many individuals and entities. First, I would like to thank my organization the Ghana Health Service, and the Department of Health Policy, Planning and Management, School of Public Health for financial support for the study. My deepest gratitude goes to my principal supervisor Dr. Fred Wurapa, Head of the Department of Health Policy, Planning and Management for his countless efforts in bringing this work into fruition. I am exceedingly beholden to the co-supervisors; Prof. Edwin A. Afari, of the Department of Epidemiology, for his technical advices and comments, and Dr. Rexford K. O. Asante for his support. I would like to show appreciation to Dr. Margaret Gyapong and staff of Health Research Unit, Dr. Evelyn Ansah and staff of DHD, and all healthcare providers of the Dangme West for their help in data collection. I am equally indebted to my good friend Prudence P. Mwinituo, lecturer of School of Nursing whose comments helped shaped my qualitative analysis. Very special thanks goes to my late husband, Dr. Kwadwo Ansah Ofei and my children, Selma, Yaw Titi, Kwadwo Ansah and Kwaku Quartey for sharing a home with a mother who was always surrounded with books and papers. My dear mother and sisters could not be left out; their steady support and care really saw me through the dark days of this programme. I also recall with gratitude the support and encouragement given me by the director, Dr. Ken Sagoe and staff of the Human Resource Directorate, GHS. Finally, I wish to thank Dr. Irene Agyepong, Regional Director of Health Services, Greater Accra, whose critical review and comments tremendously improved this thesis; I will forever be indebted to her. University of Ghana http://ugspace.ug.edu.gh v ABSTRACT Objective: To assess the strategic management practice for malaria control in the Dangme West district. Methods: Strategic management (SM) practice was assessed in all HCFs both in the public and private and some chemical shops within the Dangme West district using semi- structured questionnaires and question guides. In-depth interviews were carried out with healthcare providers in their clinical setting. The status of key malaria control indicators was assessed by interviewing 385 healthcare consumers and 100 pregnant women who were selected by multi-stage cluster sampling from 21 communities. The study utilized both qualitative and quantitative methods in describing the SM practice and assessing status of key malaria control indicators. In addition to the above data was also collected through desk top reviews of HCFs‟ records, district‟s health annual reports, published and unpublished literature, textbooks, etc. Results: Healthcare managers were using all the elements of SM in the management of malaria but these were not holistically coordinated. Present were short ranged informal planning based on the objectives of NMCP and day-to-day operation of the HCFs especially with Ghana Health Service facilities. Due to homogenous nature of Dangme West district, management of culture wasn‟t given much attention by healthcare managers though healthcare providers were acutely aware of its importance to quality service delivery. Competition was woefully absent in the healthcare environment. No formal structure has been created for the management of malaria control activities with the exception of the involvement of Community Based agents. The district was widely implementing all the strategies of the NMCP with favourable outcomes. University of Ghana http://ugspace.ug.edu.gh vi Conclusions: The practice of strategic management though present in the district, it was fragmented. Hence, while there was significant improvement in the status of key malaria control indicators, this could have been further enhanced if the practice of strategic management has been carried out in a more holistic way. Thus, the assumption; the degree to which malaria control is systematically managed using the process of SM will enhance the status of key malaria control programme indicators is true. HCFs should be able to define their needs based on the realistic needs of the communities and develop plans, which would creatively lead to competitive advantage. There should be adequate involvement of chemical sellers in training programmes for healthcare providers with keen supervision and monitoring of their activities within the district. BCC should target groups to make it more acceptable using local approaches. Strategic Management should be developed as a taught course for In-Service Training within the service for all staff in leadership and management positions. Key words: Assessment, Strategic management, Practice, Malaria control, Dangme West University of Ghana http://ugspace.ug.edu.gh vii Table of Contents DECLARATION .......................................................................................................................................II DEDICATION ......................................................................................................................................... III ACKNOWLEDGEMENTS ..................................................................................................................... IV ABSTRACT ............................................................................................................................................... V LIST OF TABLES ..................................................................................................................................... X LIST OF FIGURES ................................................................................................................................. XI ABBREVIATIONS/ACRONYMS ......................................................................................................... XII CHAPTER ONE: ........................................................................................................................................1 INTRODUCTION .......................................................................................................... 1 1.1 Background........................................................................................................... 1 1.2 Statement of the Problem ................................................................................... 10 1.3 Justification for the Study ................................................................................... 11 1.4 Conceptual Framework ...................................................................................... 12 1.5 Research Objectives ........................................................................................... 15 1.6 Definition of Key Terminologies ........................................................................ 16 CHAPTER TWO ...................................................................................................................................... 17 LITERATURE REVIEW ............................................................................................. 17 2.1 The Theory of Strategic Management ............................................................. 17 SOURCE: HUSSIN J. HEJASE, DIMA A. BALTAGI, AND KASSEM KASSAK (2000) ..................... 19 2.2 Situation Analysis and Strategy Formulation ................................................... 21 2.3 The Implementation Process or Strategy Implementation ................................ 27 2.4 Programme Monitoring and Evaluation or Strategic Control ........................... 35 2.5 Status of Key Malaria Control Indicators ........................................................ 36 CHAPTER THREE .................................................................................................................................. 43 METHODS .................................................................................................................. 43 3.1 Study Area ...................................................................................................... 43 3.2 Study Design .................................................................................................. 45 3.3 Data Collection tools ...................................................................................... 45 3.4 Data Collection Technique .............................................................................. 46 3.5 Operational Definition of Variables ................................................................ 47 3.6 Study Population............................................................................................. 54 3.7 Sample Size Calculation of Healthcare Consumers and Pregnant Women ....... 54 3.8 Sampling ........................................................................................................ 56 Pregnant Women ...................................................................................................... 57 Opinion Leaders ....................................................................................................... 58 3.9 Sources of Data .............................................................................................. 58 3.10 Recruitment and Training of Data Collectors ............................................... 58 University of Ghana http://ugspace.ug.edu.gh viii 3.11 Data Quality Control Measures ................................................................... 59 3.12 Data Analysis .............................................................................................. 59 3.13 Ethical consideration ................................................................................... 60 3.14 Utility of the Study ...................................................................................... 60 3.15 Institutional support for the study ................................................................ 60 CHAPTER FOUR .................................................................................................................................... 61 RESULTS AND FINDINGS ........................................................................................ 61 4.1 Introduction .................................................................................................... 61 4.2 Objective 1: To Describe the Conduct of the Situational Analysis Phase of Strategic Planning in Dangme West. ......................................................................... 63 4.3 Objective 2:To Describe the Planning Process of malaria control in the district. .. 73 4.4 Objective 3: To Describe Implementation of NMCP Strategies in the District . 77 4.5 Objective 4: To Assess Systems Designed for Monitoring and Evaluation of Malaria Control Activities within the district ............................................................ 88 4.6 Objective 5: To Describe the Status of Key Malaria Control Indicators .............. 91 CHAPTER FIVE .................................................................................................................................... 119 DISCUSSION OF FINDINGS ................................................................................... 119 5.0 Introduction .................................................................................................. 119 5.1 Objective 1: To Describe the Conduct of the Situational Analysis Phase of Strategic Planning in the Dangme West district. ...................................................... 120 5.2 Objective 2: To Describe the Planning Process of Malaria Control in the District. ................................................................................................................... 128 5.3 Objective 3: To Describe Implementation of NMCP Strategies in the District 130 5.4 Objective 5: To Assess Systems Designed for Monitoring and Evaluation of Malaria Control ...................................................................................................... 139 5.5 Objective 6: To Describe the Status of Key Malaria Control Indicators ......... 140 5.6 Key Findings ................................................................................................ 150 CHAPTER SIX ....................................................................................................................................... 154 CONCLUSIONS, POLICY AND RECOMMENDATION ......................................... 154 6.0 Introduction .................................................................................................. 154 6.1 Implications for Health Policy, Planning and Management ........................... 154 6.3 Implications for Future Research .................................................................. 157 6.4 Insight Gained .............................................................................................. 157 6.5 Limitations of the study ................................................................................ 159 6.6 Conclusions .................................................................................................. 159 6.7 Recommendations......................................................................................... 161 REFERENCES ....................................................................................................................................... 165 APPENDICE .......................................................................................................................................... 175 Appendix 1 ................................................................................................................. 175 APPENDIX 2 .......................................................................................................................................... 184 APPENDIX 3 .......................................................................................................................................... 187 APPENDIX 4 .......................................................................................................................................... 190 University of Ghana http://ugspace.ug.edu.gh ix APPENDIX 5 .......................................................................................................................................... 191 University of Ghana http://ugspace.ug.edu.gh x LIST OF TABLES Table 3.1 Population projection for Dangme West district…………………………..44 Table 3.2 Dangme West district healthcare facilities and staff…………………..….45 Table 3.3 Operational Definition of Variables……………………………………….46 Table 4.1 Demographic Characteristics of Healthcare Managers……………..….…62 Table 4.2 Characteristics of Pregnant Women..………………...….………………..63 Table 4.3 Communication of Operational Strategies…………………………………66 Table 4.4 Objectives for the Management of Malaria Control activities……………..67 Table 4.5 Management Tool Used in the Situational Analysis……………………….68 Table 4.6 Environmental factors used for external auditing………………………….69 Table 4.7 Methods for internal auditing………………………………………………72 Table 4.8 Facility weakness…………………………………………………………..73 Table 4.9 Key partners involved in the planning process…………………………….75 Table 4.10 Activities held by healthcare managers………………………………….....77 Table 4.11 Factors impacting on promotion of malaria control….……………………78 Table 4.12 Systems Developed for Appropriate Referral and Response…….………..83 Table 4.13 Measures for Delivering Quality Healthcare Services……………..………83 Table 4.14 Constraints Hindering Malaria Control……………………….……….......87 Table 4.15 Control Process Enacted for Malaria Control……………………………..90 Table 4.16 Feedback Approach for Control Process……………..……………………90 Table 4.17 Partners Involved in Monitoring and Evaluation…..………………….......91 Table 4.18 Drugs for Management of Malaria…………………………………….......97 Table 4.19 Knowledge of Malaria by Healthcare Consumers…………………………98 Table 4.20 Home-Based Management of Children with Malaria………..……………99 Table 4.21 Drugs Used in the Management of Malaria………………….…………...101 Table 4.22 Household Utilization of ITNs…………………..……………………….104 Table 4.23 Name of Drug Used for IPTp as Given by Pregnant Women………..…..108 Table 4.24 Adverse Effects Developed by Pregnant Women……..……………........113 Table 4.25 Development of Malaria in Pregnancy and SP...………………..……….113 Table 4.26 Treatment for Malaria in Pregnancy…………………………..……........114 University of Ghana http://ugspace.ug.edu.gh xi LIST OF FIGURES Figure 1.1 Trends in Reported Out-Patient Malaria Cases (2002-2006)..………….6 Figure 1.2 Percentage of Malaria Cases in Under Fives and above Fives…….……7 Figure 1.3 The Conceptual Framework..………………………………………......14 Figure 2.1 The Strategic Management Process……………………………………19 Figure 3.1 Dangme West District Map Showing the Location of Health Facilities...44 Figure 4.1 Vision of National Malaria Control Program…………………..…….....64 Figure 4.2 Types of Planning ………………………….……………………….…..74 Figure 4.3 Duration of Plans……...………………………………………………...75 Figure 4.4 Frequency of Planning Meetings..…………………………………........76 Figure 4.5 Resistance to Change..……………………………………………..........77 Figure 4.6 Staff Trained in the Strategies of NMCP……………………………….79 Figure 4.7 Frequency of Staff In-Service Training.………………………………...79 Figure 4.8 Culture and Leadership Style Adopted for Malaria Control…………...80 Figure 4.9 Frequency of Control Process..…………………………………………89 Figure 4.10 Reported Cases of Malaria in 2006………………………………….....92 Figure 4.11 Severe Malaria Cases in Children under five Recorded by CBAs…......94 Figure 4.12 Average Birth Weights before and after Inception of SP……….……..95 Figure 4.13 When to Seek Further Management for Malaria at HCF……………..100 Figure 4.14 Education of NMCP Strategies to Community Members……………..102 Figure 4.15 Knowledge, Acquirement and Utilization of ITNs.……………………103 Figure 4.16 Multiple Prevention of Malaria by Healthcare Consumers……………106 Figure 4.17 Perception and Attitude of Healthcare Providers.……………………...107 Figure 4.18 Source of Information on IPTp……………..………………………….108 Figure 4.19 Information on IPTp and Utilization of IPTp………………………….109 Figure 4.20 Utilization and Adverse Effects of IPTp……………………………….109 Figure 4.21 Uptake of IPTp-SP.…………………………………………………….110 Figure 4.22 Uptake of IPTp versus Gestational age/Time after delivery…………....111 Figure 4.23 Adverse Effects and Willingness to Take more Doses..……………….112 University of Ghana http://ugspace.ug.edu.gh xii ABBREVIATIONS/ACRONYMS ANC Antenatal Care BCC Behaviour Change and Communication CBAs Community Based Agents CDO Community Drug Officers DA District Assembly DDHS District Director of Health Services DHA District Health Administration DHD District Health Directorate DHMT District Health Management Team DSS District Surveillance System GHS Ghana Health Service GLSS4 Ghana Living Standard Round 4 GSS Ghana Statistical Service HCF Healthcare Facility HRU Health Research Unit IPTp-SP Intermittent Preventive Treatment for Pregnancy IST In-Service Training ITNs Insecticide Treated Nets MDAs Ministries, Departments, and Agencies M&E Monitoring and Evaluation NADMO National Disaster Management Organization NGOs Non-Governmental Organizations NHIS National Health Insurance Scheme NMCP National Malaria Control Programme PPAG Planned Parenthood Association of Ghana RBM Roll Back Malaria SM Strategic Management SP Sulphurdoxine Pyrimethamine SWOT Strengths, Weaknesses, Opportunities and Threats University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE: INTRODUCTION 1.1 Background The healthcare system in Ghana is confronted with the formidable task of improving and guaranteeing the health and well-being of all people living in Ghana. Such a broad goal encompasses many specific objectives for individuals and populations, e.g. increased life expectancy, reduction in avoidable deaths and improvement in quality of life. Recognizing that resources are never adequate, a rethinking and restructuring of priorities is inevitable at all levels. Thus, the health care system has since independence gone through series of progressive reforms intended to develop and improve public health practice in Ghana. Prominent among these reforms, are the adoption of Primary Health Care (PHC) concept, creation of the Ghana Health Service by an act of parliament (Act 525), development of the Medium Term Health Strategy (MTHS) and a 5-year Programme of Work (PoW). In all these developmental approaches malaria control has been given some form of prominence. Malaria as a public health challenge seems to be on the increase globally with over 1-2 million deaths each year. Over 90% of these are African children who due to poor access to health care facilities and local perceptions about the disease fail to seek prompt help. Indeed, malaria is accredited to be a major cause of poverty and low productivity especially in poor countries (Ijumba et al., 2004). It is estimated that the annual economic burden of malaria in Africa is about US$ 1.7 billion or 1% of the Gross Domestic Product. In Ghana, malaria is hyper-endemic and accounts for more than 44% of reported out-patient visit and an estimated 22% of under-5 mortality. Reported cases however, represent only a small fraction of the University of Ghana http://ugspace.ug.edu.gh 2 actual number of malaria episodes in the population because the majority of people with symptomatic infections are treated at home and not reported (Ghana Malaria Program, 2005). Malaria is a life threatening disease in individuals with low or impaired immunity, but malaria is both preventable and curable. Ghana therefore, has identified Malaria as one of its priority diseases targeted for control in the medium term. Resources are sent directly by the National Malaria Control Programme (NMCP), with support from the Global Fund, Development Partners, etc. to the district for the management of malaria and other diseases of public health concern to help strengthen decentralization (MTHS, 1995). For instance available data at the NMCP office showed that from 2004 to 2006 first quarter, a total of thirty thousand and one dollars, ninety seven cents ($30,001.97c) was sent to the Dangme West district health directorate for malaria control activities. The issue is, what management processes have these healthcare managers put in place to cope with the increasing trend of morbidity and mortality associated with malaria? Strategic management (SM) according to Duncan (1996) is a major thrust that would guide the management of healthcare organizations to anticipate and cope with the variety of external forces operating beyond their control. 1.1.1 Concept and Definition of Strategic Management (SM) “Strategic” is the most overused word in the vocabulary of business. Frequently, it is just another way of saying, “this is important”, but the aim of true strategy is to master environment by understanding and anticipating the actions of other economic agents, especially competitors (Greenwald and Kahn, 2005). A strategy to a programme is amongst other things a plan of how the programme can achieve its goals and objectives (Davies 2000; Mintzberg, 1996). It is a „commitment of present resources to future expectations‟ (Drucker, University of Ghana http://ugspace.ug.edu.gh 3 1999). The aim of SM is to decide on programme goals, the means of achieving those goals, and ensuring that the programme is sustainably positioned in order to pursue these goals. Furthermore, the strategies developed provide a base for managerial decision making (Robbins et al., 2000; Browne 1994; Porter, 1980). SM according to Macmillan and Tampoe (2000) is the most exciting of the management disciplines which requires both clear thought and judgment in envisioning and realizing the future. SM uses the systems approach in the management of programmes with the assertion that the whole is greater than the sum of its parts. Hence, SM gives a holistic approach to management and attempts to achieve a fit between the organization‟s external environment (political, regulatory, economic, technological, social and competitive forces) with its internal situation (vision, values, culture, finance, organization, human resources, marketing, information systems, etc). Through SM, programmes gain a framework providing structures necessary to the management process. SM allows programmes and their managers to identify opportunities and threats within the environment, formulate plans to exploit some of those opportunities, and marshal the resources to implement those plans. SM process may be applied at different levels in the organization; the corporate level, the divisional level and the operational level. These levels in the GHS are the Headquarters, the regions and the districts respectively. The resulting strategies differ in scope as well as in purpose from one level to the other. SM is a unique perspective that requires managers to cease thinking solely in terms of internal operations and adopt what may be a fundamentally new attitude; an external orientation. It is basically optimistic in that it integrates “what is” with “what can be”. SM is both a skill and an art; it has body of knowledge that can be learnt and techniques that can be University of Ghana http://ugspace.ug.edu.gh 4 used with greater or lesser competence while dealing with a future that is unknowable and with the hearts and minds of people that transcend reason (Macmillan and Tampoe, 2000). Understanding the nature of the healthcare environment, the relationship of the programme to that environment, and the often conflicting interests of internal functional units requires a broad conceptual paradigm to comprehend so many and important interrelationships. The “system‟s thinking” is a useful framework for organizing and understanding the variables of strategic management. SM according to Duncan et al. (1996) is an externally-oriented philosophy of managing an organization that links strategic planning to operational decision- making. Strategic managers constantly relate the programme to its external environment, not just to assure compatibility and survival, but also to understand the environmental trends sufficiently well to “create the future.” The practice of SM therefore, is the key for efficient and effective malaria control programme because it would bring a proactive and creative dimension to the totality of management. SM would be able to identify clients‟ needs and attempt to satisfy these needs competently. With adequate survey of the environment, a fit is always being managed with considerable involvement of stakeholders and efficient management of resources. 1.1.2 The Global Fund Approximately a decade ago, the United Nations declared HIV/AIDS, tuberculosis (TB) and malaria global emergency. These three diseases were publicly recognized as a threat to the social and economic stability of the world. In view of this challenge, the World Economic Forum launched the Global Health Initiative (GHI) to increase the quality and quantity of private sector responses in the fight against HIV/AIDS, TB and malaria. Now, the GHI or the Global fund is the largest public-private expert network on HIV/AIDS, TB and malaria in University of Ghana http://ugspace.ug.edu.gh 5 the world. It works to catalyze public-private partnerships in health around the world through innovative policy frameworks. The Global Fund is the largest contributor to the three diseases and engages businesses for synergistic and sustainable contributions to health. 1.1.3 The Ghana National Malaria Control Programme Strategies Ghana‟s malaria control strategy, which has been adopted by the RBM Partnership, involves multisectoral and intersectoral partnerships working together on an agreed plan with the goal of reducing death and illness caused by malaria by 50% by 2010. Progress has recently been made in improving access to prompt and effective treatment, supply of ITNs and using IPT with SP. Based on evidence from drug efficacy studies, Ghana has recently changed from Chloroquine to Artesunate Amodiaquine for treatment of uncomplicated malaria. IPT for pregnant women has now been extended to all districts, including training for health staff with funds from the Global Fund. On Africa Malaria Day, that was 25 th April 2005, Ghana launched a wide-scale ITN voucher programme and used high-impact media and advocacy pieces to raise awareness about malaria at community level. Available data at the NMCP suggested that the Global Fund has committed a total of US$8,552,684.05 and US$29, 987,776 in two grants namely round two (2) and round four (4) respectively. The NMCP has disbursed monies based on individual proposals from either districts or NGOs for malaria control activities and the Global Fund has been a key financier to NMCP. Ghana adopted the Roll Back Malaria (RBM) initiative in 1999. The NMCP developed a strategic framework to guide its implementation at all levels (national, regional, district and community levels). Significant to the RBM initiative has been the under listed strategic components: University of Ghana http://ugspace.ug.edu.gh 6 Improved malaria case management; to ensure early detection and rapid treatment for malaria at all levels from household to referral health facility. Multiple prevention interventions; to reduce the occurrence of malaria in the country. Research and Development; to ensure that efforts to RBM are supported and informed by well-researched information. Create and sustain partnership; establish social movement that is supported by well coordinated national action supported by all stakeholders to RBM. These strategic components have guided the entire management of malaria control being promulgated by the NMCP. 1.1.4 Situation of Malaria in the Dangme West District Figure 1.1: Trends in Reported Out-Patient Malaria Cases 2002 - 2006 Trends in Malaria Cases over the Trends in Malaria Cases over the yearsyears 0 10000 20000 30000 40000 50000 60000 70000 2002 2003 2004 2005 2006 N o. n ew c as es Total Malaria Non-malaria Source: Dangme West Annual Report, 2006 Malaria is hyper-endemic in Dangme West district, and like any other rural district in Ghana, reported malaria cases at the OPD have consistently risen over a period of five years (2002- 2006) with a percentage rate of reported cases of febrile cases presumed as malaria at 51% University of Ghana http://ugspace.ug.edu.gh 7 and annual reported cases of about 23515 (Annual report, 2006). Transmission was all year round but seasonal with peak transmission usually during the rainy season. Gyapong et al., (2005) asserted that local perceptions of malaria such as the different types of malaria and their mode of management may have accounted for the persistent increase. Community members perceived that there were two types of “Asra” (term for malaria); the “Eyoo” female type was mild while “Eku” which was the male type was more serious and can kill. Uncomplicated malaria was mostly managed at home. Inhabitants only visited healthcare facilities when faced with “Eku”. Figure 1.2: Percentage of Outpatient Malaria Cases in Under-Five Years and Above Five (2005) 0 20 40 60 80 100 120 Dodo w a Ago m ed a Dawhe ny a Nya gb en ya CH IP S Afie nya G ra ce You th Above five % Under five % Healthcare facility % Malaria cases Source: Dangme West Annual Report, 2005 Malaria accounted for the highest reported cases in the out-patient attendance and for the past five years, it had been among the five top communicable diseases in the district. According to district annual reports, the reported malaria cases within that period have been between 69.7 to 86.0 %. Malaria in pregnancy have been equally an issue in the district with 575 (1.9%) reported cases only in 2005. University of Ghana http://ugspace.ug.edu.gh 8 Another concern of the district was the high reported cases of malaria in the under-fives. Although the under-fives was just 12.82% (16,095) of the projected population of 2006, the out-patient reported cases of malaria for the under-fives ranged between 15.4% (229) in Grace clinic to 45.1% (316) in Nyigbenya clinic as compared to the percentage reported cases of the above-fives. Thus, clearly malaria affected the under-fives more than any other age group in the district. 1.1.5 Malaria Control in the Dangme West District Management of malaria within the district has been the integrated approach (where all diseases of public health interest are being managed by the same healthcare providers) to public health diseases and for the past three years, the malaria control programme has been funded mostly by the Global fund. Proposals were written quarterly to the Global Fund to solicit for funds for activities delineated for malaria control. Objectives outlined for the control programme included the following: Provision of Intermittent Preventive Treatment (IPTp) to pregnant women; Promotion of home-base management of malaria; Promotion of the use of Insecticide Treated Nets; and Monitoring and Evaluation of the programme. Activities carried out were the following: BCC on IPT, ITNs and Home-Based care had been on-going in all out-patients departments, church groups, mosques, schools and market places in the sub- district; University of Ghana http://ugspace.ug.edu.gh 9 All Community Health Nurses in the district as well as new midwives have been taken through orientation on Intermittent Preventive Treatment (IPTp), ITNs and Home Based Care; ITNs from the DHMT had been heavily subsidized and given to all health facilities and outreach points for pregnant women and mothers with children under five; Community Based Agents (CBAs) in the communities had been trained in home- based care, to treat and re-treat nets, to follow-up pregnant women referred to healthcare facilities at home and to report any adverse effects to the clinic quickly; Staff, NGOs, and Community Drug Distributors in all the sub-districts had been trained to monitor side effects of SP; Community Drug distributors had been trained to identify and distribute rectal Artesunate for the initial management of nil-per-os malaria at community level; and Unique system had also been developed for the monitoring of CBAs in the district. The Health Research Unit (HRU) in Dodowa has also played a major role in malaria control within the district. Many clinical trials and surveys have been carried out by the unit and these have greatly enhanced and sustained malaria control in the district. Significant among these trials have been the deployment of rectal Artesunate to the CBAs to prevent severe malaria in the under fives. The District Assembly has also contributed towards the malaria control process; one percent of its budget has been annually allocated to the activities of malaria control. Records University of Ghana http://ugspace.ug.edu.gh 10 available at the DHD indicated that within the period of 2003 and 2004, the district assembly gave one thousand dollars ($1000.00) and one thousand five hundred and seventy five dollars, thirty two cents ($1,575.32c) respectively for the implementation of malaria control activities. Although they were not part of the decision-making body, the District Health Directorate would submit to the assembly their budget for a particular period to access the package. Other partners involved in the Malaria Control Programme were the NGOs namely World Vision, PPAG and African Youth Alliance. 1.2 Statement of the Problem As GHS continues with its decentralization process, resources are being disbursed directly to the district for the delivery of healthcare services. For example, financial data at the Dangme West DHD showed that between 2005 and 2006 first quarter the NMCP/Global Fund sent twenty thousand, six hundred and thirty dollars, seventy six cents ($20,530.76c) to the DHD for malaria control activities. It is however, uncertain what structures the districts have developed to manage the health system in coping with the increasing malaria morbidity and mortality. Malaria is a public health problem which no doubt accounts for a substantial disease burden in the Dangme West and for many years various control measures have been undertaken with limited success. The percentage of reported cases of febrile illness presumed as malaria at the OPD has consistently risen over a period of five years (2002-2006) with annual OPD reported cases of 17675 to 30070. Current percentage rate of reported cases of febrile illness presumed malaria at the OPD was 51 percent (DHD Annual report, 2006), which was just the tip of ice burg because most people managed uncomplicated malaria at home. What management processes have the healthcare managers practiced all this while and how have University of Ghana http://ugspace.ug.edu.gh 11 they managed increased morbidity and mortality in malaria control? What are the outcomes of the efforts exerted by healthcare managers in malaria control? The assumption for the study is that the degree to which malaria is managed using the process of strategic management will improve the status of malaria control indicators within the district. This study describes the extent to which strategic management process is being used to manage malaria control in the Dangme West district. There are numerous decisions and actions that managers and administrators take in the course of operating a development programme. While all of them have an impact on the direction of the programme and its outcome, certain interventions by the government and the programme leadership is critical in that they provide the basic framework for operational decisions and set the pace for programme performance. This means that for effective and efficient malaria control, we should go beyond the leadership, resources and political commitment bit and use holistic approach or the SM approach in the management of malaria within the district as suggested by Paul (1983). Pertinent questions that need to be asked in this study are what management processes have the district developed for malaria control and how has management thought their way out to cope with increasing morbidity and mortality of malaria? The reason for using the SM model was that this area has not been studied in depth although it is a promising area. 1.3 Justification for the Study The study aims to evaluate the extent to which the practice of SM is fully integrated into the management principles of GHS at district levels and make recommendations for the way forward to improve strategic management practice. This will give a holistic approach to University of Ghana http://ugspace.ug.edu.gh 12 management such that malaria control programmes can wholly be linked to their environment with realistic objectives that can always be verified. It will also ensure appreciable handling of the three major spheres of administrative responsibility of health care managers namely, day-to-day operations, management of the culture of the health care facility and management of strategy. All three must coexist and synergize each other for optimal performance or output. The district is the operational level of the Ghana Health Service. It is the operational level where all decisions concerning the delivery of healthcare are implemented. The study will provide knowledge about issues and needs of district health system management and directions for strategic management in malaria control. It will let the membership of DHMT appreciate the importance of their environments especially, the concept of competition. Develop a common sense of purpose and shared values with the community thus, improving effectiveness and efficiency of malaria control programme within the district since malaria is a developmental issue. It will encourage management training for all healthcare providers regardless of the size and site of the healthcare facility. 1.4 Conceptual Framework SM is most easily understood, studied and applied by using a conceptual model of the process. The use of a descriptive model, based on systems thinking, provides an overview of the rationale, logic, context, and the inherent interrelationships in the process of strategic management (Duncan et al., 1996). The assessment of the practice of SM in the district can be best studied with a logical framework. The conceptual framework will provide an outline for the study and a framework of significant variables and their relationships. University of Ghana http://ugspace.ug.edu.gh 13 This model therefore, illustrates and organizes the major components for district health systems. It represents a clear and practical understanding of the organizational setting (the external environment) for health care as well as the healthcare facility itself. The SM process is made up of 4 stages namely: (1) the situation analysis; (2) the formulation or planning stage; (3) the implementation stage; and (4) the monitoring and evaluation stage. The situation analysis stage in this study of the extent of SM practice in malaria control in the Dangme West district comprises of the vision of NMCP, vision of malaria control in the Dangme West district, the mission or operational objectives of NMCP, the goals of the NMCP and the internal and external environmental analyses of healthcare facilities. The situation analysis provides the information for the formulation stage or the planning process of the programme. The strategic analysis process, depicted in figure 1.3, focuses on the integration of opportunities with distinctive competences. The internal analysis is used to identify assets (resources) and competences (capabilities) currently possessed by the healthcare facility. These would influence the strategic options developed in the next stage of the planning process, as would the external market environment of clients and competitors. The formulation or planning stage involves analysis of data generated from the situation analysis into strategies or action plans for implementation. Strategies may be developed around existing assets or distinctive competences through matching them with environmental opportunities (Pearce II & Robinson, 1994). Alternatively, they may identify new University of Ghana http://ugspace.ug.edu.gh 14 Feedback competences that would be acquired, developed and supported. Growth strategies such as product expansion, market expansion, and diversification often require that competences should be extended and enhanced to meet environmental opportunities (Aaker, 2001). Figure 1.3: The Conceptual Framework Within the bounds of this framework, the independent variables such as the vision of NMCP, goals of NMCP, external and internal environmental analysis, a number of candidate strategies will be generated. From these candidate strategies, the selected strategies will determine the products and services to be provided, in effect, the healthcare facility‟s position and scope. The products and services to be produced, in turn would determine the Vision of NMCP, Mission/Operational goals of NMCP, Objectives of NMCP External analysis of the environment (Opportunities and threats) Internal analysis of healthcare facility (Strengths and weakness) Planning process for malaria control program would generate strategies and activities for the program (STRATEGY FORMULATION) Promotion of NMCP objectives Implementation of planned strategies and activities of malaria control (STRATEGY IMPLEMENTATION) Monitoring and evaluation of strategies and activities of malaria control (STRATEGY CONTROL) Status of key malaria control indicators Feedback University of Ghana http://ugspace.ug.edu.gh 15 resources, which include knowledge, skills, attitudes and logistics required to produce them (Teece, Pisano & Shuen, 1997). The implementation stage involves putting all the strategies or plans developed into action within the stipulated time. Effective implementation requires careful selection, development of system or structures and management of both the programme assets and competences required to support the strategies. It also requires effective promotional strategies, human resource development and good motivational process. The final stage is the monitoring and evaluation of the programme. Information from the monitoring and evaluation then feeds back into the situation analysis. Effective utilization of the SM process, all things being equal will improve the status of malaria control indicators in the district. The aim of SM is to ensure that organizations are competitive and able to satisfy both clients‟ and stakeholders‟ expectations. 1.5 Research Objectives 1.5.1 General Objectives To assess the extent of strategic management practice for malaria control and the current status of key Malaria Control Programme indicators in the Dangme West district. 1.5.2 Specific Objectives 1. To describe the extent and approach to the conduct of the situation analysis phase of strategic planning in the district. 2. To describe the extent and approach to the conduct of the planning process of malaria control in the district in relation to its environment; 3. To describe strategies used in the implementation of NMCP strategies in the district; University of Ghana http://ugspace.ug.edu.gh 16 4. To describe systems designed for monitoring and evaluation of malaria control activities within the district; and 5. To describe the status of malaria control programme indicators in the district. 1.6 Definition of Key Terminologies Healthcare managers: officers‟ in-charge of healthcare facilities or chemical shops in the district. Healthcare providers: healthcare professionals/chemical sellers providing healthcare services in the district. This shows that all healthcare managers are also healthcare providers. Healthcare consumers: residents in the district who are patronizing the services of healthcare providers. Strategic management: formulation of the programme‟s strategies and plans using vision, mission, and the strategic objectives of NMCP with assessment of the external and internal environments (SWOT analysis); plans and strategies are then implemented, after which monitoring and evaluation is carried out. External environment: physical surroundings and conditions outside the healthcare facilities which affect peoples‟ lives in the district. Healthcare facilities: public health institutions, private health institutions, private-not-profit health institutions or chemical shops providing healthcare services to people within the district. Structure: formal/informal system of task and reporting relationship that controls, coordinates, and motivate employees so that they cooperate and work together to achieve organizational goals. University of Ghana http://ugspace.ug.edu.gh 17 CHAPTER TWO LITERATURE REVIEW 2.1 The Theory of Strategic Management SM can be defined as a continuous, iterative process aimed at keeping an organization as a whole appropriately matched to its environment (Certo & Peter, 1988, p.5). It is a process of making explicit the goals of the enterprise, the environment in which it operates, the strategies, and finally the feedback loops that tell the firm whether each of these steps has been identified correctly (Gardner & Rachlin, 1986, p. 2). Furthermore, it is a stream of decisions and actions that leads to the development of an effective strategy or strategies to help achieve corporate objectives (Jauch & Gluek, 1988, p. 5). What is more, SM is the way in which strategists determine objectives and make strategic decisions with regard to: (a) Determine the organization‟s mission; (b) Establishing long and short-range objectives to achieve the organization‟s mission; (c) Determining the strategy that is to be used in achieving the organization‟s objectives; (d) Formulating policies to guide the organization in establishing, choosing a strategy, and implementing the chosen strategy (Byars, 1984, p.7). According to Asch (1992), SM is the process of making and implementing strategic decisions; it is about the process of strategic change. Hence, strategy can be seen as a key link between what the organization wants to achieve- its objectives- and the policies adopted to guide its activities. Organizations are in competition- competition for factor inputs, competition for customers, and ultimately, competition for revenues that cover the cost of University of Ghana http://ugspace.ug.edu.gh 18 their chosen manner of surviving. Because of competition organizations have to make choices if they are to survive. The process of SM may range from a formal process to an intuitive one and uses the systems theory model. Gluck, Kaufman, and Walleck (1982) acknowledged that the development of strategy may be the result of strategic thinking, formal strategic planning or opportunistic decision making. SM is therefore, the exciting future of effective health care management. Henry Mintzberg (1978) also asserted that strategy may be viewed as a pattern that emerges in a stream of decisions concerning the positioning of the organization within its environment. In other words, when a sequence of decisions relating the organization to its environment exhibits a logical consistency over time, a strategy is formed. Strategy does not exist in a vacuum; it has both an influence on, and is influenced by the culture of the organization, its structure and the people it employs. How you want people to act is driven by strategy: how they actually act depends on reward systems, control mechanisms, and the climate of the organization. Liz Johnson (1992) in her study of executives concluded that there were three main functions that they performed; management of day-to-day operations, management of culture and development of strategy for future orientation. All the three should be carried out concurrently for synergetic results. If anyone function is ignored, performance would be ineffective and inefficient. One important element of SM process is the development of a vision for the organization by top management. SM is in large part, a decision-making activity. The strategy of an organization hence, is the result of a series of managerial decisions often supported by a great deal of quantitative data. Strategic decisions are fundamentally judgemental and generally University of Ghana http://ugspace.ug.edu.gh 19 the more important the decision, the less quantifiable it is and the more it is reliant on opinions of others (Duncan et al., 1995). 2.1.1 The Strategic Management process SM has been described as a management process that has the objective of making the organization compatible with and successful in its external environment. In managing to achieve that compatibility, many constantly changing external and internal factors must be considered. SM is based on the systems theory; with the assertion that the whole is greater than the sum of its parts. From these very aspects, SM can be described as the formulation, implementation, and evaluation of actions that will enable an organization to achieve its objectives. The SM process can best be studied and applied by using a SM model. The model presents a clear and practical approach to formulating and evaluating strategy in actual situations. Figure 2.1: The Strategic Management Process Source: Hussin J. Hejase, Dima A. Baltagi , and Kassem Kassak (2000) 2.1.2 Malaria Control and Issues in Strategic Planning Despite the magnitude of the burden of malaria and the wake of renewed interest in malaria prevention and control resulting from the Roll Back malaria initiative and the political commitment made by the African Presidents at the Abuja Summit, there are still no significant initiatives for strengthening capacity for malaria control through training within University of Ghana http://ugspace.ug.edu.gh 20 Africa. Thus, Ijumba and Kitua, (2004) acknowledged that Africa needs to develop and institutionalize malaria training to sustain malaria control capabilities. The RBM baseline survey (2001) revealed that quality of malaria case management was not good and only a tenth (11.7%) of uncomplicated malaria cases received prompt and accurate treatment whilst only about a quarter (24.8%) of severe malaria cases were managed appropriately. These insufficiencies were attributed to the fact that less than half (41.5%) of health workers had in-service training in malaria and few health facilities had malaria treatment guidelines. In implementing RBM strategies and to ensure that these insufficiencies were abridged, existing inter-sectoral committees at the district and regional levels were used to ensure performance. To achieve clearly defined malaria control targets, the NMCP developed framework of strategies to guide implementation and action of key stakeholders. The strategic components pursued were - Improved malaria case management; Multiple prevention; Focused research; and Improved partnerships. The objective of improving case management was to ensure that symptoms and signs of malaria were recognized early and appropriate management provided promptly at individual, family, community and facility levels. The objective of multiple prevention was to ensure that multiple preventive strategies were adopted to reduce the occurrence of malaria in the country. The objective of research and development was to ensure that the efforts to roll back malaria were supported and informed by well-researched information to guide policy decisions, and monitor progress and outcomes of main interventions. While the objective for developing partnership among major stakeholders was to establish a social movement that University of Ghana http://ugspace.ug.edu.gh 21 would be supported by all stakeholders to roll back malaria. Implementation of malaria control interventions and activities were at all levels of management i.e. national, regional, district and community levels (MOH, 2000). 2.2 Situation Analysis and Strategy Formulation To survive and prosper, all developmental programmes must constantly develop strategies to meet the challenges of dynamic environments. In some programmes strategy is planned, in others this may occur in the mind of one person responsible for direct implementation of strategic decisions. Regardless of the manner of developing strategy, the long time survival of the programme depends on sound strategic decisions, which are effectively implemented. Planning according to Ackoff (1970) is the design of a desired future and of effective ways of bringing it out. Thus, for the NMCP to realize its dream of halving the incidence of the disease by 2010, healthcare managers need to critically assess their capabilities and resources to come up with strategies for the management of malaria. Malaria is, and has been, the most important parasitic disease of man in Africa in terms of mortality, morbidity and effects upon life generally. The malaria parasites are of great antiquity; evolving along with man with accelerated rate of major epidemiological changes over the past fifty years (Bradley, 1992). Bradley acknowledged that the complex biology of the vector, present health care, history of the use of medicines and insecticides, migration and environmental changes, did not fit simply into the idea of a single unidirectional process. Therefore, the need for collaborative efforts and effective planning in the management of malaria is very crucial especially, community participation. University of Ghana http://ugspace.ug.edu.gh 22 The Roll Back Malaria Initiative launched in 1998, was a global effort, led by World Health Organization (WHO) and supported by the global fund. RBM representation is drawn from malaria affected countries, United Nations Organizations, Bilateral Development Agencies, Development Banks, Non-Governmental Organizations and the Private Sector committed to a common purpose, ways of working and outcome. WHO provides strategic direction, co- ordination and technical support to individual countries within the context of sustainable health sector development through its NMCP (WHO, 1998). The approach of RBM has been built on all current malaria efforts and the existing Global Malaria Control strategy to achieve targeted levels of coverage in the affected populations based on regional, epidemiological and health systems‟ needs. RBM focuses on community and district level action (WHO, 1998). After the introduction of RBM, many countries especially in Africa developed strategic plans towards the control of malaria. The Regional Support to Roll Back Malaria and Integrated Management of Childhood Illness in Africa (2005), in its output-to-purpose review stated that all countries reported having a basic intervention packages as part of their national plans and almost all (97%) had malaria prevention and control as part of such plans. Tanzania was among the first 20 African countries selected to plan and implement a programme for accelerated malaria control; a four-year plan of action for malaria control was thus, developed in1997 (MMTSP, 2002 – 2007). Ghana was also among the first countries to introduce RBM and was signatory to Abuja Declaration of African Heads of States and Governments in 2000. Ghana set regional targets for achievements by 2005, implementing the core RBM strategies and priority interventions (GHS, 2001). A baseline survey University of Ghana http://ugspace.ug.edu.gh 23 conducted in six selected districts based on eco-epidemiological situations in 2001 formed the basis of effective planning and monitoring to malaria control programmes. 2.2.1 The Development of the Programme’s Vision. Vision identifies the future and is the philosophy of a programme; the quality of which is tied in directly with the quality of leadership (Hussey, 1994). The vision is an expression of hope and is simply regarded as statement of basic principles that governs the direction in which a programme seeks to develop. The vision of RBM was to half global malaria mortality by 2010, and a further half by 2015 (WHO, 1998). Vision of NMCP for partner countries was generally from this strategic dream. For instance, the vision of Tanzania was to reduce malaria to a level where it wouldn‟t be a major public health problem and obstacle to socio- economic development, whereas the vision of NMCP in Ghana was to have a malaria free environment. Thus, all is being done to achieve this dream; there has been massive distribution of ITNs to children under fives and pregnant women together with IPTp-SP. The goal of NMCP in Ghana was to facilitate human development by reducing the malaria disease burden by 50% by 2010. 2.2.2 Choice of Objectives and Services Critical to management is the choice of objectives and the programme‟s services. Objectives describe fairly what the programme hopes to accomplish thus, provides guidance and unified direction, facilitates planning, inspires motivation and commitment, and promotes evaluation and control. Objectives spread along different time dimensions translating the mission University of Ghana http://ugspace.ug.edu.gh 24 statement more tangibly. Effective objective setting promotes good planning, and good planning facilitates future objective setting (Griffin, 1999). Multiple objectives and multiple services according to Paul (1983) are usually pursued in a homogenous environment whereas single-service strategy is pursued in diverse environment where uncertainty in relation to market or public response is high. Multiple objectives are desirable because such diversification tends to yield better results when attempted sequentially. The general objective of RBM was to significantly reduce the global burden of malaria through interventions adapted to local needs through reinforcement of the health sector (WHO, 1998). To reduce the burden of malaria, Partners of RBM (global organizations, national authorities and local communities) were to develop strategies to meet this challenge. Objectives developed by Partners of RBM have been mostly dominant multiple objectives (GHS, 2001; MOH, United Republic of Tanzania, 2002). Ghana‟s NMCP strategic plan for 2001 to 2010 for instance, adopted multiple objectives to meet the challenge of malaria control. These strategic objectives have been the basis for malaria control in Ghana since 2001 (MOH, 2000). Quarterly strategic plans have therefore, been developed by districts health systems using these strategic tenets over the last two years to sought resources from the NMCP and the Global fund. 2.2.3 Management Tools Used in the Situation Analysis External environmental analysis is a process for understanding the external environment of organizations and acts as a window through which, healthcare managers can view external environment for information and/or issues. These issues are trends, developments, dilemmas University of Ghana http://ugspace.ug.edu.gh 25 and possible events that affect the programme as a whole and its position within the environment (Duncan, et al., 1996). These issues are fundamental in planning and the analysis normally utilizes several different tools and techniques. These techniques are informal and generally unsophisticated or judgemental (Klein and Linneman, 1984). Some of these tools are simple trend identification (review of previous objectives, etc), SWOT analysis, community assessment, etc. SWOT Analysis: The starting point in the process of SM is to determine precisely where the organization is today and where it wants to be in the future. The external environment is examined to determine key external forces that could either be opportunities or threats. The internal environment is also analysed to determine the internal strengths and weaknesses of the organization that will be used to take advantage of the opportunities while avoiding threats. Information Technology: For effective co-ordination of malaria and its control in the district health system, an integrated Health Information System is needed to ensure regular and accurate reporting on age and sex-specific malaria morbidity and mortality (MOH, 2000). According to Sprague and McNurlin (1993) information technology can be used strategically as a catalyst to fundamentally revamp ways of doing business. Information technology is used to analyze competition and develop competitive advantage. Epidemiological Analysis: is the surveillance and case investigation to identify causes, mode of transmission, and appropriate control and preventive measures. The analysis examines the incidence of the disease or health event and its distribution by time, place and person. The analysis also calculates rates and identifies parts of the population that University of Ghana http://ugspace.ug.edu.gh 26 are at higher risk than others. It is concerned with the search for causes and effects, or the why and how. Community assessment: is the appraisal of the demographic characteristics, socio- economic, physical and/or environmental conditions of the community that impinge on the health of its inhabitants. Stakeholder Analysis: The communities, groups or individuals are referred to as stakeholders because they have an interest or „stake‟ in the success of the developmental program. Stakeholders are almost always influential thus, if identified and evaluated, „forces‟ affecting the programme may be specified. This analysis is particularly important to malaria control because it is believed that the involvement of all partners involved in health will greatly enhance the vision of the programme (GHS, 2001). 2.2.4 Types of Planning Obviously, some programmes grow and prosper with relatively rudimentary planning systems, but are these programmes successful because of pure luck or have their managers managed to develop strategies without going through a formal process? A programme may have a strategy even though it lacks a formal planning system as long as its decisions are consistent over time. Thus, Duncan, et al., (1996) asserted that SM may take place in several different modes and this may range from a formal process to an intuitive one. Henry Mintzberg referred to these strategic management modes as the informal mode, the planning mode and the adaptive mode. Whereas informal planning is an implicit strategy worked out by a dominant or powerful leader without the support of a formal process, the formal planning mode is a highly ordered process resulting in logical strategies developed by University of Ghana http://ugspace.ug.edu.gh 27 a purposeful developmental programme. The adaptive manager reacts to changes rather than anticipates and plans for change thus, has both formal and intuitive elements of planning. Formal planning becomes increasingly important to programmes when their markets stop growing, when there is an increase in the level of competition and when the rate of change in such environmental factors such as legal, regulatory, economic, demographic, and social, etc., are fast. Again, a formal systematic plan is needed for large organizations so as to ensure effective internal coordination and communication (Duncan, et al., 1996). Hussin et al. (2000) in their study of Middle East hospitals concluded that long-range planning and strategic thinking was common to most healthcare managers but not strategic management which was still vague to many managers. The general practice was more towards short-range horizons and not many used contingency plans, a fact that jeopardized future planning. 2.3 The Implementation Process or Strategy Implementation The first barrier towards implementing new strategies is resistance to change. Internal involvement of staff in the exposition of the planning processes and inter-institutional communication patterns between top and bottom layers of the HCFs according to Hussin et al., (2000) are strategies used to reduce resistance. Implementation is critical, in that if planning is creative and brilliant but strategies are poorly implemented, little is likely to change. Support outlined by WHO (1998) for RBM implementation in countries were prioritization and phasing of support, and support to interventions in districts with stable, high transmissions in Africa. Technical and financial support to districts for situation analysis was to ensure that interventions would be adapted to local needs which would be University of Ghana http://ugspace.ug.edu.gh 28 sustained after RBM support. The interventions could include community-based interventions, strengthening of public and private health sector and the establishment of local partnerships. Interventions required adequate resources but Duncan et al. (1996) acknowledged that although financial resources were important reality checks to strategic decision making, the vision of management should not be limited by the financial resources available. Duncan reiterated that there were dedicated personnel whose attraction to the field goes beyond monetary rewards and is mostly focused on some of the “strategic uniqueness” of healthcare. These strategic unique characteristics of the healthcare are inspiration-related currencies, task-related currencies, position-related currencies, relationship-related currencies, and personal-related currencies. Cohen & Bradford, (1990) also remarked that individuals are normally grateful, have a sense of ownership, freedom from bureaucratic hassles, and affirmation of the basic service-oriented values that attracted them to the profession. This “strategic reorientation” away from salary- and benefit-driven recruitment and motivation philosophy could do much to attract and retain the kinds of healthcare professionals who are capable of providing the high quality services desired in healthcare institutions. Thus, the difference between employees who perform well and those who do not is not how much they are paid but how they are treated. Katz (1988) also asserted that with respect to professional employees, meaningful products from their labor, freedom to use personal judgment, time to do quality work, and challenge are the primary motivators of high performance. University of Ghana http://ugspace.ug.edu.gh 29 2.3.1 Training Training and motivation are very essential elements to implementation of programmes. Regular in-service training (IST) therefore, has been a strategy of GHS for sustaining competencies, interests, morale and quality of the workforce. In-service training is designed to build on the basic level training of staff to enable them meet the ever changing health demands. The objective of in-service training in GHS is to ensure that all staff have at least one IST that is relevant to their functions every three years. Acharya (2000) remarked that the success of any health intervention cannot merely be justified by its efficacy but on factors such as the knowledge and skills of service providers and users, their motivation, attitudes, practices and a range of other socio-economic factors. 2.3.2 Programme Excellence and Culture In a competitive enterprise, a programme has to be good in terms of efficiency and effectiveness to survive. Likewise in the public sector, a programme should at least perform satisfactorily at what taxpayers created it to do to survive. Excellence to a great extent begins with the culture of the programme. Culture permeates the environment of programme activities and is important in determining the internal capabilities of a programme. Kotter and Heskett (1992) found that the strength of an organization‟s culture and its “fit” with the demands of the external environment only partially explained the culture-performance relationship. Adaptive cultures are associated with superior performance over the long run and allow for reasonable risk taking. It is built on trust and a willingness to allow people to fail, and exhibit leadership at all levels. Bovee et. al., (1993) stated that when innovations occur, two things seem to be present – an organizational culture that encourages everyone to University of Ghana http://ugspace.ug.edu.gh 30 think and share ideas, plus a champion of change, a person who is determined to overcome all odds and all bureaucratic barriers to shepherd the new idea into reality. 2.3.3 Quality Delivery of Healthcare Service Access to quality basic healthcare through empowerment of communities to improve their health was a key strategic objective in priority health intervention of the health sector (PoW, 2001 – 2006). Quality service include all services pertaining to customer care such as healthcare providers‟ behaviour when dealing with clients, waiting time at service delivery, availability of drugs, technical competence/skill of a healthcare provider and other basic services (Hanson, 2004). Adongo (2005) remarked that families preferred hospitals for cases of malaria, based on their knowledge about modern medicine, good quality care, and advanced technology. However, people‟s ability to utilize hospitals is being constrained by cost and convenience, as most healthcare facilities were not within reach. Users‟ perceptions of quality of care according to Hanson et al., (2004) and Goodman et al., (2003) are highly subjective; patients expect courtesy and attention from healthcare providers as well as proper clinical examination and medical advice. Studies in Tanzania (de Savigny et al., 2004) and elsewhere (Goodman, 2003) observed a relationship between user- perception of quality of care and healthcare seeking behaviour for malaria and other illnesses, which had negative implications on users‟ compliance with the recommended treatment procedures. Staff motivation is also an important factor in determining the quality of care, and evidence has shown that a well-functioning health system depends on a motivated work force (Wyss, University of Ghana http://ugspace.ug.edu.gh 31 2004). In resource limited HCFs, solving problems related to staff de-motivation and poor quality healthcare depends on cost and priority setting. Effective measures designed to improve staff motivation through systematic, long-term and well-planned IST and supportive supervision contributes to the successful functioning of an intervention programme. Measures linked with proper performance monitoring of service providers and periodic user satisfaction assessment, would likely affect the quality of healthcare in a positive way (Wyss, 2004). Desired quality of healthcare cannot be fully realized when there is shortage of healthcare providers and supporting infrastructural facilities. 2.3.4 Community Participation The need to involve communities at all levels of the programme (Bopp, 1994; Ofosu-Amaah, 1983) is necessary for determining the needs and shaping malaria control activities. The key to sustaining a community-based implementation plan according to Winch and Premji, (1996) is to build up a partnership among the community, district authorities, and central government. Adongo et al., (2005) acknowledged that understanding local knowledge about malaria would help in designing sustainable community-based malaria control programme that would lead to behaviour change and adoption of new ideas and technologies. It would also emphasize the concept of investing responsibility in local people (Coombs, 1980) which would ultimately ensure that programme activities dovetail community needs. The global RBM provided both technical and financial support to endemic districts to undertake situational analysis of treatment and prevention practices at household and community level. The global RBM acknowledged that obtaining national commitment for University of Ghana http://ugspace.ug.edu.gh 32 district-based plan would be crucial to avoid further compartmentalisation of malaria work. The Tanzania Malaria Medium Term Strategic Plan (2002-2007) acknowledged household sensitization whereby community health management teams (CHMTs) would proactively sensitize communities on early recognition and treatment of febrile illness in children, creating awareness on dangerous signs of malaria in children and actions to be taken by caretakers. In the Dangme West district, community participation was well entrenched in the malaria control programme, community based agents have been trained to administer Artesunate suppositories and tablets Artemether-Lumefantrine (Gyapong, 2005) to children under five as a first aid to malaria. In the Tano district, all pregnant women on SP were listed in the community registers for CBAs to follow up. For effective monitoring of information, education and communication (IE&C) activities, CBAs were provided with log books and bicycles to enhance home-based care. It has been realized that, with the strengthening of collaboration of the district assemblies, a lot could be achieved by way of health through malaria control (Offei-Akoto, 2005). 2.3.5 Maintaining Competitive Edge Successful business strategies are those that use the capabilities of the firm to address clients‟ needs in a way that leads to sustainable competitive advantage. Competitive advantage is highly desirable, hard to define or measure and may be imaginary (Macmillan and Tampoe, 2000). Greenwald & Kahn (2005) described competitive advantage as something a firm can do that rivals cannot match which either generates higher demand or leads to lower costs. They asserted that “demand” competitive advantages/customer captivity give firms unequal access to customers whereas “supply” or “cost” advantages always come down to superior technology that competitors cannot duplicate. Competitive advantage comes from matching University of Ghana http://ugspace.ug.edu.gh 33 internal capabilities to external opportunities and can be achieved through several ways: Cost-based advantages: where clients are always aware of the price and would choose the lowest price; Advantages from differentiated products/services; first mover advantage; time based advantage, technology based advantage; and knowledge based advantage (Kay, 1993;4). Over the last several years, there has been increasing awareness of knowledge as a wealth creator in its own right. Professional services are knowledge intensive enterprise who sell knowledge directly, their success depend on how well they develop the knowledge of their staff and transmit it as benefits to clients (Scott, 1998; Maister, 1993; Katz, 1988). Successful SM depends on understanding the approaches‟ dimensions of the context and the issues to be resolved. 2.3.6 Leadership With so many forces at work against making choices and trade-offs in programmes, a clear intellectual framework to guide strategy is a necessary counterweight (Porter, 1996). Strategic planning is considered a major part of leadership functions of a programme. Leadership is a process that uses non-coercive influence to shape teams‟ goals, motivate people‟s behaviour towards the achievement of those goals and help define the organizational culture (Heifetz and Laurie, 1997). Leadership involves setting direction or creating a vision, enfranchising people in decision making, building coalitions that get things done, inspiring and motivating others (Kotter, 1990). Whereas management is concerned with order and efficiency, leadership is concerned with inspiration, change, movement and doing things in different and ideally better ways (Griffins, 1999). Leadership is stewardship not ownership (DuPree, 1990) and is critical at all levels skillfully developing and communicating mission, University of Ghana http://ugspace.ug.edu.gh 34 vision and values of the programme. Hence effective leadership is very essential for the improvement in the status of malaria control indicators. 2.3.7 Structures Developed for Implementation of Malaria Control Organizational structure is like the bones of the body - it holds the organization together. The key in structure is to divide tasks into manageable pieces and decentralize to achieve focus and empowerment. At the same time structure needs to be able to centralize in order to integrate and co-ordinate to make the body move as one. The appropriateness of a structure can be judged only in relation to a programme‟s strategy and environment. Adaptation of structural forms (functional, matrix, network, etc.) goes through the process of differentiating and integrating tasks and functions, the choice of patterns of authority sharing (e.g. the degree of decentralization) and level of autonomy. Through this media, structure influences performance. The creation of structures, by and large, follows the evolution of programme strategies, which in turn influence changes in the external environment and government objectives. Without implementation, plans remain theoretical. Implementation ensures that programme activities are executed as planned with services delivered as intended. Personnel are deployed in the right number, at the right time and in the right place to perform activities. Essentially, there is alignment, mobilization and allocation of the physical and financial resources needed to perform the activities. Standards, protocols and guidelines are developed and used to achieve the expected outcome. The management of malaria control activities needs the creation of some informal structures to ensure that the community benefit immensely from national effort. The creation of University of Ghana http://ugspace.ug.edu.gh 35 community based agents (CBAs) in Dangme West for the administration of Artemether- Lumefantrine in the communities for instance, enhanced compliance to drug therapy (HRU, 2005). Nsabagasani et al., (2007) argued that community appreciation of home-base management of fever is based on the availability of drugs at the community level through the services of drug distributors (DDs). They reckoned that if well trained, facilitated and integrated into the local healthcare system, DDs could contribute substantially to prompt and appropriate management of acute febrile illness but the approach should be iterative enough to be able to improve itself. 2.4 Programme Monitoring and Evaluation or Strategic Control As malaria morbidity and mortality continues to increase in most countries in Africa, international agencies and malaria control programme managers have identified the strengthening of programme evaluation as an important strategy for improving the efficiency and effectiveness of malaria control programmes (Bryce et al., 1994). Evaluation helps managers to account for the investment made, refine strategies and identify and correct flaws in programme implementation. Monitoring according to Kim (2006) is a continuous ongoing and step-by-step recording of the progress made by malaria control programme. Monitoring provides information and matches it with set norms or standards ensuring accountability and implementation of programmes in the correct and agreed-upon manner. It provides decision-makers with the required tools for refined planning and modified strategies by updating on progress, as well University of Ghana http://ugspace.ug.edu.gh 36 as any problems or constraints. Monitoring and evaluation are concern with; work progress (inputs), staff performance (process) and service achievement (output). Indicators normally developed for M&E, were directly related to programme objectives and selected on the basis of validity and reliability; ability to detect change within a reasonable time period and as a result of successful programme implementation; ability to be interpreted; and useful in guiding programme change. Only those indicators that could be measured with available programme resources should be selected. 2.5 Status of Key Malaria Control Indicators Despite the efforts of government and other agencies to control the incidence of malaria, malaria continues to be a major cause of morbidity and mortality accounting for 43.7 percent of all OPD attendances in 2005, ranging between 54.4 percent in the Northern region to 37.0 percent in the Volta region (GHS Annual report, 2005). Key indicators developed for evaluation of management of malaria control activities were according to the strategic operational strategies adopted for implementation. Agyepong and Manderson (1994) asserted that people‟s ability to comply with interventions and to treat sickness is affected by their acceptance of the interventions, their understanding of the nature of the illness and the relationship between vector and infection, and other social, economic and cultural factors. 2.6.1 Knowledge of Malaria Studies done in the district (Agyepong and Manderson, 1994; Gyapong et al., 2005) and other places (Anh et al., 2005) found high levels of correct knowledge about transmission and symptoms of malaria. Majority of people in the district were aware that mosquitoes cause malaria, even though some still perceived malaria as a result of the sun and other University of Ghana http://ugspace.ug.edu.gh 37 factors (De La Cruz et al., 2006; Gyapong et al., 2005; Agyepong and Manderson, 1994). Signs and symptoms recognized by caretakers as severe malaria were hot body, severe vomiting, loss of appetite, convulsion and anaemia. Treatment included wide range of interventions such as sponging, giving of drugs bought from a chemical shop, going to a traditional healer and going to the HCF (Gyapong et al., 2005). Studies have shown that about 4 percent of rural caretakers resorted to herbal traditional healer for simple fever (Waltin, 1986). Knowledge about malaria in pregnancy generally was high among pregnant women however, risk factors associated with malaria in pregnancy was inadequately known to them. Dissemination of information about malaria prevention and management to women attending ANC was very poor with inadequate recognition that Sulphurdoxine Pyrimethamine (SP) prescribed was for malaria preventive purposes. There was also uncertainty about whether the IPTp strategy was substituting or complimenting the promotion of ITNs (Mubyazi et al., 2007). Mubyazi declared that intensified health education and sensitization programs at ANC and community level would be useful measures for increasing acceptability and coverage of IPTp-SP services among its users. 2.6.2 Insecticide Treated Nets (ITNs) ITNs have been adopted as a key malaria control strategy in all Sub-Saharan African countries because studies in Ghana (Binka et al., 2006; Binka et al., 1996) and Kenya (Nevill et al., 1996) have confirmed earlier findings in The Gambia (Alonso et al., 1991) that ITNs are a simple, low-cost, and appropriate technology that has enormous potential to prevent malaria and decrease childhood mortality and morbidity from the disease. Therefore a number of organizations, governments, and donors are seeking cost-effective and sustainable strategies for implementing ITN interventions. University of Ghana http://ugspace.ug.edu.gh 38 Although studies have shown that ITNs are effective this has not yet been translated into an increase supply and use across the country. In two rural communities, whereas 98 percent of people slept in bed nets, in the other community only 4 percent used it and less that 3 percent of people in both communities used ITNs (GMICS 2006, 2007). According to Ghana multiple indicator cluster survey in 2006, almost a third (30 percent) of households had at least one mosquito net while almost one fifth (19 percent) had at least one ITN. The likelihood of possessing a mosquito net or an ITN was 15 percent higher in the rural areas than in urban areas. 33 percent of children under the age of 5 years slept under any mosquito net whereas, 22 percent slept in ITNs and the use of bed nets among children under 5 years declined steadily with age. The main barrier to the use of ITNs was not just people‟s unwillingness, treated nets were costly, not always available and low value people placed on ITNs compared to their market price (Conteh and Ahorlu, 2006; Agha et al., 2007). Main reason for not using ITNs had been the size being sold for twenty thousand cedis; it was too small as women mostly sleep with children. The use of ITNs was based on availability, affordability and the match between products offered and cultural factors such as local sleeping arrangement influence household purchasing of ITNs (Stephens and Ahorlu, 2006). 2.6.3 Management of malaria Gyapong et al., (2005) contended that the use of herbal and other preparations rectally for treating various signs and symptoms of “Asraku” (malaria) was common in the district, and normally the enema consisted of combinations of pepper, ginger, soap, etc. She reiterated that the use of rectal Artesunate at the community level had the potential of reducing severe malaria. Adongo (2005) indicated that while most people had confidence in the formal University of Ghana http://ugspace.ug.edu.gh 39 health sector for treating malaria, it was usually treated first at home with herbal teas and baths prepared from neem, pawpaw, guava and eucalyptus leaves. Malaria was also treated with Chloroquine (and other anti-malarias), Paracetamol and multivitamin at home. Artesunate-Amodiaquine was the most common treatment for patients with probable malaria at public health centres (Gersti et al., 2007). The multiple cluster survey indicated that 61 percent of children with fever were treated with “appropriate” anti-malaria drug and 48 percent received anti-malaria drugs within 24 hours of onset of symptoms. Appropriate anti- malaria drugs included Chloroquine, Sulphadoxine-Pyrimethamine/Fancider, Amodiaquine, quinine, Artemisine combination drugs, etc. The most widely used drugs were Chloroquine and Amodiaquine. Drug vendors in the community stocked very large quantities of Chloroquine and SP. Many of them have been trained (73.3 percent) in malaria as compared to 41.5 percent of health staff. However, they did not always sell drugs in full dose and neither did all of them have malaria treatment guidelines. Besides less than a quarter (24.4 percent) of them were supervised by the HCF in their locality (RBM baseline study, 2001). Williams (2006) acknowledged that malaria treatment continues to consist of a single less effective drug (mono-therapy) rather than the internationally recognized combination anti- malaria therapy (ACTs) which agencies cannot afford. Families living in drug resistance area to mono-therapy were willing to pay more for more effective ACTs. However, these amounts were far from the real cost of delivering the new medicines. Only with subsidy would ACTs realistically make any impact. Thus, Chloroquine and SP were the most commonly prescribed drugs (GMP, 2006). University of Ghana http://ugspace.ug.edu.gh 40 2.6.4 Intermittent Preventive Treatment for Pregnancy (IPTp-SP) Intermittent preventive treatment with Sulphadoxine-Pyrimethamine (IPTp-SP) is currently the recommended regimen for prevention of malaria in pregnancy in endemic areas. Starting from 16 weeks of pregnancy, three doses would be given sequentially within four weeks interval using the direct observation therapy. IPTp-SP is effective in preventing maternal and placental malaria as well as improving pregnancy outcomes (Schulman et al., 1999; Njagi, 2002; Falade, 2007). Alternative measures for those who couldn‟t take SP were to sleep under ITNs throughout pregnancy, undertake indoor residual spraying with Pyrethroid insecticide, avoid staying outside in the night and using mosquito repellant (IPT of malaria in pregnancy training manual, 2005). Treatment of malaria according to the IPTp training manual (2005) was taking either Artesunate-Amodiaquine or Quinine. The RBM baseline study (2001) noted that although majority of pregnant women (69.8 percent) attended ANC at public HCF, less than half (34.6 percent) took malaria chemoprophylaxis and only 11.6 percent take it appropriately. The successful implementation of the IPTp-SP strategy, Mubyazi et al. (2005) acknowledged depends on proper planning and support to the training of health staff and sustained sensitization of pregnant women at HCF and community levels about the benefits of IPTp-SP to mothers and their unborn babies. There was no effect of folates according to GMP (2006) on the efficacy of SP and both drugs could be used together. Using of SP in first pregnancies in relatively high transmission areas is effective but there is little evidence that it‟s efficacious in second and subsequent pregnancies, for the negative effects of malaria decreases as the number of pregnancies increases (GMP 2006). University of Ghana http://ugspace.ug.edu.gh 41 2.6.5 Behaviour Change and Communication (BCC) Treatment and prevention of malaria deaths occurs if the condition is promptly identified, treated and/or referred. Delay in seeking therapy, misuse of anti-malarial drugs and resistance of malaria parasites to existing drugs frustrate measures to effective management of malaria in Ghana (Buabeng et al., 2007; Nyamongo and Muturi, 2006; NMCP, 2005; Marsh et al., 2004; Binka et al., 1994; Ahmed, 1989). Choice of treatment for childhood fevers is influenced by a range of socio-cultural factors that need to be understood if children are to be successfully treated e.g. previous experience with the illness especially young mothers, or bad timing of the sickness such as when HCFs are closed, the lack of social support and appropriate advice from members of ones‟ social net-works (Kamat, 2006). Kamat (2006) suggested that most mothers with sick children would try to seek immediate care from HCF, but help was not always available or effective and mothers were forced to look elsewhere e.g. traditional healers. Nyamongo (2006) noted that treatment at HCF is not always as effective as it should be; only 29 percent of children are examined for malaria. Agyepong and Manderson (1994) argued that if information is given on the most appropriate anti-malaria drugs, correct use of drugs at home could be significantly improved. Home-based management of malaria would be well appreciated by the community if, more efforts is used to improve uptake of the strategy through systematic community sensitization and community dialogue. There would be the need for enhanced public health education on home-based management of malaria and training for chemical sellers to ensure effective use of anti-malaria drugs (Opiyo, 2007; Buabeng et al., 2007; De La Cruz et al., 2007). BCC should stress promptness of healthcare facility visits, improved access to appropriate drugs, and accurate dosing for home-based treatments (Kazembe, 2007). Webber advocated that, if University of Ghana http://ugspace.ug.edu.gh 42 multiplicity of simple methods is likely to be more successful, there should be community participation and health authorities must advise and assist them in achieving this. When the understanding of the symptoms of folk illness seems to correspond to biomedical malaria while local epidemiological knowledge departs considerably from the biomedical model, enormous problems confront malaria control efforts. Issues regarding the cause, recognition, treatment and prevention have far-reaching implications for bed-net use. Simply informing communities that mosquitoes cause malaria does not appeal to people. Studies have shown that poor people often spent a larger proportion of household income on malaria prevention than the rich, and mosquito coils were