Expert Panel: [ARCHIVED] Managing Health Care Delivery: Your expertise

When: Sept. 9, 2013 - Sept. 13, 2013 | Community: Site-wide

This Expert Panel is Archived.

This Expert Panel is no longer active as of December 2018. Thanks to those who posted here and made this information available to others visiting the site.

Managing Health Care Delivery: Your expertise

Posted: 05 Sep, 2013   Recommendations: 16   Replies: 183

At the Global Health Delivery Project at Harvard University (GHD), we are marking our 6th year by taking stock of our progress, limitations, and the state of global health delivery as a whole.

To better understand the role and needs of those who manage delivery around the world, we ask you to share your expertise with us in a new, site-wide, Expert Panel here at GHDonline – there are no featured speakers, no guest panelists – you’re the experts.

As someone who manages delivery, you are supervising community health workers and clinic staff; tracking, monitoring and ordering supplies and medicines, even seeing patients throughout the cycle of care. Perhaps you also develop budgets, manage relationships with stakeholders in your community, or assess the performance of your team and make improvements.

Whether you manage some of these aspects of delivery yourself, or work with those who do, we hope you will all join us by sharing your thoughts on the following questions throughout the week:

1. What kind of management duties or responsibilities do you perform in health care delivery or see others perform?

2. How important is management (of people, processes and resources), compared to other issues or challenges in health care delivery? How do you prioritize this element of your work?

3. What core skills do those who manage delivery need to be effective? How did you or others gain these skills – are management training or capacity building opportunities available in your work?

4. What factors in health systems, organizations or communities impacts the work of those who manage delivery? What are the main barriers to improving the efficacy of your management?

5. How can the Global Health Delivery Project address the challenges and barriers faced by those who manage delivery, especially at the frontlines? What kinds of resources or programs would be most helpful to you in your work?

As always, we look forward to a rich discussion, and are grateful for your input as we seek to identify ways the Project can advance the science of delivery and better serve your needs.



dian marandola Replied at 12:09 PM, 6 Sep 2013

I am new to this group and look forward to viewing contributions.
What are your thoughts about placing a question around financial management such as " How have you incorporated the knowledge of general financial principals and healthcare finance into your practice/work setting?"

What are your thoughts about placing a question that provides insight as to the role nurses have played in the policy arena?

Thank you, Dian (Peds NP with MPH)

Maysa Alkhateeb Replied at 12:11 PM, 6 Sep 2013

Thanks for iniating this important discussion , I`m working with health systems strengthening project (USAID) , my role involve improving the quality of health care delivered by primary health care centers, I`m working in Jordan where medicine and nursing have a good reputation especially if it compared with middle and third world countries, the challenge I found is the lack of comprehensive management system by practioners, usually the manager of any health institution reach to this position by time and experience, where he or she been involved almost for more than 20 years doing a technical role, supporting them with proper training shown a good advance but yet connecting between processes and the ability to perform informed decisions is one of the major challenges

Marie Connelly Replied at 12:43 PM, 6 Sep 2013

@Dian - Thank you for raising the issue of financial management - this is a very important topic to be sure. I hope our members here will consider this aspect when we discuss the question of core skills needed for managing delivery, and share some details on how they have brought financial management skills and knowledge to bear in their work, whether training opportunities have been made available for them to do so, etc.

Of course, we very much hope that our nursing colleagues will join us for this discussion as well, as we all have much to learn from their experiences in managing care delivery. I expect many of our members here may also be interested in an related Expert Panel discussion being hosted in the Global Health Nursing & Midwifery community next week, on the role nurse leaders can play in shaping the future of global health:

Many thanks to Dian and Maysa for sharing some initial thoughts and questions - we invite all of our colleagues to contribute their own initial ideas and questions for one another in the coming days as we prepare to dive in and discuss our first question of this Expert Panel on Monday!

Brook Courchaine Replied at 5:30 PM, 6 Sep 2013

Question #4: We find in Honduras that the well-intentioned foreign (mostly US) medical professionals flooding in to the country to visit villages with analgesics, parasite control and gifts do so much more harm than actual good. Many are not familiar with the culture. They spend a week or two going from village to village with no patient follow up or education. All of this undermines the Honduran medical professionals and healthcare delivery system in place and makes the day to day care of patients nearly impossible. Why? 1. Honduran patients view the foreign doctor as superior (at the very least better educated and wealthier because they can travel) 2. There are many unemployed providers whose jobs are taken over by these groups 3. The visiting doctors do not educate so lives do not improve.
Please read: When Healthcare Hurts by Greg Seager
We are starting new projects that provide support to the already existing delivery systems.

Sujata Bhatia Replied at 5:36 PM, 6 Sep 2013

This is a very thoughtful and important observation by Brook. As an educator, I am working on training our students so that they can be more effective when working in foreign countries. We have observed that it is essential to train students who are global citizens, and who are ready for such experiences and understand the local culture. I am interested in the opinions of Brook and others, regarding how we can best educate and train our U.S. students, starting at the undergraduate level.

Brook Courchaine Replied at 11:09 PM, 6 Sep 2013

Sujata, one aspect we have created to change the dynamics is a 4th year US medical student rotation in Honduras. Tell me how I can send you the flyer that we sent out to invite students to participate. It lays out the requirements and expectations we have of the students who must understand first and foremost that they are guests in a given country. I have seen and heard of too many of these mission trips which focus purely on the volunteers experience and the benefits they will reap from the trip abroad, yet so very little about how the very people they will serve benefit from the encounter.
Our questionaire asks the applicant to state how exactly they will make a difference with their contribution of time and talent. I can send you the questionaire as well.

ReLAB Bamenda Replied at 4:04 AM, 7 Sep 2013

The work done by most health care workers is legendary, especially in the developing world. Its a great relief to see someone who was made slim by TB, regain muscle, strength and stamina.

Health care workers need to be well managed for them to do their job well. We tend to pay administrators huge sums and consider health care workers as volunteers. This should change, health care workers should have job protections, social security, and all the other benefits which are present in the private and other sectors.

Aamer Ikram Replied at 6:12 AM, 7 Sep 2013

Thanks, this is really wonderful. I am sure participation of experts around the world would multiply as well as mutually beneficial.

natarajan ilanchezhiyan Replied at 1:55 PM, 7 Sep 2013

1.I am in charge of technical and administrative responsibilities of 5 doctors(though one doctor on maternity leave and another went for higher studies) 12 sanitary inspectors, 13 (basic health workers)BHWs and 126 workers working for health care delivery system including prevention and promotion of health in zone 4 of corporation of chennai. my designation is zonal health officer. of people ,processes and resources is an important part of health care delivery system. only a good manager can train and get work done from people under him. for example in mosquito control activity in chennai city we are in losing battle due to lack of manpower and training. although processes and resources are adequate due to efficient funding system we are not able control mosquitoes due to lack of research and continuity in the fight against mosquito control due shortage of manpower as per WHO standards.
3.core skills for manager according to me is the skill in man power management and getting work done from the sub-ordinates to achieve what to achieve. managers also need good communicative skills and computer knowledge. they have to also be trained in managing stressful situations as it is needed in case of epidemics. unfortunately we have no training system and it is by ourselves through self study and internet.
4.lack of research in the health system, political commitment and funding in the organisation and lack of community participation impacts those who work as managers in the health system. lack of training and moral support from bureaucrats and supervisors are the barriers in the efficacy of my management.
5.GHD can help me out as database referral system to find out cause for my failure in mosquito control by giving me opportunity to learn from mistakes of others like me in other countries. new methodologies in the disease prevention activity from the success stories of others like me can be resource for me to help out in my work. programs can be software of GIS tracking system of workers in the field will be helpful for me to track their field work from my office.

x y Replied at 2:53 PM, 7 Sep 2013

@Sujata, Brook: Prior to joining medical school I served in the Peace Corps in Tanzania for three years. I found my work in a rural village as a teacher so compelling, and the need so great, that I determined to work in Tanzania as a physician in the future. Throughout medical school I have been struck by how constrained opportunities for clinical training abroad are at my school. I was able to return to Tanzania during the summer after my first year of medical school. However, I was not able to pursue my true passion for clinical work by learning at the bedside from Tanzanian clinicians during this time as our school made funding for international work contingent on producing a “scholarly project.” Thus summer became a time for students interested in global health to publish. I wonder: why is our education structured such that research is given priority over learning at the bedside from those whose goal it is to provide direct patient care to those most in need? I have been considering how to get clinical training in Tanzania prior to graduation. When I investigated taking five years for medical school and spending one year in Tanzania learning at the bedside, I was told that such experiences typically don’t get grant support from our medical school: only scholarly projects. I’m disheartened that my medical education prioritizes research about over provision of clinical care to those who most need it. I fear that despite my ardent dedication to clinical practice in Tanzania, precious opportunities to learn at the bedside as a medical student have been missed, and I too will emerge from medical school ill prepared for my future clinical work abroad.

Attached resource:

Sujata Bhatia Replied at 4:05 PM, 7 Sep 2013

@Brook, Greg: Thank you so much for these thoughtful reflections and recommendations. I really like Greg's idea about having clinical training on-site in Tanzania. I also like Brook's concept of a 4th year US medical student rotation in Honduras -- I'd love to receive a copy of your flyer and questionnaire for this rotation. My email address is sbhatia at seas dot harvard dot edu, and I look forward to hearing from you! All the best, Sujata

Douglas Krakower Replied at 3:27 PM, 8 Sep 2013

Dear Panel,

I would like to add my thoughts about #5 above in advance of the larger discourse.

I think that GHD should regularly assess the needs of the online community by asking (1) open ended questions about what information and support would be most helpful to its members, (2) surveying the membership to assess which topic are likely to meet the needs of the largest group of members, then (3) create online forums or updated “topic cards” that are moderated by experts, involve non-experts in the discussion and problem-solving aspects of these topics, and are accessible to members at all times, as each member may have his or her own schedule of needs that may not match a specific online forum held on a specific date. In essence, create a living library of expert-moderated topics that address the expressed needs of the membership. Then GHD should periodically reengage in these steps to remain in sync with the needs of the members.

When the time comes to discuss this question, I would be interested to know what others think about this type of approach that draws from qualitative research methods, Delphi methodology, and adult learning theory.

Thanks very much,

Cameron Wright Replied at 12:03 AM, 9 Sep 2013

Dear all,

I have just enjoyed reading through some of the early discussion from this forum. I was struck by the Honduras example above - of foreign health professionals coming for short term placements and the potential negative impacts that this can have.

I am a pharmacist from Australia currently working in a public health role for an anti-tuberculosis NGO in Mongolia. My role is largely in the background - grant writing, project planning and management, network building and maintenance as well as some training. While I have delivered some presentations to patients I have been very mindful of the need to highlight the great work done by local health care professionals. I think that health care professionals traveling from developed to developing countries to work can have a hugely positive impact - however, it is important that this is carefully managed to mitigate the potential for unintended consequences arising from the communities perception of the quality of 'foreign provided care' versus that of locally provided care. The time frame of placements and the cultural awareness of health professionals (through temperament and prior training) both influence their ability to have a positive impact in developing countries.

I look forward to following this panel over the coming days.

Kind regards,


Manuel Lluberas Replied at 9:16 AM, 9 Sep 2013

As a public health entomologist during the course of the past three decades, I have not dealt directly with health care, but have seen the effects of how health care is managed. I work frequently and directly with ministers of health, members of parliament and field staff in the design, implementation and evaluation of mosquito control programs against malaria, dengue fever and Chagas disease. It is my impression that very few physicians understand the use of insecticides in public health though they know what these are with respect to antibiotics and other drugs. Considering the current status of malaria, dengue fever and Chagas disease, just to name the most visible ones, and that insecticides are drugs for the environment, I find difficult to understand why many of the managers running these programs have an aversion to the use of insecticides and would want to ban them.

Perhaps GHD Online could help clear the misconceptions about insecticides in public health and help place them where they should be: in the hand of people who understand their use, limitations and counter indications, not to mention the organisms they are supposed to target. When it comes to malaria control, which continues to have about 50% of the world's population under its yoke and claims a person every forty seconds or so, it is rare to see a public health entomologist running a malaria vector control program. Instead, it is common to see pediatricians and ophthalmologists in charge and very seldom do they have mosquito control expertise or experience. This is like putting a obstetrician fresh out of medical school as head of an orthopedic department.

We need to get serious about malaria and other vector-borne diseases. After a decade of spending about US$1 billion on malaria control, we are not further along than we were in the early 1970s.

Marie Connelly Replied at 9:58 AM, 9 Sep 2013

Many thanks to everyone for the insightful comments and discussion over the weekend - we are excited to begin the Expert Panel today!

In an effort to cover so many important questions in a short period of time, we’ll aim to address one question each day this week and we hope you'll join us today in sharing your thoughts on our first topic of discussion, “What kind of management duties or responsibilities do you perform in health care delivery or see others perform?”

In posing this question, we hope you will share your expertise, whether it comes from directly managing some aspect of care delivery, or working with those who do, so that all of us in the community might better understand the various responsibilities and duties being performed by those who are managing people, processes, resources, and more, in health care delivery.

You are the experts here - so please don't hesitate to chime in with thoughts and follow up questions for colleagues throughout the day. We look forward to learning from your expertise!

Elizabeth Glaser Replied at 11:14 AM, 9 Sep 2013

As someone participating in the expert nursing panel on the nursing and midwifery page, I want to take a crack at addressing Q4. and Q5.
There are many entrenched ideas about how we should address health systems. If economic theories were put to a genuine test, we would see as many failures as successes. Yet we still continue to rely on models of demand and supply which fail to capture the complexity of health systems.

Creating truly interdisciplinary leadership might help change systems by breaking down long existing ideas about how we must address certain problems.For countries reliant on external support, this could be a challenge as their approaches to health system reform are typically dictated, directly or indirectly, by the expectations of the donor.

The lack of nursing in leadership roles in health systems and organizations likely decreases the possibility of success in health initiatives. What is the logic in purposely and systematically excluding leaders who represent at least half of the direct care work force and 60-80% of the professional cadre?

What factors in health systems, organizations or communities impacts the work of those who manage delivery? What are the main barriers to improving the efficacy of your management?

Re.,For the nursing expert panel, I reviewed the list of GHDonline panelists, their degrees and background, since GHDonline's inception since 2010 and noted that only 7% of the participants were nurses, even fewer were social workers or other non-physician professionals. I really like GHDonline but have noticed that aside from an emphasis on community health workers, nurses, case managers, social workers and those who do the bulk of direct care are not represented in your panels. Nurses were primarily present in nursing only panels, while physicians were considered expert in every situation. Yet I know that there are nurses and other professionals in public health and epidemiology , in HIV and in NCD who could easily have served on some of these panels.


dian marandola Replied at 11:36 AM, 9 Sep 2013

I'd like to expand on Elizabeth's comment that there are nurses and other professionals in public health and epidemiology , in HIV and in NCD who could easily have served on some of these panels. There are nurses who are reasearchers, policy analysts, economists, health care system designers and expert clinicians who are resources in managing health care delivery. Your comments and advocacy for what nursing brings to the table helps to raise our visibility and expertise profile. More and more, nurses are gaining access to policy makers and enhancing our credibility for nursing's contribution to transformation of health care in the US and the direction of health care around the world.

Blessings Banda Replied at 12:26 PM, 9 Sep 2013

1. Management duties that i perform include conducting staff appraisals, managing program budgets, assignment of program resources and planning will all the staff i supervise. Again i am also responsible for reallocating staff to different sites according to need and demand. I am managing 19 providers of ART, 26 HIV Testing and Counseling staff and three Nutrition staff. These are spread across the District and I am responsible for activity supervision through the group leaders that were assigned to the team members.

2. Management of people, processes and resources is very essential compared to other challenges in Health care because i believe a frustrated health care provider will always deliver frustrating results. And mismanagement of resources leads to mismanagement of health problems that poor people show up with at the Health center level. Sometime should be given to management alone aside Health care provision and this ensures maximization of all resources at a Health care center (Human, Financial, Infrastructural and material resources).

Prioritization is basically focused on Health Care delivery as compared to management of people, processes and resources because of the systems do not really provide a space to focus largely on management issues. In the resource poor countries like Malawi, we focus much on dealing with/or helping the patient first than looking at the systems that help us deliver. Shortage of staff and shortage of Management training are some of the issues that are attached to lack of much focus on management practices.

Neno, Malawi
Partners In Health | Abwenzi Pa Za Umoyo

Masoud Dara, MD Replied at 2:13 PM, 9 Sep 2013

Dear colleagues,
During the past 20 years, I have had the privilege of working with many brilliant managers at national and district level in different settings from the Philippines to Egypt and from Russian Federation to Mali. I believe the most successful ones often share the same characters, among others:
- Self reflective and strongly motivated to improve the situation in their settings
- Supporting and motivating their staff
- Transparent, with strong networking and negotiation skills
- Having strong analytic skills, using data continuously to improve performance
- People/patient-sensitive adapting services to individual needs particularly the most vulnerable population
The gaps in resources exist in most settings with the budget cuts in many countries. Therefore the managers need to intensify advocacy measures and mobilize resources while improving efficient use of the existing resources.
I will forward this announcement to national TB programme managers in our Region, many of them are already member of GHD online and look forward to hearing the lessons learned, success stories and challenges from the different corners of the world.
I take the opportunity to thank all GHD online team members for their excellent work and congratulate them with the 6th anniversary of GHD online.
Thank you and all the best,

Dr Masoud Dara
Programme Manager & Medical Officer
Tuberculosis and multidrug-resistant tuberculosis
Division of Communicable Diseases, Health Security and Environment
World Health Organization Regional Office for Europe
| Tel: + 45 45 33 66 49 | Fax: + 45 45 33 70 01
UN City, Marmorvej 51, Copenhagen, Denmark

Rebecca Weintraub, MD Replied at 3:36 PM, 9 Sep 2013

Thank you all for your insightful comments in this discussion so far. As we continue our conversation this week, I'd like to share a few articles that have highlighted out the importance of management to effective delivery of health care in resource-limited settings.

Despite challenges such as resource shortages, policy misalignments, etc. effective managers of delivery can still bring significant value to the patients and communities they serve. These authors argue for the need to focus on developing management talent and disseminating management innovations in global health delivery. I hope you will reflect on these pieces and share how their ideas resonate with your experience.

1. Anjali Sastry's recent blog post on Huffington Post "Biggest obstacles to decent health care in the developing world are managerial":

2. Josh Ruxin's 2008 article in Democracy Journal "Doctors Without Orders":

3. Sachin Jain and colleagues' 2008 article "Delivery Global Health" in Student BMJ:

In addition, I'd encourage everyone to review Atul Gawande's recent article in the New Yorker "Slow Ideas": This article describes the complex set of challenges those who are involved in delivery of health care in resource-limited settings must navigate daily. Although the hospital physician, nurses, and young BetterBirth trainer in the article may not be formally designated as managers, they all performed some activities that are management in nature.

It would be ideal to hear your perspectives on these "informal" managers of health care delivery. Are all the people who partake in management of delivery equipped with the necessary management skills? What are the most critical gaps you've experienced or observed?

Hugo Flores Navarro Replied at 6:18 PM, 9 Sep 2013

Hello all

I have been managing the PIH site in Mexico for 1.8 years.

I see there are several key components to the global health initiatives, each one with its own challenges.
On the side of delivering quality care services at the site itself, we can look at budgetary and geographical constrains affecting supply chain and referral systems. Investing in good communications system is importan though may times not the highest priority when there are not enough medicines to address the burden of disease.
In the human resources field, we also face high turnover and lack of local capacity.
These two are still big questions and so far there is no magic formula to address this.

Maximizing benefits to the patients with the limited budgets available everywhere, makes the management be always a situation of hard choices between two very necessary things.
This is not the situation that other institutions outside the non profit segment face. Care for wealthy individuals is not thought making the same analysis.

So if we are going to be managing global health models in a model of scarcity or poverty, I think we managers will keep using most of our time putting off fires and this leaves little room for the growth and development of such systems.

Advocacy is very important if we are to see a different logic behind funding for global health.

Jason Bae Replied at 7:10 PM, 9 Sep 2013

Apologies for my previous post: it was accidentally sent before being completed.

I believe management training is absolutely critical in global health but is generally underutilized and under-appreciated.

I have a background in clinical medicine, research, consulting, and non-profit management, and recently acquired my MBA. The reason behind pursuing my MBA was precisely because my global health experiences made the necessity for management training very obvious. Now that I have a theoretical framework from my business school to guide my work in global health, I appreciate even more what good management skills--which I am still trying very hard to develop--can do for global health.

Management, in essence is a discipline that brings resources, people, and processes together to create value. In global health, value means better access to health, better health outcomes, etc. Every single organization has technical experts as well as managers, and they add value to the organization in different ways. For example, Google has many computer programmers and engineers as well as many managers. Without those technical experts, Google would've never gotten to where it is. But without its managers, those technical experts will likely not have been able to work towards creating Google as it stands.

I think the same applies to global health. We need technical experts, in clinical research, epidemiology, clinical practice, nursing, etc. My experience in global health thus far is that the current experts/managers balance is closer to the experts than the managers. The dearth of managers in global health, leads to underutilization of great potentials and talents in global health.

I sought out management training (via MBA and management consulting) after an failed attempt at starting and managing a non-profit. I don't think 2 years of finance, accounting, marketing, strategy, and other course works that are taught in business school are all necessary for a global health manager--although I have learned concepts in each that can be useful for global health delivery.

The concepts that I have found most useful in my current global health work--advising a non-profit with program and strategy--are organizational behavior, leadership, strategy, and operations. How do you align internal processes of the organization or system so that the entire organization moves towards the same goal? How do you influence others? How do you give feedback, manage a team, and manage your boss? What is the goal of your organizational and how do you structure your operations and processes towards that goal? What operational instruments or tools are needed to support the mission of the organization?

These are sections of management training that I have found valuable to my current work. Yet, the truth is that besides business school or learning via experience, books, or mentorship, there are few other ways for global health professional to acquire these skills, which is why I chose the MBA path.

One way that GHD can contribute to this management vacuum in global health is via developing curriculums, seminars, or other teaching medium (other than 2 years of MBA or working in the private industry) that is easily accessible to most global health professionals.

As Anjali mentioned in her article, it is the simple concepts in management that will likely be most valuable for managers in global health. These may be in human resources management, simple operations concepts, team management, and other fields of management. One thought is to develop GHD cases on issues commonly faced by managers, in dealing with the government, organizational misalignment, or human resource problems, and providing guidance and some framework through which they could start to address these important managerial issues.

Anjali Sastry Replied at 7:30 PM, 9 Sep 2013

Looking at these thoughtful ideas, I've been reflecting on the work that I see frontline staff--those in clinical, clerical, administrative, logistical, and many other roles--conducting in the clinics, hospitals, NGOs, and companies we work with from MIT.

In the US and globally, I think we need to support and enable practical, field-tested management knowledge. Folks need to know useful approaches to cost accounting--so that we know how much one treatment will cost versus another--and known principles of inventory management. There's also need for knowledge on communication and marketing, which offer ideas that could help to reach more patients and reduce loss to follow up, and employee motivation and engagement. We could add much more!

I'd like to go beyond listing gaps, however. It's not yet very formal, but I have been developing my own running list of some of the everyday invisible work that takes place in every hospital, clinic, or program. This work includes:
- coming up with creative ways to address unmet patient needs, including by leveraging or repurposing existing services or infrastructure;
- sharing information about patients and the community with others as needed to enable better patient care, including for non-medical services and inputs;
- gathering new diagnostic data from the organization's own daily operations to find opportunities for improvement or to make the case for change;
- creating new materials, systems, or processes for patients or staff, to help better manage care and operations;
- fixing things that aren't working;
- crafting workarounds for broken or missing inputs;
- building internal coalitions and momentum that will enable change or improvement;
- advocating for missing resources;
- cleaning up and organizing physical and electronic spaces;
- building external relationships to support the program or organization;
- learning from colleagues and peers in other organizations about how they tackle the same challenges you face; and
- teaching others how to do the work you do and sharing what you have learned.

Does this ring true for you? Is there a lot of "invisible work"? What have I left out? Is invisible clinical work different from invisible managerial work? I have a theory that much of the work that people do in order to make the system better is unrecognized, and is assumed to take place "on the side of the desk", in addition to the (real) regular work. if this is true, that efforts to improve performance are inherently invisible, and inevitably undervalued.

What would it mean to recognize this work?

Jumatil Fajar Replied at 9:07 PM, 9 Sep 2013

I manage a community in very remote area in Central Kalimantan, Indonesia.

Management is very important in health care delivery. Resources are very limited, that why we need management to make them available to community.

I think the core skill that should be effective for managing people is good attitude. With this skill he can create good communication with people who work with him. He can create openness in working environment so that all of the people that involved in the work, know what happened and the can contribute positively.

I have experience where in the previous management, they did not open regarding financial condition in community health center. It created tension between staff and manager. But after the openness become value, there was no tension anymore.

This skill can be get through interaction with good environment such as religious environment, good friends etc.

The other skill that should available in a manager is leadership. This skill can be get through involvement in organization during studying in high school and university.

Financial regulation has impact on our work because with tight regulation, it is difficult to do an innovation during work, because everything has been planned before.

The influence of big family decision regarding family member's health problem also have impact on health care delivery. Sometimes when big family did not approve to refer the patient, the probability of death become increase.

Global Health Delivery Project can help with providing knowledge and online training for manager on how to manage community health center in remote area.

Ogtay Gozalov Replied at 12:04 AM, 10 Sep 2013

Dear colleagues, I'm TB Medical officer in Uzbekistan and let me sher ideas on the q2 and q3. To me, proper management of the activities and health care delivery is the paramount for the success. In many settings we observe availability of the resources (financial, human etc) but ineffective management of them significantly decrease the results of the efforts taken. Now the question is how to increase efficacy and what shall be done, so probably that will be one of the interesting areas to be explored.

Best regards,

Ogtay Gozalov,
WHO TB Medical officer, Uzbekistan

Pierrette Cazeau Replied at 7:14 AM, 10 Sep 2013

Thank you Dr Palmer for the invitation also thank you all for allowing me to read your postings.

Pierrette Cazeau Replied at 7:36 AM, 10 Sep 2013

1. What kind of management duties or responsibilities do you perform in health care delivery or see others perform?

2. How important is management (of people, processes and resources), compared to other issues or challenges in health care delivery? How do you prioritize this element of your work?

3. What core skills do those who manage delivery need to be effective? How did you or others gain these skills – are management training or capacity building opportunities available in your work?

4. What factors in health systems, organizations or communities impacts the work of those who manage delivery? What are the main barriers to improving the efficacy of your management?

5. How can the Global Health Delivery Project address the challenges and barriers faced by those who manage delivery, especially at the frontlines? What kinds of resources or programs would be most helpful to you in your work?

All these questions are effected the health care system also in the industry of Home Health Agencies. In the early years none of home health agencies required to be accredited with the states. However, we were managed to obtain our licenses to operate in order we could provide services to the community as the same token other licenses required to be certified with biowaste permit due to wound care. Now we are required to be more accreditation with JACHO, ACHC or CHAP. With these accreditation allowed home health agencies to follow the rules and regulations more serious than ever in order for home health agencies to remain open. Due to the fact, most home health agencies applied to be certified with the Centers of Medicare and Medicaid (CMS) made home health agencies to be more cautious with the ICD-9 (billing) to avoid the penalities with the government. In the past few home health agencies do not follow the rule and regulations with Medicare and Medicaid billing led to Medicare and Medicaid Fraud. Since then the states changed the procedure and made it hard for the industry. As a manager it is hard to follow every single employees on the field to prevent error either on the care plan or the patient care due to language barriers.

Marie Connelly Replied at 12:17 PM, 10 Sep 2013

Dear colleagues,

We have just opened up this discussion to the entire GHDonline community. If you have just received a notification about this Expert Panel discussion, please join us as we reflect on the 6th year of the Global Health Delivery Project (GHD) and discuss the roles and needs of those who manage care delivery around the world.

You are all the experts in this panel discussion - we welcome your input on these important questions, and encourage you to review the responses from your colleagues to date by visiting this Expert Panel on the GHDonline website at:

Today we will be discussing the importance of management (of people, processes, resources, etc.) in comparison to other issues and challenges in care delivery - whether you are directly managing some aspect of care delivery, or work with those who do, we hope you will share some thoughts on how management responsibilities seem to be prioritized in the organizations and agencies you've worked with. For those who directly manage some aspect of delivery, we hope you will also share some thoughts on how you are able to prioritize the management elements of your work.

As always, we encourage you to respond directly to colleagues in this discussion, and share any resources or articles you feel may be relevant.

As a reminder, replies to GHDonline email notifications are publicly posted and immediately distributed to the GHDonline community - if you have questions about participating in this Expert Panel, or would like to stop receiving email notifications, please contact us directly instead: .

Looking forward to your contributions, and continuing a rich discussion throughout the week,

Marie Connelly, GHDonline Community Manager

Rakesh Biswas MD Replied at 1:26 PM, 10 Sep 2013

Thanks Rebecca and Marie,

We are a group of voluntary engineers and health professionals working for
a non profit NGO to
further Health Information equity in India.

We currently have offline patient advocates/social workers posting patient
centered health information to our tele-medicine platform here: and we also have a global
network of 'online health information analysts' who primarily
a) Search for current best evidence for diagnosis and further management of
the patient described and posted health condition.
b) Match the available individual patient data (for this particular patient
input) to generalizable patient data/current best evidence available online
c) Come up with a contextually matched patient management plan and send it
to our moderators to be posted to the local physicians through
'patient-advocates/social workers' as an output here:

To further prioritize the management elements of our work we have a program
for medical student electives that instills the virtues of 'health
information analysis' and 'patient advocacy' through case based learning
(more details in this link):

These are a few initial thoughts. Would be good to learn more from the

Catherine AWA Replied at 1:55 PM, 10 Sep 2013

Dear Dr Rebecca,
I feel honored to be included in this discussion but unfortinately, i do not manage people. I was as a staff nurse at NWH and also as a visiting nurse performing initial assessments to establish pt needs and forward the information to the primary nurse.
Thank you

Stacey Pulk Replied at 3:07 PM, 10 Sep 2013

I also do not manage health care as a medical ethicicist. However health care should be needs based goal oriented and cost effective. Stacey

Kim-Son Nguyen Replied at 3:24 PM, 10 Sep 2013

Thank you all for a great discussion so far. I've learned a lot from reading these comments. I'm involved with various research and educational projects to improve cancer care and research in Vietnam and, likely many of you, have seen how management-related improvements can have a much bigger impact than more knowledge in clinical medicine.

When I'm in Vietnam, I'm supposed to share with the local physicians the latest treatments on non-small cell lung cancer, or how to treat locally advanced gastric cancer, etc... but it is hard to imagine how this clinical knowledge can effectively translate into better outcomes for patients when almost all steps of the health delivery chain need improvements. Better clinic flow, better utilization of manpower, better utilization of available facilities, safer clinical practices, truly listening to patients instead of making assumptions, better bedside manners,... are just few of the many things that should be implemented.

But it is very hard to spread or implement what we think are good ideas without coming across as being arrogant foreigners--see the Honduras example above. And many leadership positions in Vietnam, like in the United States, are occupied by MDs, many of whom, frankly, are not qualified to be in those management positions. We know that we cannot go in there and state, "you guys need professional managers." You can't try that at the Brigham or the Mass General, and you can't try that in Vietnam either.

So what we are trying to do in Vietnam to improve cancer care and research there is doing what Atul Gawande describes in his New Yorker article--thanks, Rebecca, for the pointer--the painstaking, time-consuming process of having boots on the ground, high-touch, person-to-person sharing of ideas with genuine humility. Most of us from Western countries have no idea what the local staff have to deal with on a daily basis. And we can't persuade them unless we know them personally, hanging out with them, knowing their families, discussing the latest Man U-Liverpool match with them, etc... These social skills are not taught in medical schools and not even at our GHD courses if I remember correctly. An MD with the latest medical knowledge or a management consultant with HBS or Sloan ideas will fail miserably if not possessing the social skills to do the "seven touches."

As we are working to gain the trust of the local providers, Anjali, I would love to have your students come to these cancer hospitals and help improve the processes there!

Zohra Mhamdi Replied at 4:34 PM, 10 Sep 2013

Hi everybody; thi is Dr Zohra
Im dealing With all the aspects of this discussion:
Managing people, resources, relations With the different steakholders and the community and I find it very hard especially that Im dealing With a new hospital...
Please all the advises, recommandations are very welcome...especially from experts that are uses to the telemedecine

Osmán de Jesús Argüello Sequera Replied at 4:47 PM, 10 Sep 2013

1. What kind of management duties or responsibilities not performed in the
delivery of health care or watch others perform?
R = there is liability of directors and managers of health, of ensuring
proper care and services to patients in all areas, including emergency and
ICU. In practice I have not appreciated that, and for me as a manager of
Hospitals management I put it in practice, but my bosses did not agree, I
saw in the areas of jobs from supply failures of inputs to serious flaws in
the management of patients, staff did not support their actions based on
rules and procedures manuals and worse at the discretion of each person in
a room or particular area, which really helped to establish parameters to
manage quality care criteria. I established some manuals in critical areas
with specific problems and corrected many of the common problems, but this
was the exception and not the rule, I turned frustrating that much of the
health personnel do not apply known parameters but even when they believe

2. How important is the management (of people, processes and resources),
compared to other issues or problems in the delivery of health services?
How can prioritize this element of your job?
R = is the most important! Without a correct management of each process,
the management of human resources, and the resources, management simply
becomes a chaos, wanting to do things the way empirical or without certain
rules correctly apply administrative and quality control procedures and
processes in an institution. To prioritize the controls, one should have a
effective management of quality control, resource control and obviously
have staff that can adapt to work with pre-established procedures to help
continuously improve care processes of patients.

3. What basic skills do they handle delivery need to be effective? How do
you or others gain these skills - are training in management or training
opportunities available in your work?
R = Among other things the personnel providing health services must be
especially empathetic with people who try to be patient, tolerant to the
extreme, and thus began to be efficient! And this is gained through
personal self-development processes, Coaching, study neurolinguistic
programming, leadership conversion tasks so that staff have thus proactive
and open to learning and apply new paradigms in the management of patients
with willingness to change continuous but based on the continuous
improvement of each person as an individual and as a professional! And you
can always get this kind of training and coaching services in HR training

4. What factors in health systems, organizations or communities impacts the
work of those who manage the delivery? What are the main obstacles to
improving the effectiveness of their management?
R = What most affects health providers are their financial resources in
general health services in the Latin American countries are very poorly
paid, this directly affects performance because many professionals work in
various institutions, and the level of stress and workit becomes for many a
wear factor ending many lives even for extreme physical exhaustion. This
obviously affects the entire system, which in many instances may be
exceeded, particularly in emergency situations in particular, so that the
recommendation in this case is much better value and reward all
professionals, and give them certain privileges by the institutions, such
as special training courses in your area, group weekends, to apply coaching
techniques and stress management, among other things you can do!

5. How do you tackle the project delivery Global Health challenges and
obstacles facing those who manage delivery, especially in the front? What
kind of resources or programs would be of great help to you in your work?
One of the most common complaints is the overhead professionals working in
their hours, patient load actually surpasses what can be handled in many
cases, so my first recommendation would be to redistribute the workload
among more professional and / or allocate more staff from other areas for
management, for example nursing staff and other areas that support the work
of service providers. The main obstacle is financial resources, to which
managers of global health should hold their governments in emphatic
fashion, with plans well supported and numbers from the administrative
point of view and welfare, and thus change the old patterns distributional
improve primary care areas, establish service parameters for areas
asecundarias well supported also through professional practice studies and
clinical statistics of cases, among other points that could handle. And as
a final point for professional programs described above! In the private
sector many companies make and the results are the difference between staff
tired, physically and mentally exhausted and obviously with poor performers
and staff satisfied with their work, efficient, effective, proactive and
willing to work with like turning your work in your true second home, to do
the work entrusted to it, and who likes to return every day, without
complaint or unnecessary pressure!


Su servidor...Dr. Osmán Argüello
Asesor de Tecnologia y Equipamiento Medico Hospitalario de AJAIMEROJAS S.A.
Presidente y propietario de Tecnologia, Salud y Creatividad C.A. (

John Elianu Replied at 5:01 PM, 10 Sep 2013

Thank you for the discussions. In Uganda there is feeling that the biggest problem affecting the health sector is poor management and leadership and not necessarily lack of resources. There is thinking to have health managers to lead and manage health care who are not necessarily doctors. nurses should stand up and demonstrate leadership potential if they have to recognise.

Ivahn Dockter Replied at 5:13 PM, 10 Sep 2013

Hello everyone, I am not a Doctor, I am an IT person who is forming a team here in the U.S. to help a hospital in Guinea West Africa gain some technology with computers. Our current plan is to help them with managing their medical supply inventory. We will use MS Excel initially to document the container of medical supplies we are sending. We will load the Excel spreadsheet on a Laptop and send it to the hospital where someone will update the spreadsheet each time an item in the inventory is used. We've written a macro that will alert the person managing the inventory to re-order an item when it has reached a certain threshold. The next step will be to introduce software the processes a patient through their visit and creates an electronic medical record. The hospital does not have internet at this time and has power between 8:00 - 5:00 Mon-Fri. Solar will be introduced at the hospital next year and completed the following year. We realize that plans may change based on how technology is accepted at the hospital, but we are all in agreement that technology can be very helpful.

Margy Robinson Replied at 5:15 PM, 10 Sep 2013

I agree wholeheartedly with Anjali's post regarding all the invisible work that is done to improve processes and systems. So little of that work is recognized! I believe that GHD could help by offering webinars in quality management, including very practical training such as how to create a work flow chart to identify bottle necks, or duplicative work.

Emma Varley Replied at 5:35 PM, 10 Sep 2013

As a medical anthropologist whose research focuses on the impacts of conflict for maternal health services in northern Pakistan, it is a pleasure to read everyone's contributions to this panel, many of which reflect the diversity of approaches, managerial frameworks and service delivery practices found around the world.

It is exactly this diversity, I believe, that should call our attention to the importance of considering the organizational cultures which inform how medicine is practiced, ethics are deployed, and health systems managed. After five years of ethnographic fieldwork on this subject in Pakistan, my interests lie in better understanding how, in low-resource environments, the usually standardizing and protective influence of policies, programs and clinical and professional models may be mitigated by local concerns or struggles with -- for instance -- insufficient resources, political instability and economic insecurity, forms of corruption, or violence and conflict.

And what of the role in local culture in determining how patients respond to and take up available health services? Or, in shaping healthcare providers' and administrators' sensibilities concerning the key characteristics of 'good', 'effective', and 'ethical' -- or -- 'bad', 'ineffective', and 'unethical' medicine and clinical services?

Could our discussion, then, also incorporate recognition of the ways that issues of context -- whether it be cultural, political, economic or even religious -- intersect with health care systems and management practices to produce particular forms and qualities of care?

In so doing, we might be able to better map out and respond to the complexity which defines the management of global health care delivery. An expanded discussion could also permit us to draw on the interdisciplinary and critical approaches which have made a strong and positive contribution to the study, practice and management of medicine around the world.


Dr Emma Varley
Assistant Professor
Department of Anthropology, Brandon University

Osmán de Jesús Argüello Sequera Replied at 6:03 PM, 10 Sep 2013

Hello Rebecca

As I said I answered the questions, and well there is a good summary of how
should health services be improved, I hope to help them through this route!


your server...Dr. Osmán Argüello
Asesor de Tecnologia y Equipamiento Medico Hospitalario de AJAIMEROJAS S.A.
Presidente y propietario de Tecnologia, Salud y Creatividad C.A. (
Presidente Asociación Venezolana de Informática en Salud (

Sungano Mharakurwa Replied at 6:05 PM, 10 Sep 2013

Many thanks Dr. Weintraub. I am no expert in this field but this is one of the most critical if not ultimate determinants of success for any activity, process, project or programme. Most thankful for the opportunity to partake this discussion.

Muriel Finkel Replied at 6:30 PM, 10 Sep 2013

Being advocates for a rare disease, amyloidosis, we are truly "coping" with health care delivery.
Some of our patients can't get to one of the few centers of excellence and we try to navigate the way for them.
We hold support group meetings in 21 cities for patients and care givers with
all types of amyloidosis, AL, AH, ATTR, AA, Localized, CAA and SSA and others.

Kaiser is often a challenge along with other companies and we are still not sure yet just how the
Affordable Care Act will help; but are optimistic. We did manage to get our disease fast tracked to \
Social Security Disability but our patients still must wait two years for Medicare to kick in.

We are a nonprofit and live on donations while not charging our patients for these meetings.
We bring in the who's who in the amyloidosis world to educate and every meeting is a "happening".
We work with NORD< and Eurodis and have online groups
and as we need to not feel alone as we support, educate, and empower our patients
while educating doctors who misdiagnose our disease much too often. Granted the symptoms mimic other
more common diseases, but some of them should be "aha moments" for these doctors and are not.
There is one form of our disease that strikes close to 4% African Americans in the heart at the age of 50-65
and few cardiologists or PCP's know about this disease let alone the black caucus in congress or our President
(this last thought is an assumption).

We've made great strides, getting Medicare to approve Autologous Stem Cell Transplants for AL amyloidosis in 2005
(before that they felt there was no hope as they believed all the old articles one wades through on the internet).
With Agent Orange umbraelling our disease for VA benefits, and the LLS offering our patients $100 a year to help them
(they give up to $10,000 to Multiple Myeloma which is a true blood cancer. We are an orphan cousin) we are making strides.
We now have some Phase I clinical trials for several types of amyloidosis and the FDA does seem to be listening to us more.
It is a nonstop, never give up thing we do at the ASG...but we have seen much happen and can only hope that one day
we see a cure and can go out of business; which is our true goal. Thanks so much for letting me vent.

Muriel Finkel
Amyloidosis Support Groups Inc.
Toll Free Hot/Help 866-404-7539 - over 1430 - over 175
Member NORD>

Ask your doctors to stop by and see us at ASH, Booth 3000, December 7-9, 2013.

"Recycle yourself, be an organ donor!"

Kimando Emmanuel Replied at 6:39 PM, 10 Sep 2013

Hey. Am a software developer and in Africa. Am Kenyan but in Ghana for
sometime. Guinea is not very far. How can i be of help?

Antonia Eyssallenne Replied at 6:46 PM, 10 Sep 2013

Thank you Rebecca for those references they were on point. These are exactly the concepts I have been trying to teach my residents in my global health track but I failed to express it as eloquently as those essays. The concept of managing an intervention is completely foreign to those who enthusiastically want to jump into the global health arena and want to glean from that jump an experience, any experience, regardless of the true consequences. The concept of helicoptering in and out is alive and well in many who call themselves lovers of global health. Something as simple as including an EKG machine into the ER will fail if it is not managed properly, i.e. who is responsible for the EKG machine? Who will maintain it? Who will replace the paper? Who will order the paper? Who will fix it when it is broken? Is there a back up? Who has the back up? Is the back up working? I could go on.

Global health delivery is not just about the experience of delivering the health, because as health care professionals we are great at delivering health...that is what we do. But the context in which we deliver that health, the goal that we have for delivering that health needs to be driven not by our desire to have that experience, but for the true (not perceived) need that causes that experience to be manifested. Brooke was right on with her discussion regarding Honduras. Very important and thoughtful discussions all around I am privileged and excited to be able to participate!

Brook Courchaine Replied at 7:08 PM, 10 Sep 2013

This is fabulous information. The Carrizo Project currently uses Google Drive to record our financial transactions which we share after every transaction, but as you know there has to be Internet to even record data in this system. But the great thing about Google Drive is that we can easily access it on an IPad, we have had several donated.
I would like to introduce an inventory system for medications in our neighborhood clinics in Honduras. Help me start introducing this valuable record keeping by addresses the following:
1. In a country where transparency and accountability is not a priority how do help the staff see the value in this record keeping?
2.Who could be in charge of the actual data entry; doctors and nurses have no time and there are limited funds to pay for a dependable data entry employee.
3. Do you have any examples of your excel sheets?

Pierre Bush, PhD Replied at 7:53 PM, 10 Sep 2013

Well said Margy. Providing practical training would greatly improve the processes and systems. It would enhance knowledge of healthcare providers and receivers.

edi hardjati Replied at 8:17 PM, 10 Sep 2013

thank you for the opportunity to join the discussion. my name is edi hardjati, I am a doctor at ministry of health in indonesia. ia m interested at the topic since I 've just read the book about managing professional and smart people just like " hearding cat" ( gaeme davies dan garret). It is not easy managing smart professional people especially from health sector background. some of the books's topic :

In increasingly competitive, ‘knowledge worker’ environments, people working at all levels prize their freedom and resist direction. The challenging job of leading them can often feel like the business of ‘herding cats’.
The benefits of having a highly educated, independent and proactive staff include gaining a competitive advantage, enhancing creativity and nurturing innovation.
The down side is that many professionals resist direction, question authority and like to be their own boss.
Professionals of all sorts can be difficult to manage. New graduates have been schooled to question instructions rather than follow them; old timers have mastered the art of appearing to follow instructions whilst ignoring them in practice.

it's a good book

Rebecca Weintraub, MD Replied at 8:48 PM, 10 Sep 2013

Many thanks to all for your thoughtful comments.

We recognize that some of our colleagues in this discussion may not have direct experience in managing aspects of care delivery, but we hope everyone will share their observations from research and observations, ie what skills and capabilities are essential to manage health care delivery?

How might we separate training opportunities that build management capacity? Ideally, individuals would be able to bring these skills to bear throughout their careers, but often it seems that access to these kinds of training programs is highly dependent on being employed by an organization with the means to offer their employees professional development opportunities. How else do you access training in management?

Looking forward to your comments, Rebecca

Roman Pathak Replied at 9:14 PM, 10 Sep 2013

When we are talking about health care delivery, what would be the role of clinical governance in the context of third world countries like Nepal where the health system looks quite disjointed.One of the challenges of the clinical governance, as mentioned in different review articles is the involvement and empowerment of all concerned members but how that will be possible in low resource countries where the system works so discohorently. In fact, when I was working in my country, most of the time management would intervene only when there was some grave clinical failures otherwise the health care delivery would mostly go on without systematic concern regarding the patient's or care provider's safety. So I would love your comments on how this can be made to work irrespective of the resource constraints or maybe whether it is even worthwhile to implement in the first place when the verdict regarding its importance seems to be so ambivalent.

SHYAM CHATURVEDI Replied at 9:16 PM, 10 Sep 2013

Dear Dr Rebecca,

I feel honored to be included in this discussion. I am a former UNICEF official and held senior technical and managerial positions and now retired. I have been associated with various aspects
of health care delivery. I will be responding soon to the queries raised as I have seem the mail
just now.

George Otto Replied at 9:48 PM, 10 Sep 2013

Thank you for inviting me to this discussion. My name is George and I
manage the cancer centre in Papua New Guinea (PNG). I am involved in
managing resources, processes and developing and managing budgets. Our
centre is the only cancer centre in the country that provides cancer
treatment to a population of about 7 million people. It's an
enormously challenging task in providing cancer care in a setting
where resources are limited, management and political will is lacking,
cancer knowledge in general is lacking as well as infrastructure for
managing cancer is lacking. We have a lot of work to do to improve our
care infrastructure, processes and outcomes.
Despite the circumstances, we make do with what we have in delivering
cancer care. We have plans to improve cancer care services but that
is very slow because of lack of management and political support. We
are currently on a recruitment trail for oncologists and radiation
therapists. We have to recruit overseas as we do not have locally
trained oncologists and radiation therapist. Medical training
institutions here do not have the capacity to train oncologists and
RTs locally. My experience in my setting is that delivery of health
services will occur but it must be supported by strong leadership and
political commitment and partnership support to mobilize resources and
manpower to see improvements in health outcomes, otherwise there will
be no improvements in health service delivery. In the face of many
competing health priorities and limited resources, putting cancer in
the country's health priorities is also a challenge, but I am
determined to make it a health priority because cancer kills more
people especially women every year in PNG. I'm glad to be here and
will learn more from this discussion. Thanks.

Robyn Churchill Replied at 9:58 PM, 10 Sep 2013

I am a nurse-midwife and work on the BetterBirth project--which was described by Atul Gawande in his Slow Changes article in the Newyorker. We are a Gates-funded study in northern India led by Gawande on the effects of a simple checklist at the time of birth on maternal and newborn mortality and morbidity. While our work is in research, we are implementing this Safe Childbirth Checklist in front line facilities which are chronically understaffed, lack supplies, and do not have robust systems in place. We have seen hints of beginning conversations around safety and quality improvement which begin through the checklist. We engage with leadership as well as front=line nurses and ANMs (Auxiliary Nurse Midwives) to review essential supplies, best timing of a few key interventions (e.g. oxytocin within the first minute of birth, and skin-to-skin "kangaroo care" for the newborn).
The management/leadership of a facility is paramount to the success in making improvements. The leader can bring an expectation of quality, and a respect for his/her staff which changes all other functions within a facility. From my vantage point, that leadership--with clarity of vision, and respect for the staff--can create the space where improvement can occur. Without it, I don't see how any attempts at quality can survive.
Robyn Churchill

Karen von Bismarck Replied at 11:23 PM, 10 Sep 2013

Rebecca, thank you for this great opportunity to contribute! My name is Dan Swann, and I am the communications associate for Technology Exchange Lab (TEL). TEL is an independent, not-for-profit organization that provides a platform for the global community to share and discuss low cost, high impact solutions to poverty.

We at TEL are grateful to be members of the Global Health Delivery Project. We believe that TEL’s mission is relevant to this discussion about managing quality frontline health care. We wanted to inform you all of our curated online database of solutions to poverty that includes many methods and devices designed to improve the delivery of health care in the developing world. Everyone is free to visit our website and browse our database to learn more. I have added a link to our database as part of this post.

Please feel free to contact us with any questions or comments using the emails below:

Thank you, and best of luck with your panel discussion!

Dan Swann
Communications Associate

Attached resource:

Amanda LaBoucane Replied at 11:44 PM, 10 Sep 2013

Great discussion so far everyone, and indeed a variety of input from a wide range of disciplines and backgrounds!
My contributions come from a Community Health Development perspective. A significant amount of my education was spent studying Global Health, in addition to the management and health care experience I gained while working overseas in East Africa. Although I am not currently in East Africa, I am working in very rural and remote communities in Northern Canada. Although culturally specific adaptations are necessary, there are some things and the heart of Community Development that can be applied anywhere and my work never ceases to inspire and motivate me.

1. My management duties as the Director of Community Health Development include daily management of front line staff, on-going monitoring and evaluation of existing programs and staff performance, development of new community programs and initiatives based on needs, the ability to work within an incredibly constrained budget, and in the face of scarce community resources and an isolated and very wide geographic spread between communities. From the community perspective, there are several roles of a health care provider, and not just from the clinical/acute/primary care side of things. In the Community Health Department, our populations look to us for everything from health promotion information, referral to services, translation services (much of our Aboriginal population is fluent only in their native language and is unable to read or write), integrated programming involving other sectors (education, social services, law enforcement, etc.), and a variety of programming targeting specific health concerns such as TB, HIV/AIDS, physical health, maternal mental health, suicide, and nutrition/limited availability of healthy food in the north, all while taking a holistic approach to health (spiritual, mental, emotional and physical).

2. While there are many issues and challenges in health care delivery, and the need to provide timely, accurate, mistake-free service to address complaints, issues, conditions and symptoms is incredibly important and certainly at the heart of primary health care, it truly is the people that make the difference. In order to have committed, passionate staff, leadership must exhibit these same qualities and support and nurture the staff as they grow and develop personally and professionally in order to provide the best care possible to patients and communities.

3. A sampling of skills: Communication, interpersonal skills, relationship building, sensitivity, adaptability, willing to learn, working well as part of a team, continuous improvement. I believe that organizations should provide some management support or capacity building in order to ensure that their managers develop with the qualities that align with the organization and the needs of the population with which they work. However, personal characteristics and personality play an integral role as well, and those components are not so easily swayed.

4. Everything from community to senior leadership in an organization impacts the work of health care workers. Senior leadership sets the stage for the culture of the organization, while community members and clients should ideally contribute their input, suggestions and feedback to the organization in order to inform the process and the work being done. That in turn, impacts the work of the health care service provider. Barriers to improving efficacy of management (in my region/line of work) include: challenges with recruitment and retention of staff, difficulties obtaining qualified staff locally, [cultural] differences between communities within the same region/population, local politics and gossip, as well as historical issues that can sometimes delay or slow down management progress and development.

5. Any online tools for management capacity building and support would be incredibly helpful as it would be something that could be accessed by front line supervisory staff and managers regardless of the geographic location or isolation.

Thank you everyone for being a part of this I look forward to the continued discussions!

Kind regards,

Amanda LaBoucane, MPH
Director, Community Health Development
Keewatin Yatthe Regional Health Authority

Appolinaire MANIRAFASHA Replied at 1:05 AM, 11 Sep 2013

Dear Panelist
I am glad to contribute to this subject,as someone who is working in developping country where they reside poor population and sometimes there is lack of infrastructure in such places
I think my duties in health care delivery start by use little means and materials we have to provide qualitative care to our patients and if it was above our level we transfer to specialist and equipped refferal hospitals..
The main challenge we have is the limitation of our health care system in terms of diagnosis and if diagnosis is possible we meet the issue of management.
Networking is the solutions to the issue we are facing because if you meet a challenge in health care delivery there is a way to make a discussion online and get adequate solution or advice
The global health delivery is key to help us because is a platform of discussion where we find different poeple with different knowledge and everyone contribute to the health care delivery.
I could encourage everyone to give idea on discussion while he /she has idea on the topic of discussion.

Dr Arun Gadre Replied at 1:36 AM, 11 Sep 2013

Thanks but I am quite engaged.
I am now working in health policies, and not managing care.

SHYAM CHATURVEDI Replied at 2:34 AM, 11 Sep 2013

Dear Rebecca,
This is in continuation to my earlier email. I am responding to the first two queries and of course
would also respond to others in the course of time.
 1.      What kind of management duties or responsibilities not
performed in the
delivery of health care or watch others perform?

R = As a person working with Unicef, I had lots of opportunities making field
visits either alone or with the government  counterparts.  In  India managers  have the
responsibility, of ensuring proper care and services to patients in all areas,
including emergency and at all levels and the expected  roles include planning, organizing, staff
management including  updating them on
circulars, updates and handed down instructions,  controlling the resources, directing and  decision making. In practice, however,
doctors lack the requisite experience in management issues especially in the
areas of supply and logistics, patient flows, analysis of very useful data and
not sharing back with the staff for programme improvement. There is obvious
lack of qualitative improvements especially in the rural areas, largely because
of supplies which are not streamlined, lack of supportive supervision, and
hands on training of health professional.
2.      How important is the management (of people, processes
and resources),
compared to other issues or problems in the delivery of health services?
How can prioritize this element of your job?
R = I feel the management roleconsists of 3 dimensions- Techinical,
transactional and  transformational.
While you find that medical officer are good in technical role, they fail to
perform optimally in the other two roles. The Transformation Dimension refers
to activities associated with leadership. Here the Manager is acting as the
Leader. Softer people, relationship and communication skills need to be put to
work, seeking to get the best performance from the Team..

Debashish Naik Replied at 2:58 AM, 11 Sep 2013

Whether you manage some of these aspects of delivery yourself, or work with
those who do, we hope you will all join us by sharing your thoughts on the
following questions throughout the week:

1. What kind of management duties or responsibilities do you perform in
health care delivery or see others perform?

*I work as a consultant to improve the performance of the system. My work
is focused on application of Theory of Constraints (originated by Dr.
Eliyahu Goldratt) , integrated with Lean and fundamental management
principles of Peter Drucker. Healthcare is one of my FOCUS areas and have
provided my services to a few healthcare delivery organization. One of them
is managing PHCs. *

2. How important is management (of people, processes and resources),
compared to other issues or challenges in health care delivery? How do you
prioritize this element of your work?

*I strongly believe management of people, processes and other resources are
key to healthcare delivery, whatever the environment be. The prioritization
is based on the Goal and we try to FOCUS what matters most to achieve the
Goal given the constraints/ limitation of resources. FOCUS on aligning the
system to the Goal, resolving conflicts that block in achieving the Goal,
designing simple solution involving the people, and ensuring a buy in. *

3. What core skills do those who manage delivery need to be effective? How
did you or others gain these skills – are management training or capacity
building opportunities available in your work?

*We understand that A manager’s responsibility is to Improve her/his area
of responsibility. Gaining the expertise to improve performance in
healthcare delivery is through education, training, practice and a MINDSET
of Continuous improvement. Whatever the environment be and the system be
there is always opportunities to improve capability and capacity. A person
must be open minded to learn from different field, industries and people to
add value and resolve problems. Specifically innovation is a key skill and
attitude that a manager needs to work in healthcare.*

4. What factors in health systems, organizations or communities impacts the
work of those who manage delivery? What are the main barriers to improving
the efficacy of your management?

*What I perceive that for many (may not be for all) INDSET is the biggest
barrier. Other than that infrastructure, support from different
stakeholders create stress in the system.*

5. How can the Global Health Delivery Project address the challenges and
barriers faced by those who manage delivery, especially at the frontlines?
What kinds of resources or programs would be most helpful to you in your

*various innovative approach used in different projects to resolve issues
or to overcome challenges*

As always, we look forward to a rich discussion, and are grateful for your
input as we seek to identify ways the Project can advance the science of
delivery and better serve your needs.

Stewart Mennin Replied at 3:00 AM, 11 Sep 2013

I don't know if I fit neatly in this group. I was an assistant dean for
educational development and research at the University of New Mexico School
of Medicine for 26 yrs and an independent consultant for the last 9 years,
now living and working out of Brazil. We represented the WHO for
community-based, problem-based learning in the 1980s and 1990s. I've been
working with the Ministry of Health in Brazil and the Secretary of Health
in the Federal District of Brasilia in the formation of teachers for health
professional schools and for preceptors teaching from their practices in
communities everywhere, I also do faculty development work, program
evaluation, and leadership development for sustainable change in times of
uncertainty. It's not NGO work, however, it is managing institutions and
programs that provide professional development for all levels of health
practitioners. I'd be pleased to participate in any way I can be helpful.
My main interests are in how learning happens in health professions
development, how change works and especially in complex adaptive systems
applied to all the above.

Stewart Mennin
Mennin Consulting & Associates

Rua Inhambu 1708
Sao Paulo, SP

Dr. Ankush Shinde Replied at 3:00 AM, 11 Sep 2013

Patient Care is resource intensive. It needs expert people, robust processes and harness technology to diagnose, administer and manage care.

Any health organization needs to plan clinical , administrative and financial activities and all healthcare delivery involves these three sections.

Compared to other Industry  like banking, telecom and transport healthcare Industry is lagging behind in terms of adopting best management practices.

To manage any healthcare organization implementation of policies and procedures along with use of the modern management principles,  technology will surely help in to become well managed organization.

Gaddo Flego Replied at 3:46 AM, 11 Sep 2013

Dear all,
as health service director at a local health unit in Italy (caring for a population of 150,000) I cope with people who more directly manage health care delivery. In the field of managing people I believe that our most important issue is the feeling that the national health system is no more seen as a real priority at a political level. This leads to a decouraging atmosphere, the career and incentive policy is no longer satisfying, the mixture of public and private practice (for doctors) distracts people from the goals of the NHS. Generally, people think that they are blamed for a system that costs too much (not true, comparing to other OCSE countries) and doesn't work, despite the good achievements in terms of effectiveness of care and economical sustainaibility. On the contrary, I believe that recognising these achievements makes people work for even better results, and I believe that this approach is the thing that works in managing people. When I started my career in 1989 working for more than four years in Chad as district doctor and 3 months in Rwanda with an MSF emergency relief team (june-august 1994...) I had the same feeling. Maybe the fact of having directly delivered health care should be required in the process of becoming and health care manager? On the side of of managing processes and resources, I believe that the key words are accountability and evidence-based decisions. I found very interesting the health technology assessment (HTA) approach, that we are trying to implement at regional and local level, through the mini-HTA or hospital-based HTA method. Maybe if it's not as new as we like to believe, this is a language that can be spoken in countries that are building an health system, ones who are trying to sustain it, and ones who are resisting to its dismission, as it addresses issues like setting priorities and disinvestment that are really global. As I volunteered as coordinator of the HTA network of Liguria (my region) I would be very glad of sharing thoughts and facts about this.
Thank you for having started this discussion!

SHYAM CHATURVEDI Replied at 4:36 AM, 11 Sep 2013

I fully agree with George Otto that delivery of health services will occur but it must be supported by strong leadership and political commitment and partnership support to mobilize resources and manpower to see improvements in health outcomes, otherwise there will
be no improvements in health service delivery. But the million dollar question how to produce such strong leaders and elicit political commitment to mobilize resources including human resource.

Dr Arun Gadre Replied at 4:53 AM, 11 Sep 2013

Many thanks for your valid thoughts.
I need to carve out time, that is the basic issue.
Since I practiced on my own as a private gynecologist in resource poor
rural India for more than twenty years I might be of some help in maternal
Please let me know about such discussion when it is on the board.

K. Rivet Amico, PhD Replied at 6:08 AM, 11 Sep 2013

These posts show amazing diversity. I would be quite interested in learning more about HTA mentioned in Gaddo's post.

From a social-behavioral perspective, there is a thriving literature on dissemination and implementation of interventions and technologies- models that identify core factors that would propel successful adoption of an innovation. Some factors have already been well represented in these posts (leadership, resources and support with within and "above" institutions).

I wonder also about "consumer" perspectives. In many areas, resourced and under-resourced, healthcare is presented as something patients should feel 'lucky' to have access to. Long wait times, forms that take the place of conversations, hurried examinations, minimal involvement of patients in treatment planning, and numerous other aspects of getting care create an impression of a non-responsive/non-collaborative system of care. If our goal is prevention or treatment through self-directed behaviors, even the most resourced and supported provider will be unsuccessful if the patient/person is not engaged. And yet support for, training on, supervision, and use of quality metrics capturing the patients' perspectives of care delivery is often viewed as an "extra" (get the services available and then worry about "bedside manner"). From my perspective, targeting interactions between care delivered and patient/individual/community is essential for uptake and success of self-directed treatments or prevention.

I would very much like to learn more about research that has targeted these aspects of patient perceptions of care and how that may influence the provision of care, or in-field experiences of observed outcomes associated with changes in the responsiveness of care, adoption of shared decision making or movement towards patient-centered care.

Thank you for the insights and discussion.

Mohammed Ali Replied at 6:10 AM, 11 Sep 2013

Rebecca and others,
Thanks for the opportunity to comment. We actually just started offering an 18 day course at Emory University in Atlanta on public health leadership and implementation sciences (<>) for mid-career professionals from LMICs (as many of them manage care/preventive service delivery). We spend a fair amount of time with the trainees talking about management and leadership - in particular, aspects not described on this email chain include: emotional intelligence, understanding organizational design and how that impacts one's outputs, and setting the organizational culture to achieve what you are aiming for.

If anyone wants more information about our course, please contact <mailto:>

SHYAM CHATURVEDI Replied at 6:28 AM, 11 Sep 2013

Very useful insights !

Sandeep Saluja Replied at 6:43 AM, 11 Sep 2013

Thanks for inviting me to this lovely discussion.I spend most of my time as
a clinician with very little administrative or managerial responsibility
and this is more because I elect to do so and be able to focus on clinical

However,it is impossible for a clinician to actually escape managerial role
since that happens all the time without our really realising it.All other
doctors and medical and paramedical staff inherently look upon you as a
leader and one needs to constantly be a role model and teacher.

One of the simple things I have learnt is that a good team leader needs to
be good at every role-be it nursing,laboratory work or even sweeping
floors.I mention the last item because there have been instances when I do
not find the place clean and it happens on a couple of occasions,I
unabashedly pick up the mop or the broom and quietly do the cleaning when I
am alone.I love to learn nursing and laboratory skills from my colleagues
howsoever junior they may be and that helps to keep their morale up as also
help me guide them when needed.

Louise King Replied at 9:36 AM, 11 Sep 2013

I am appreciating this discussion, though I am more a clinician/teacher than a health care manager. I really enjoyed the Atul Gawande article about how to effect change. In Rwanda, I've seen a lot of expats come and go. Staying and working alongside local medical staff is a must for buying credibility.I would also add that many projects with good ideas underestimate the amount of work they are adding to an already overworked and underpaid staff, or else they hire away needed medical staff from government hospitals to receive higher salaries in NGOs. I would encourage GHD project to give us more examples of projects that work, and that could be feasible in other limited resource settings. Keep up the discussions!
Louise King, MD, Family Medicine and Community Health Supervisor, Ruhengeri Hospital.

Joe Welfeld Replied at 9:37 AM, 11 Sep 2013

Good morning:

My name is Joe Welfeld. While not having a significant amount of time in managing the front line delivery of healthcare, I have worked with many that do. I have spent many years as a consultant and over the past few years have been very active in coaching and mentoring.

One of the key areas of disconnect that I find is the lack of appreciation of management skills by many providers. Some of the key competencies required of a manager/leader are very different from those of a provider. Things like communication and consensus building are two. In trying financial times, management is also perceived to be "overhead" and therefore is either under-compensated or minimized.

While there are many formal training programs including courses they are usually targeted toward meeting certain regulatory or financial issues. These "offsite" courses provide valuable information but do not help current or future managers learn other soft skills.

One of the areas I believe can be most helpful is that of mentoring/coaching of active employees - helping them analyze problems, identify objectives, assess strengths and weakness (of themselves and others). If this type of service can be provided in a supportive and non-threatening way, it could be extremely valuable.

Stephan Rabimov Replied at 10:43 AM, 11 Sep 2013

Managing health care delivery is often a question of efficiency and effectiveness of the human resources and the health systems. In my recent op-ed on The Huffington Post, I use the example of the Global Fund Against TB, HIV, and Malaria, and highlight the following conclusions, drawn from our decade-long experience at the International Management Development Programme:

1. Management is management. Many of the effective management concepts addressed within the private sector professional development -- project management, budget and financial management, human resources management, leadership, and communication skills -- are essential for the success of public health programs worldwide;

2. Organizational culture for training has a positive impact on the program effectiveness. Programs that support management training and knowledge transfer, and reward trained employees, produce a well-educated network with a greater capacity for health care delivery;

3. Global professional networking complements local management development. Through cross-cutting health systems strengthening (HSS) and human resources development (HRD) management trainings, program managers and those managing delivery establish direct contact with regional and international professionals addressing similar public health issues, which greatly enriches the experience pool and results in a shared learning environment, and a wider global knowledge disbursement. The combined effect of such knowledge transfer is a greater efficiency of knowledge application, and consequently, a greater potential for health delivery costs reduction.

4. The previous experience, prior knowledge, training, and education all facilitate HRD and HSS, as they are cumulative in nature. The more training and education public health program managers receive the greater use of the new knowledge and skills application will be, leading to better performing programs.

"Efficiency is a management issue, not a medical issue," advocates the Global Fund in its recent documentation on the New Funding Model. It underlines that: "Effectiveness is what gives value, and efficiency is to achieve that value for the least amount of money. Together, effectiveness with efficiency give value for money."

Attached resources:

Virginia Lipke RN, MHA, ACRN, CIC Replied at 11:05 AM, 11 Sep 2013

Hello to all,
After reaing many of the posting, I beieve that Robyn Churchill and Masoud Dara's posting have much usable information. In so many situations, doctors and nurses must assume the roles of leaders and managers by default. In the haste of getting doctors and nurses trained (regardless of the country setting) we do not prepare them with the practical tools to become managers and leaders. This again is a bigger part of a "systems" problem where institutions have not recognized the need for these skills and offered the training. In the developing countries, where I work, the MoH that have oversite into the education for physicians and nurses offen either don't see the need, have the resources to alter the curriculum---so the situation perpetuates. But it does not need to be that way ...and we can be a voice to change the training. In the meantime, books by Dr. Atul Gawande on analyzing current practice and how to change to "evidence-based practice" using a simple check-list and Patrick Coonan's "A practical Guide to Leadership development" can show both MD's and nurse's how to develop the necessary skills. It will take a lot of persistance on everyones part to make these kinds of changes---but I've seen it done.

Sabeena Jalal Replied at 12:15 PM, 11 Sep 2013

After returning to Pakistan I was able to help set up the first school of Public Health in the Sindh province. In the first semester 33 students took admission in MSPH and 9 students in shorts courses. Also have been experimenting with ceramic incisional tool to be used by traditional birth attendants. Lets see what the results of rate of infections during delivery.

Attached resources:

Aamer Ikram Replied at 12:30 PM, 11 Sep 2013

Hi everyone, must appreciate the ongoing discussion, it remains a learning.
I am a consultant microbiologist and in addition in charge of management of an elite diagnostic institute.
In my opinion management is equally important as medical consultancy and the force which moves the consultancy in a refined manner. Expert management can handle the challenges much better way, rather it is part of management training to handle difficult issues.
Management and medical consultancy go together. Leadership qualities and team work are pivotal components combined with dedication and devotion to the assigned task.
Well, certain managerial qualities you learn with experience but I strongly believe that training is mandatory component. In that case single institutional training may not be sufficient; course and exposure play important role.
In my opinion, the most important factors are 'approach and attitude', with these two positive qualities any objective can be attained and problems solved.
GHD Project is already putting an impressive show by regular discussion and bringing the experts from different fields at one platform. We look forward for programs on leadership.

Mary Kasule Replied at 12:58 PM, 11 Sep 2013

Thank you Rebecca for this invitation, and to everyone for raising such important issues about the status of health care delivery in different parts of the world. My name is Mary Kasule and I work for the Council on Health Research for Development (COHRED: ) at the Africa office as Senior Research Officer. As someone who works in a health research environment particularly research ethics, I strongly believe that the missing link to improvement of health care delivery in low and middle-income countries especially Africa is lack of capacity for evidence-based practice. We at COHRED believe that research has a direct role in improving health care delivery. Therefore we support and provide technical support to low and middle-income countries especially Africa to build and strengthen their research and innovation systems. We work globally, but prioritize on LMICs. Our primary goals are to optimise countries’ research and innovation capacity so that countries can improve their health care delivery through evidence-based practices in order to provide better access. Furthermore, COHRED also engages with outside agencies whose actions impact on research and innovation capacity of LMICs with the aim of ensuring that their actions are system-supportive.

Currently many LMICs, particularly African countries have realized the importance of research for improvement of health care delivery. This has resulted in an increase in volume and complexity of health research conducted to reduce the burden of disease. However, this research is hampered by lack of strong research governance systems in many countries especially be the by research ethics committees or institutional review boards (RECs/IRBs). This has resulted into inefficiencies that cause delays in ethics review and ultimately delay research ( In response to this challenge COHRED has developed a cloud-based package the Research for Health and Innovation Organizer (RHInnO) tool “RHInnO Ethics” ( that RECs/IRBs can use to streamline and speed-up ethics reviews and accelerate research in order to develop decision-support systems that integrate clinical data with current evidence-based practice.

I would like to hear more on how innovations in research information management systems can contribute to improvement of health care delivery in your region especially Africa.

S. Mehtar Replied at 1:09 PM, 11 Sep 2013

Dear All
I work at the Unit for IPC, Div of Comm Health, Fac of Medicine and Health Sciences having taken semi-retirement last year. We run TB-IPC programmes, extensive education and training in this field as part of the larger IPC programme. I have a background in microbiology, community health and infectious disease and find myself constantly amazed at the transmissibility of MTB. We have a busy 1300 bedded tertiary academic centre and we see about 10 to 30 new cases per week but since the HIV epidemic is under control, these figures are declining. My experience is in simplifying TB-IPC in low to middle income countries so that containment and prevention can be done without much resource. Administrative support is available but our main problem is the lack of accountability and therefore following the guidelines. We do manage a whole spectrum of antimicrobial resistance in MTB. We have recently upgraded and revitalised parts of the hospital to accommodate a growing number of MTB admissions in both adult and paediatrics.
Our commitment is in both management and health policies in the Western Cape. As Chair of ICAN we also work across other parts of Africa.

Prof Shaheen Mehtar

Om G Replied at 1:16 PM, 11 Sep 2013

K.R. Amico

I have felt for a while that the critical shift is for the patient to feel some level of efficacy. This is possible of they are not merely responding to a query or receiving a check-in call from a nurse. Actually what has been reported as 'poor compliance' necessitating a nurse check-in call, may actually be a result of poor attention to the 'user experience'. Relevance fits in here hugely.

It may take longer on the front end to educate a patient, by describing the bigger picture and how it all fits together. Far, far easier to walk in and say "I know what's best" and then perform an intervention.

The kind of systems I'd like to build take as a first step, the lateral communication between community members to describe and drive the needs quantification for their community. Give humans the right and ability to provide their own priorities as a set of needs to be met and then have communication, tracking etc. all be responsive to that.

From the community perspective, efficacy can easily be seen by where they look for solutions, to whom is my request going out to this time? next time? Does my needs list shrink after interacting with this agency or facility?

From the clinic as a central focus, it seems impossible to me to break the cycle of disempowerment. Plus, this approach forces a dissolution of the idea that an individual's experience can be broken into discrete 'functions' and that community as a whole must be respected.

Abigail Wetzel Replied at 3:02 PM, 11 Sep 2013

Rebecca and all,

Thank you for your insightful contributions to this discussion. As someone overseeing the management of community health workers (CHWs) for a small organization (Ghana Health and Education Initiative [GHEI]; in Ghana, in addition to heading all program budgeting and staff and volunteer assessments, I have some insight into the issue of management in health care delivery in a rural context. A few observations are included below, most of which address questions 3-5 in the original post.

In our communities, even as non-managers, CHWs often find themselves in management roles while leading community groups and mobilizing volunteers for various initiatives. They are constantly faced with the challenge of maintaining a professional presence in the community when working with peers or family members. The health program assistants who manage the CHWs face a similar challenge when managing CHWs who are peers, community members, and even elders. The line between personal and professional involvement in the health of a community member or group is significantly less clearly defined for health volunteers in rural, community-based contexts than it would be in a more formal environment (e.g. hospital, community health clinic staffed by health professionals from different communities).

While the challenge of maintaining professionalism when working in a small community can be minimized through targeted training, formal management training (as opposed to training in health delivery) for CHWs and program assistants is treated as low priority when funding is scarce. Further, for such training to be successful, health workers must redefine their perspective on community relations, a process that, for all its value, can be frustrating and time-consuming.

Considering the multitude of management challenges such as those described above, managers in rural, small-community contexts need to be creative, flexible, and patient. Successful implementation of community-based initiatives requires that managers, whether they are from or have moved into the community, recognize and appreciate the challenges faced by CHWs or those responsible for health delivery. The adjustments necessary to revolutionize health care delivery and promote health equity often require health workers to significantly shift their mind frame and perspective. This conclusion complements comments made by other participants who have mentioned the need for upper level managers to have experience with and/or maintain involvement in the work of those working in the community.

As far as GHD's involvement and contribution to improving management of health care delivery at the frontlines is concerned, making easily modified training manuals and guidelines for low-level management and basic professionalism (along the lines of K4Health toolkits; available to managers can make a huge difference for those working with restrictive budgets.

Lisa Susser Replied at 3:04 PM, 11 Sep 2013

Thank you for asking me to participate in this dialogue.
In my role as a training and communications specialist at a large academic medical center in the US, I oversee training and education programs for our allied health staff. This includes medical assistants. We work on building on their basic clinical skills, and on developing the necessary skills to contribute effectively in a changing healthcare environment. We work on developing critical thinking skills and decision making in the longer-term. We emphasis patient experience and patient relationships, while helping the medical assistant develop effective communication skills and stress management techniques. Many of our practices are undergoing care redesign, and we are working with medical assistants to enhance their current clinical skills and critical thinking skills in order that they may contribute more actively in the care team. Additional experiences include developing a nursing orientation program, in collaboration with nurses, for our outpatient practices.
Management skills are a priority for my area. There are many challenges to health care delivery, and in our well-resourced environment, it's the people, processes, and resources that need to be reflected upon, and re-adjusted to meet these changing needs. For me, it's a priority that our organization remains attractive to good people willing to learn new techniques and approaches to their work, and with the flexibility to change aspects of their work to meet patient needs. In our programs, we offer learning opportunities to continually improve skills on a variety of topics. We also build in time to gather feedback on what our allied health staffs need/want to learn. They are often early detectors for necessary readjustments and new skills development. This is particularly true as their patient populations adjust to health care's structural and insurance changes. They are also front line to any clinical or technology changes in practice areas.
This may seem an odd response to the question, though it dovetails with the above. In my observations, our staff needs to have strong people skills, strong communications skills, and well-honed ability to apply acquired knowledge to clinical situations. Our staff needs to manage themselves with emotional elasticity, and equanimity. Big ask! Since the staff I work with primarily are task-oriented and task-driven, we strongly encourage them to pay attention to the connection between the how and the why of the tasks they are asked to perform. They may not have had this explained fully prior to working with us. They benefit from experiencing good personal management and communication modeled in staff they work directly with. They benefit from people explaining why we ask them to perform certain tasks, and from understanding how that task fits into the overall patient visit and/or diagnostic process.
The complexity of the science, the systems, and the tools we use compound the challenges to health care delivery. Time is the enemy. We don't have enough time to do it all well. While navigating complex insurance systems, technologies, which in and of themselves may be in conflict with each other, changing regulatory environments, health policies, and working with diverse patient populations, we're not going to get it right without some failure. However, we aim to learn rapidly from those failures, and apply that knowledge quickly. Given all the advantages of working in a well-resourced hospital environment, we can be hampered by the size and complexity of our own organization in gaining agreement and adoption of sound management.
In my view, we all work in global health since what's happening in an urban hospital is happening in a distant rural setting. They are the same problem sets. As previously mentioned, we are able to address some problems more easily, given available resources. However, essentially local health is global health. Of particular interest is how these same problems are addressed and/or solved in lower-resourced areas that offer opportunities for us to deliver outstanding care utilizing less (energy, money, environmental resources,
I'm looking forward to learning more from participants in the group.

Lisa Susser
Sr. Communications and Training Specialist
Practice Support
Massachusetts General Hospital
55 Fruit Street l CAM 326-510 l Boston, MA 02114
Tel: 617 724 1757 | Fax: 617 726 8659
E-mail: <mailto:>

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Howard Hiatt Replied at 3:54 PM, 11 Sep 2013

Extraordinary contribution, Rebecca.

Sabrina Speich Replied at 4:24 PM, 11 Sep 2013

Hello everyone,

I am honoured to be on this discussion panel. I hope my experience can
contribute to something.

I work as a traditional midwife here in southeastern mexico. I am also the
director of an NGO for Mayan midwives in the area. I attend homebirths and
come into contact with local hospitals. For us attending women at home has
become a very difficult issue, because the government wants all births to
be in hospital. There exists an extreme amount of obstetrical violence for
Mayan women and women in general. Many women want to stay home, exactly out
of that reason. Attending women at home ALL the responsability for on the
midwife. Basically we have no referral net. When we have to referr we are
judged as dangerous and the women we refer suffer excess obstetric
violence, as a punishment for having stayed at home.

For us midwives, creating networks, teamwork and resources for further
education are vital to assure our existence. Every midwife has befriended a
doctor in order to escape the government run clinics. The private doctor
will help out. This ofcourse then excludes women who cannot afford private
healthcare. Our NGO is also networking with lawyers in order to back our

Our core skills are learning to keep record of our work, learn basic
medical skills and know all the traditional remedies used. In our NGO we
have trained certified midwives and old traditional midwives. The
competencies that we use most are the traditional ones. We read very much
and use the cochrane library as a tool to support our work. We have adopted
the humanized birth model as a meeting point for all midwives, whatever
their background and training. We work in pairs in order to learn from
eachother. Always 2 midwives at a birth. Sometimes we have to eliminate
dangerous practices like oxytocin i.m during labour and Christeller. First
in our meetings we identify the midwives with most problems and invite her
to our births. It´s called: "Opening her eyes", everything we do is
comented on. After 3 or 4 births she feels safe enough to try it on her own.

Our main barrier is being stigmatized as traditional midwives and therefore
on an international level we have difficulties receiving funding. The
second, much larger barrier are the local healthcare centers. We are
obliged to go to training once a month in the local jurisdiction. These
meetings are filled with discriminatory talk twds the midwives and aimed to
make them feel silly, not capable and try to inhibt their work where they
can. A woman dies from PPH in 3rd level care hosptial and they immediately
call the midwives, eventhough the woman had nothing to do with midwives. We
are treated like scapegoats for everything wrong in the system.

I do not think we are the problem. The problem is, like others mentioned
before, a corrupt political system laying the ground rules for work. Total
incompetence for conflict resolution and very little work ethics. Many
doctors work for the government so they can assure their retirment, but
then have a second job. They are overworked. I have attended hospital
births, where the woman wanted the security of the doctor by her side.
Because it was private, the doctor left me alone with the patient, whilst
doing his shift in the gov hospital. He arrives 45 mins after the birth.
But charged nearly 2 thousand USD for the service. Where was the safety?
The ethics?

I think the Global Health Delivery Project should focus their work on
frontline workers, recognize their worth, so the system sees that they
should be supported. Here, if we had more recognition and respect and be
included in policy making and staff training then things could start
changing. If I was allowed to teach doctors how we deliver babies, we could
open their eyes. But we need a strong international backing.

In mexico the government implemented an area of public health for
traditional and alternative medicine, but here in our region the doctors
are stalling this. The training has to practical and not just powerpoint
and presentations. We have to literally attend births together to be able
to shift the paradigm and we need the political power to make changes in
their internal hospital reglamentation.
Traditional midwives represent the Mayan woman, here culture and belief
system. We know what they think and feel and most of all what they need.
Thank you again Sabrina

judy wawira Replied at 4:32 PM, 11 Sep 2013

@Ivahn why focus on excel spreadsheets while there are better open source applications? Just trying to understand your motivation

ETIENNE AMENDEZO Replied at 5:14 PM, 11 Sep 2013

Correct Dr King,
In resource limited settings like ours, the issue of overworking health personel who are underpaid and who work in understaffed health institutions is one of the major challenges that people meet.

My question would then be: what models would practically work better in order to address this issue? What are your ideas/experiences?

Lottie Hachaambwa Replied at 5:31 PM, 11 Sep 2013

#3. What core skills do those who manage delivery need to be effective? How did you or others gain these skills – are management training or capacity building opportunities available in your work?
Thank you for the opportunity to participate in this discussion. I am involved in medical education and affiliated with a US University and a medical school in Zambia. Sometime last year, I attempted to participate in an online course on management organised by Association for Medical Education in Europe (AMEE) where Stewert Mennin was one of the teachers ( a very good teacher), unfortunately, internet connectivity proved to be a challenge. I could not complete the course. Later in the year, SACCORE (Wellcome Trust project for medical schools in Southern Africa) had leadership training where I had an opportunity to participate in. It was very good training, learned some management skills that I am still try to implement.
Lottie Hachaambwa
University of Zambia School of Medicine
University of Maryland School of Medicine

Corine Karema Replied at 6:32 PM, 11 Sep 2013

Dear All,

Thank you for your interesting contributions and points raised for this important topic especially for us managers in the health sector.

In response to the 4 questions:

1. What kind of management duties or responsibilities do you perform in health care delivery or see others perform?
I’m the Head of Malaria and Other Parasitic Diseases (equivalent to Director of National Malaria & NTDs control program) Division in Rwanda Bio-medical Center. We are a public institution with a legal, administrative and financial autonomy, which is also in charge of providing an integrated and high quality services in combating Malaria & NTDs through prevention, cure, operational research, disease surveillance, control and an empowered workforce within available resources. Our mission is to provide evidence-based, technical leadership for the prevention and control of Malaria & OPD, through: independent applied research, multi-stakeholder participation, improved quality of services and strengthened health systems, thereby contributing to the improvement of the health status of the population.

My management duties basically goes to the coordination of development of policies and strategies and through monitoring and evaluation/supervision ensuring implementation of all malaria and NTDs control interventions at all levels of health care in Rwanda from Referral hospitals to community where we make sure that community health workers treat children under five as per national guidelines. I 'm also in charge of mobilizing resources for implementation of interventions in Malaria and NTDs control.

I'm also directly managing colleagues from the Malaria and other parasitic Diseases Division (42 staff) and partners at central level involved in malaria and NTDs control.

2. How important is management (of people, processes and resources), compared to other issues or challenges in health care delivery? How do you prioritize this element of your work?

Coming from a post genocide country Rwanda, management of people, resources and processes is very important given that we are still in a developing countries where there is need to prioritize for impact in life saving with value for money. My view is that the key of management is having a shared vision with teammates (in my case colleagues and district authorities and health providers as well as partners) in setting priorities and coordination of resources for high impact. and this is what is being seen in Rwanda for the whole health sector and in malaria where with similar resources given to many countries, Rwanda has been able to achieve more than 50% reduction in under five mortality and malaria ( morbidity and mortality).

Compared to other issues and challenges in health care delivery such as lack of funding, human resources, management is important as well done can make a program achieving good results by maximizing available resources and adapting processes.Management is an important element for success in the health sector and global health delivery as coordination of existing partners and funding with good financial management, transparency, and accountability has allowed Rwanda to get partners embarked in country priorities and funding.

3. What core skills do those who manage delivery need to be effective? How did you or others gain these skills – are management training or capacity building opportunities available in your work?

The core skills to be effective are: accountability, ownership of decisions, transparency, evidence based orientations and zero corruption of top of performance.

Most of the skills I and my colleagues gained from what we see around us and do especially due to the Rwandan leadership given that each local leader or manager is accountable of his duties and performance based funding is instaured at all levels whereby each staff sign a contract with his supervisors for certain targets he has to achieve in a specific period and his salary and income are calculated based on his achievements, this is the case for all civil servant in Rwanda as well as local and political leaders. Everybody is evaluated periodically based on achievements and can be replaced/demoted for under-performance.
I will come back for 4 and 5

Jessy c.adrien Replied at 6:54 PM, 11 Sep 2013

Dear Rebecca,
Thank you for this very interesting discussion.
I am a pediatrician from Haiti working in a public Hospital with limited ressources
The main problem is a lack of Human ressources and poor infrastructure.and the level of education of the family.
I am dealing with many challenges despite The Leadership

Rebecca Weintraub, MD Replied at 9:12 PM, 11 Sep 2013

Thank you to everyone who has taken the time to share their thoughts and expertise with us in this discussion - it is truly enlightening to read your responses!

As we continue the conversation this week, we encourage everyone to consider our final two questions for discussion:

What are the barriers in health systems, both in the private and public sectors that impact managers role and performance?

We are eager to learn how the Global Health Delivery Project can address the challenges and barriers faced by those who manage delivery - what kinds of resources or programs would be most helpful to you in your professional roles?

We have seen a number of vital management skills raised by colleagues in this discussion so far - the ability to communicate clearly, to think strategically, to lead and support colleagues, patients and caregivers, to manage time and finances, and to gain buy-in from stakeholders in at the community and government levels.

We have also heard colleagues speak to a few of the challenges in their systems and organizations that act as barriers, even for managers with significant skill and expertise - our health systems and health centers may be significantly understaffed, political leaders may not prioritize addressing the health challenges of the populations with whom we work, other systems or government services (transportation, communication, sanitation, education, etc.) may not be robust enough to support care delivery, to name a few of the challenges raised so far.

Looking forward to discussing your insights and experiences.

Marina Rajan Joseph Replied at 10:18 PM, 11 Sep 2013

Hello all!
I am sorry for belated joining.
I am encouraged by so many from far and wide are sharing their perspectives!
Thank you for raising these discussions on this forum. I trust some thing
creative will come forth.
I am primarily a Public health teacher also actively involved in the TB
control program in Kerala India.
In my observation and thinking problems of management in health care
delivery are

1. The magnitude in India- It takes a long time to get things down to the
lowest delivery levee especially new changes. Using the computers and
internet (of course training is needed!!) by everyone may be able to make a
2. The care giver may perceive the receiver as the reason for his/her
existence only then the care giving will be meaning flu. I see often the
givers consider themselves superior to the receivers! This is a matter of
attitude. Some inbuilt and continuous truing to monitor and cultivate
proper attitudes is important in health care programs.
3. I see that prevention os not given its due respect! Only when a problem
has occurred are managers involved. Managers need to be able to appreciate
'prevented problems' and appreciate the workers concerned to keep up their
morale for any program to be effective. ( Again a training need and
attitude issue!!)

Thanks all for the patient reading.

Maureen Kimenye Replied at 10:34 PM, 11 Sep 2013

I am a medical doctor in charge of a national drug resistance program. I do manage people of different levels, district level, regional and national level. I am responsible for policy development, capacity building budgeting, strategic planning and implementation, monitoring and evaluation, provision of technical advice to TB,HIV , airborne infection control and disease surveillance projects/ programs, resource mobilization and research among other responsibilities. I chair technical working groups that steer the policy and standards direction for the management of drug resistant TB, IPC and other lung diseases.

From the above, I expect quarterly reports, good quality of care,

2. Managing people is very key in service delivery. In my country, strikes are common and this is because many people are dissatisfied with the support to their work environment. People require adequate knowledge, skills, proper tools and good working environment. These people ensure any processes in your organization are followed failure to which you end up with a failed program. Processes are the structures and work glow systems in place which assist in monitoring a program. These processes assist you to achieve the set objective or agenda. An example is in theatre where the setting if the table, scrubbing of the surgeon etc follow a particular process till a patient is back to the ward.
Resources are scarce and the cost of anything can be reduced if the processes are cost effective.
Prioritizing the people and processes is key in management

3. There are the good qualities of a manager such as decision making, good communication, team work development, time management, integrity and honest among other.
Capacity building structures in my organization: there is a special budget for capacity building in which the staff can benefit from. There are also continuous medical trainings at the various levels

4. Factors that impact work: most commonly felt are those that impact negatively such as poor working conditions, poorly defined expectations and job descriptions, burn out due to overwork and shortage of staff, poor duty allocation, mismanagement if funds and time and poorly managed changes
Efficacy if management is mainly hindered by;
Lack of resources to increase the number of staff
Lack of time to adequately capacity build the health care worker who can't take time off for training
Shortages of qualified personnel lead to poor Job description e.g. A data entry clerk is assigned human resource and office administrator
Simple incentives are unaffordable

5 GHD is doing well in prompting such discussions as these to allow us share experiences and learn from each other. I believe the challenges we face are similar. Practices that have assisted in human resource management such as the task shifting and other innovative ways can be shared here. Online and distance learning on management could be a great opportunity.


Jagannath Reddy Replied at 10:43 PM, 11 Sep 2013

Dear Panel Members,

Happy to join this group and pls see feedback. suggestions welcome

1. What kind of management duties or responsibilities do you perform in
health care delivery or see others perform?

A) As District Program Manager Iam working for implementation Mother &
Child Health programs in the District (Medak, Andhra Pradesh, India)
supported by Govt Of India under a mission mode program called National
Rural Health Mission (NRHM).

B) My major responsibility is assisting the District Health Society
which is headed by District Magistrate. Preparation of situational analysis
reports, Deployment of skilled staff at high load facilities, ensuring
skill upgradation of facility staff working at public health institutions.

C) Preparing annual budget plans for effective implementation of the
program, payment of salaries & incentives, strengthening of infrastructure
etc are part of my job responsibility.

2. How important is management (of people, processes and resources),
compared to other issues or challenges in health care delivery? How do you
prioritize this element of your work?

A) In the public Health delivery system effective management of
available resources and HR plays vital role in implementation of Govt
supported health delivery System. One such example is “ at PHC Kangti which
is a remote/tribal PHC conducting 20-25 deliveries per month without 3
staff nurses. Posted 3 staff nurses there and now the performance is 50
plus deliveries per month. Same with MCH siddipet a mother & child hospital
used to conduct only 50-70 deliveries per month. Started payment of
incentive on case basis for hired specialists and now its performance in
250plus per month. There are many such examples is rational usage of

B) People confidence in public health facilities is increased now with
the establishment of help line. On an average 30-40 million rupees are
saved every month by rural poor of Medak District by accessing services at
public health facilities which was a mirage previously.

3. What core skills do those who manage delivery need to be effective?
How did you or others gain these skills – are management training or
capacity building opportunities available in your work?

A) Continues upgradation of skills of the field staff is my priority
subject. Unless they are aware of the latest protocols in service delivery
you cannot expect quality service delivery.

4. What factors in health systems, organizations or communities impacts the
work of those who manage delivery? What are the main barriers to improving
the efficacy of your management?

A) Inspite of ensuring best possible health care
infrastructure/service delivery setup we failed to win the confidence of
the rural poor. To address this gap we have come up with a community based
program called “MAARPU” which means change. Involvement of village level
self help groups helped us in demanding their entitlements at public health

B) Major problem/barrier in improving efficacy of service delivery system
is the trade unions/employees unions. Absenteeism is another major
blockade. With new proposal of incentive system for best performers and
involvement of community may definitely help us in this mission.

5. How can the Global Health Delivery Project address the challenges and
barriers faced by those who manage delivery, especially at the frontlines?
What kinds of resources or programs would be most helpful to you in your

A) Fortunately for us Columbia University has taken up my District as pilot
district for a program called MODEL DISTRICT FACILITY. With their continues
support we were able to achieve best possible results in public health
delivery system. Small issues which we may not focus are highlighted by
them which helped us in smooth monitoring and effective service delivery. A
supportive program like this will definitely boost the morals and skills
of a manager like me.

Dr Shanta Ghatak Replied at 10:45 PM, 11 Sep 2013

1. What kind of management duties or responsibilities do you perform in
health care delivery or see others perform?

Being the Director of a private sector organisation essentially run by one
of the largest business communities in India - a lot to talk about.
Essentailly I am manging the business community who really doesnt want to
put in money , wants to save on taxes - direct and indirect benefits both
are involved . I reach out to the community at large every week through my
voluntary blood donation camps and talks and slum projecst and few other
newer intitiatives that involving pursuing my projects with the government
and networking with other local and international NGOs or tehir
representatives who have been working in some small ways in teh community.
This is my commitment to seliver something good for the society at large -
the community whose needs are a burning issue whatsoever - despite govt and
non govt support etc etc etc

I also happen to run a charitable clinic where again I mobilise support for
some thallassaemic children and children suffering with autism and some
otehr chronic diseaeses for which I try to get them the medicines free of
cost so that they can survive for some more time

Soem slum children I try to provide with clothes and winter dressing from
the business community that essentially looks at me for eatabliahing wider
connections to generat emore funds at the end of it all

It is a total team of 200 and a few more in 7 states of the country and in
total around 16 running projects and a 24 hour research centre and a 24
hour blood bank - that has been essentially functioning for the past 34
years or so - started when no other / few other blood banks existed and no
methodologies and quality control and quality protocols and guidelines or
SOPs or accreditatiosn etc existed in the proper sense as it is now today

Although I happen to have been working for the last 2 and a half years or
so - I have created jobs , I have been able to get funds and hav ebeen able
to move forward the entire system and the organisation as a whole

But as I need to move on from the private sector I have applied already to
a humanitarian organsation and will be soon starting to work for them

2. How important is management (of people, processes and resources),
compared to other issues or challenges in health care delivery? How do you
prioritize this element of your work?

Nothing can happen without people - and if we do not create the people we
need - we fail. We stand to NOT to evolve and essentially cannot
effectively manage resources or create a positive , beneficial , economic
talent pool IF we do not look at the people - their mgt , their technical
standpoints , their creativity , and of course some of the soft skills that
are so much needed in todya's world. Recognizing , reconciling and
reflecting from time to time does benefit a lot . Objectively ,
qualitatively and quantitatively monitoring may not be always feasible and
possible in totality .....but still believing in people , taking teh human
factor into consideration ALWAYS does have a very positive and definite
impact on the system and teh organisation as a whole

3. What core skills do those who manage delivery need to be effective? How
did you or others gain these skills – are management training or capacity
building opportunities available in your work?

The kind ofcapacity building that you ar etalking about was not always
available but then I firmly believe that I hav ebeen a little more lucky
than others bec I got to work in so many many sectors across teh country ,
so many kinds of people , so many designations and so many hierarchial
institutions of which one has been my family !! Starnge but true how teh
orthodox family pattern has helped me build some strngths and gain insights
for monumentous decisions and taking care of my talent acquisitions ,
retaining then and gaininng support from the management committees and
other advisory groups over all theese years in the various national and
international organisations that I have been working for

4. What factors in health systems, organizations or communities impacts the
work of those who manage delivery? What are the main barriers to improving
the efficacy of your management?

Depends on essentially my management skills and objective , evidence based
practical problem solving and strategising with long term focus . It does
not have to happen always the way that I think - I firmly believe in being
in touch and touching lives has been my clear objective so far and though
this is not a very practical outlook at times - it does work with even very
hard to crack people and teh community and believ it r not Dr Rebecca,
"kindness does pay " - if not immediately .....but eventually . :)

5. How can the Global Health Delivery Project address the challenges and
barriers faced by those who manage delivery, especially at the frontlines?
What kinds of resources or programs would be most helpful to you in your

Practical role plays and relationship building , understanding , empathy ,
seeking creativity , infusing structural carreer objectives , building
partberships and networking with the national and international community
both in the govt and non govt sector as well as other privt esector ,
seeking at times their practical tips and advices , ganing their stand
points build a lot of positve trust building and capacity in the people
with whom we ar esupposed to eb working with

Thanks for teh invite Dr Rebecca. I wish I had soem more time in my hands
to run through in little more technical details as well in proper formats
and all and I would really really loev to eb able to sharereal life
situatiosn in order to build a better global work force . It has been my
objective to creat eworking force of teh highest quality with soem empathy
embedded . And I have been trying over the years to do that and have been
successful to a certain extent but not always . But mostly . Thats good
enough fo rme at this point of my life !

Thanks again and IF I have been able to put across any successful
motivations that will be a very positive gain for me

Christophe Milien Replied at 11:01 PM, 11 Sep 2013

Thanks Rebecca for inviting me in this expert panel. I'm Christophe Millien, an Haitian physician who is working in poor setting resources. I was the director of Lacolline Hospital, after the regional coordinator of maternal health care and now chef of the OBGYN service at university hospital in Mirebalais(HUM) which is a teaching Hospital in the countryside. I'm also an attendant physician at the hospital of the state university. I manage human resources, analyze data and the social situation for making decision, training residents, implementing services at HUM, motivate the personnel for making improvement, be part in the quality improvement and research team of the hospital, and also in the clinical committee of this hospital.
Management of human resources is one of the big issue of this hospital . In our country we have a big challenge to find qualify people who have the willing to work in the countryside. Further the more, we have a big problem to keep them in the country because of social, economic, security problem etc.. The number of patients are increasing and we have an overwork by the physicians and that makes the physician unavailable for the teaching responsibility. Good communication help us to motivate them but it's not sufficient. A good work plan that identify priority is done for helping us to solve these problem. The economic recession remain a big issue to find found for hire more human resources for doing the job Beside that supply is still a challenge.

Good leadership, good communication, good capacity to understand the evolution of your department, good skill for monitoring and evaluation and capacity for interpreting data for making decision. As a worker in a teaching hospital. A good system of continue medical education is in place but finding foreign visiting professor for helping us is not a peace of cake.
The main factor who influence our work is poverty. The impact of this in the community is responsible for the structural violence that will bring us in the spiral of poverty. Bedside that vertical program without integration of services is an important factor. The lack of reinforcement of the government capacity for having good policy and found are also a big problem. This situation affect deeply our health system.
Global health technology can work on project toward to increase qualify people for training in poor setting area. Project which Bring the technology to them which help them to have a better system of management and qualify resources. Implement social and medical project by decreasing poverty like family planning. Project of reinforcement of governments and project toward retention of human resources.
Best regards.

Bistra Zheleva Replied at 12:57 AM, 12 Sep 2013

In our work of building capacity for sustainable pediatric cardiac centers of excellence in the developing world we found that organizational capacity building was equally, and if not more, important to sustainability. It's means that we need to be teaching management alongside clinical skills. Those include planning, strategizing, understanding how organizations work, managing finances and budgets, managing and promoting and motivating staff. In other words, another full time job in addition to their clinical duties. What we have found to work is to find smaller projects that can link clinical to organizational learning. For example, decreasing infectious can have a cost efficiency component, leading to better understanding of financial information.

However, a key factor remains leadership, and especially leadership development and mentoring. We still struggle with how to find, identify, and invest in new potential leaders through mentorship and training. And having a champion (leader) is key to a program's success.

A great illustration of our organizational capacity development approach was a recent visit we sponsored of hospital administrators and leaders of our partner in Brazil to their twinning institution in the US. The purpose was to understand the inner organizational workings of a pediatric cardiac program as they were preparing to move into a new hospital facility. The feedback was unanimously positive, with people telling us this was the week they learned the most in their life about hospital and health services management.

A lot of people before me outlined what the problems are, and I agree that in our each individual "spheres of influence" we can take on these kinds of trainings. However, I would argue that we also as a community need to argue for the need for health care or hospital administration education. There are many tools and training materials out there (Management Sciences for Health and USAID have excellent resources), so I am not sure it would be most effective use of time for GHDONLINE to develop and post more here. For example, we used the MSH resources to develop indicators for our organizational capacity building work.

I am optimistic and believe that anything can be learned, but ultimately, the biggest challenge that remains is the identification and development of champions and leaders. I asked one nurse from our site in Brazil today how we could help the empowerment of nurses more and identify nurses like her who can be leaders in specific areas. Her response was "It's not that they don't want to learn and improve, they do. But people get tired. When you work hard every day and at the end of the month still can't pay your bills and need to take a second job, you get disappointed and tired from the system not seeing any support from it." This can be true for anyone, burnout is a serious danger for all of us. The experience of our NGO shows that finding case by case solutions on individual level is the best possible way. Just like Dr. Gawande described it. And advocating with hospital/clinic administrators, health department officials and others in positions of power by proving our commitment and bringing up evince based solutions to problems.

Murali Ramachandran Replied at 1:02 AM, 12 Sep 2013

1. What kind of management duties or responsibilities do you perform in health care delivery or see others perform?
Check list and guidelines followed are assessed at every level. Periodic reporting every month .

2. How important is management (of people, processes and resources), compared to other issues or challenges in health care delivery? How do you prioritize this element of your work?
Resources are challenges in health care delivery. 2nd priority is the process which has to be monitored at every level of health care delivery. People though important they can be trained

3. What core skills do those who manage delivery need to be effective? How did you or others gain these skills – are management training or capacity building opportunities available in your work?
Early diagnosis of complication is important for effective delivery .
Skill lab established for capacity building- simulation case studies introduced- well developed feed back mechanism introduced
4. What factors in health systems, organizations or communities impacts the work of those who manage delivery? What are the main barriers to improving the efficacy of your management?
Frequent transfers is the main barrier

5. How can the Global Health Delivery Project address the challenges and barriers faced by those who manage delivery, especially at the frontlines? What kinds of resources or programs would be most helpful to you in your work?
Sharing of experience - and research promotion with resources /Manpower training will be helpful .
Hand out and modules can be shared
Professor and Hod, Community Medicine, CHRI- India

Sandeep Saluja Replied at 2:19 AM, 12 Sep 2013

In fact,it is impossible to convince anyone to work in remote or very
resource limited conditions purely with the lure of money.Any work with
pure money motivation is bound to fail.

It can only happen if we can generate a sense of commitment to the cause
and this again is possible if senior people display that first.

Karin Wiedenmayer Replied at 3:01 AM, 12 Sep 2013

Rebecca, thank you for this initiative to share experience and for the opportunity to participate.
I am from the Swiss Tropical and Public Health Institute. We have longstanding collaboration and offices in Africa, Latin America, Central Asia and the SE Asia supporting various health programmes, projects and the GF. In addition we conduct research in areas such as health systems, NTD, health economics, health and environment, gender etc. Personally I have been involved mainly in public health pharmaceutical systems and human resources for health.
Just as a recent example: pharmaceutical supply management in rural areas of Tanzania in 95% of health facilities is managed by clinical staff, i.e. non-pharmaceutically trained health workers whose TORs are clinical care of patients. In other words, informal and unregulated task shifting is happening. At the same time stock out rates reach up to 40% in public health sector. The supply chain itself is enormously complex and spans financing at the level of MoF down to MSD and quantification at health facility level. How can this situation be improved and “managed”? How can often untrained clinical health workers be motivated and trained to “manage” health supplies?
Management underpins every component, resp building block in the health system and is the sine qua no for planning and implementation of any activity in health care. But it equally affects research and training activities. In my experience some of the most important determinants of good management are the inclusion of stakeholders and actors at every level. Management should not be a top down process but rather a way to empower, motivate and include health care workers and authorities- both in decision making and accountability. Whether it is medicines, finances or health related data…without management, these resources will be lost and will “evaporate” to other purposes than health care. Management must be transparent and follow standards of good governance, provide role models and even champions and – importantly- offer guidance and leadership in the complexities of a health system. What is often forgotten or skipped over is a thorough analysis and understanding of underlying contextual factors including the cultural setting and belief systems. If we apply “western” style management principles only I fear we will fail……regardless of whether this management method is imported by consultants or trained local experts. Adaptation to the local situation is critical. Management in isolation from a desk may be short lived in impact unless integrated with participate consensus building, performance targets, monitoring and evaluation, with effective supportive supervision and with a clear and transparent system of incentives (material or other), and if needed fait warnings and consequences. A health system is such a nonlinear structure with complex processes and interactions and often very unexpected adverse outcomes that effective management at every level is essential. Always keeping in mind the ultimate objective…..patient care!

Tomas Ricka Replied at 3:25 AM, 12 Sep 2013

Thank you Rebecca for this initiative. I added a few remarks relateted to this topic.
1. We are now runing several projects in healthcare area as a project manageres (focus on ehealth and ecardiology).
2. We are part of The Czech National eHealth Center (NTMC), We helped to establised it and now we are responsible for economic analysis and consluting in helathcere within this platform, but we just started it.
3. We would like to use some part of GHD courses and also case studies for medicine students and also for management in hospitals.
4. To be honest we are so busy, that the implementation from our side (teachnig CS and consulting) would be slower, than we expected.

Nicholas Connor Replied at 3:55 AM, 12 Sep 2013

Hi GHD Online, I applaud this effort to construct this expert panel.

I am a Canadian working as a Research Investigator and Project manager for a large multinational community-based neonatal health (infection) study called ANISA (Aetiology of Neonatal Infection in South Asia). I have worked in Malawi prior to this but have been based in Dhaka, Bangladesh for the past 3 years conducting the cross country management of this project which involves ambitious field, laboratory and data challenges. I am in charge of ensuring that the scientific protocol is being applied in a homogenous way across the sites located in Urban and Rural Pakistan, Rural Bangladesh, Odisha and Tamil Nadu states in India. As you might imagine this presents highly complex political, social, ethical, scientific, communications and managerial challenges.

Without proper and inclusive management structures incorporating technology, accountability, tact, and a variety of other elements this project would not be conceivable.

Core skills to manage health delivery? Interesting question, knowledge, imagination, people skills, otherwise I take a fairly relativistic view here. People should know your abilities and what you expect from them and conversely, what to expect from you. I have only a few principles to guide actions, one is only ask what you would do yourself, the other is that it is much easier to succeed if others want you to succeed than if they want you to fail.

Factors in health systems? Bangladesh is an interesting case when it comes to health systems. The barriers? The trifecta of Extreme Inequality, Apathy, Corruption can be confronted by civic mindedness, change and accountability.

How can the GHD address such challenges? Help build genuine solidarity and witness for those who do not have a voice.


Charles Ndiizihiwe Replied at 4:24 AM, 12 Sep 2013

Re: Managing Health Care Delivery: Your expertise
Dear  colleagues,
my name is Charles NDIZIHIWE, I’m a General practitioner,  I'm  CPD
focal point at RWINKWAVU Hospital in Rwanda, I work in Internal medicine and at
Out Patient’s Diseases.
managing Health Care Delivery, Social factors and Economical factors are needed.
Continuing professional Development is also needed for better management of
patients. If the above factors are present, we will use some community Agents
for sensibilisation to the community.When taking a past history of patients I
note that Community agents need to put more energy in their work. Doing well
their work , they need some motivation, Salary, Equipment,.We know that Tuberculosis
is one of disease which can be contaminated by several people in village due to
breathing, coughing, proximity. We know Cholera in case there is no enough hygienic,
when people eat without washing hands,…
People really need   some community agents in their villages just
for sensibilising on some attitudes for preventing some diseases like  Typhoid Fever, Pulmonary Tuberculosis, and
other diseases from poor Hygien,

 For Doctors, nurses, we need   Practical training sessions, Reading
scientific papers in journal and presenting to other staff and other educational activities which serve to maintain, develop or increase the knowledge, skills, and professional
performance and relationships that a health professional uses to provide
services for patients, the public, or the profession.
exchange is important for reaching future Career development.
I finish here, thanks for my
invitation on ideas exchange, Good day!.

Dr Charles, Hop. Rwinkwavu/Rwanda.

Louise King Replied at 4:58 AM, 12 Sep 2013

I have appreciated the discussions. I am a clinician/teacher in Rwanda.
One of the main barriers we have to change is that there is such rapid turnover, especially among doctors. Therefore, people are trained, and then they move on, and their successors have not been trained. and we start back at the beginning again.
It was interesting to read of examples in Atul Gawande's article about change of approaches that work. The GHD project could help us all by letting us know what's working out there, and what's not, to effect change. Also, it would be good to understand what are the most cost effective changes to bring about.

Ismail Lawal Replied at 5:32 AM, 12 Sep 2013

This has been a nice discussion and am following with keen interest.
One thing that we need to take more serious is attitude of care providers.
No matter how best the management skill is, attitude is key.
Best regards.

Henry Kilonzo Replied at 5:43 AM, 12 Sep 2013

Dear all
I am a public health professional. I am monitoring the capacity development of health focused national level civil society organisations. The CSOs are are working with their affiliates, government and mission health facilities to implement health service delivery projects. The purpose of the capacity buiding through mentorship, coaching and peer support is aimed at strengthening their organisational systems, that will ultimately impact on their efficiency and sustainability of their health projects. The CSOs' projects focus on HIV/AIDS, prevention, care and treatment, health systems strengthening and vulnerable children in Kenya.

The community health stategy in Kenya initiated in 2006 by the MoH has seen improved uptake of health services by the community. Community Health Care Workers (CHWs), are at the centre of its implementation. They profile community members, identify community health needs and refer clients to the nearest health facilities. They have a monitoring role through data collection and feedback to the sources/community members.

The presence of the CHWs at the community level, who are known by the community members, and coordinated by Community Health Care Extension Worker, provides the required extra hand/human resource for linking the community and the health facilities. Carrying out prevention and sensitisation roles (disease prevention, surveilance, referals etc) that do not require specialised skills remain their key roles. They are a key resource in health service delivery!

Henry Kilonzo, MSH, Kenya

anaclet mugali Replied at 6:00 AM, 12 Sep 2013

Thanks, this is really wonderful. I am sure participation of experts around the world would multiply as well as mutually beneficial, Thanks for iniating this important discussion , I`m working at district hospital as a Family Physician , my role involve improving the quality of health care delivered by primary health care centers even if in the hospital, I`m working in Rwanda. The challenge I found is the lack of comprehensive management system by practioners, supporting them with proper training shown a good advance but yet connecting between processes and the ability to perform informed decisions is one of the major challenges.

ALICE OJWANG Replied at 7:50 AM, 12 Sep 2013

I am nutrition professional, lecturing at the university and running a Nutrition consultancy.
Kenya like the rest of the world is experience and increase in NCDs. The challenge is that there is very little prevention activities going on. I look forward to the day when Nutrition education/prevention will be in the agenda of  Ministries, Health Insurance companies an organizations and schools of all levels.

We know for sure, that eating healthy will save the world.

"To lengthen thy lives, lessen thy meals" Abraham Lincoln

Busi Mombaur Replied at 7:56 AM, 12 Sep 2013

Firstly, I would like to address Rebecca’s question about accessing training opportunities. It is true that access to opportunities such as the intensive global health program at the Harvard School of Public Health (HSPH) is probably dependent on being employed by an organization. Most of my colleagues at HSPH this past summer were working for organizations. I was fortunate to participate in the program, and the experience has certainly had a positive impact on my approach to patient care back home in South Africa. It would be helpful to explore options for providing these opportunities to frontline individual practitioners, perhaps through local GHDI-like courses.

Secondly, to address the issue of barriers in health systems – after reading the recent Michael Porter’s article, “The Strategy That Will Fix Health Care”(HBR, October 2013), I wished there were avenues to provide integrated specialist care in resource-limited settings. Patients often see several specialists, travelling long distances – at a huge cost – before finding solutions (or giving up on management of disabling conditions). The idea of Integrated Practice Units where specialist care is organized around what patients actually need rather than what physicians offer is extremely appealing, and I hope this is indeed the future of health care delivery, whether it is primary or tertiary care. Specialists care needs to be integrated so that patients do not feel alone, navigating the health care system without accompaniment.

In the meantime, I hope what we learn from these panels (and the global health community at large) will enable us to do what Kim-Son Nguyen (above) urges us to do in this panel – “the painstaking, time-consuming process of having boots on the ground, high-touch, person-to-person sharing of ideas with genuine humility’ - whether we are working as part of enabling organizations or as lone practitioners hoping to put patients first.

Busi Mombaur Replied at 7:59 AM, 12 Sep 2013

And, Rebecca, thank you for inviting all of us to participate in this inspiring panel. I am constantly humbled when I read about what people in the GHD community are doing. The posts are inspiring, we learn from the questions as well as the solutions.

Josiah Onyango Replied at 9:46 AM, 12 Sep 2013

What kind of management duties or responsibilities do you perform in health care delivery or see others perform?

· Making workplan and budget

· Monitoring and Evaluation implementation

· Supervising TB officers

· Liason/Coordination with the Ministry of Health and other stakeholders

· Capacity building through training, ,OJT and mentorship

· Representing the organization at different functions

· Providing positive image of the organization

2. How important is management (of people, processes and resources), compared to other issues or challenges in health care delivery? How do you prioritize this element of your work?

· Main objective of my job is to increase access to quality TB diagnostic and treatment services through the MOH staff.

3. What core skills do those who manage delivery need to be effective? How did you or others gain these skills – are management training or capacity building opportunities available in your work?

· Communication skills. Counseling skills. Adult training skills. Technical skills; interpersonal relations, supervisory skills. Capacity building skills available on line and face to face sessions.

4. What factors in health systems, organizations or communities impacts the work of those who manage delivery? What are the main barriers to improving the efficacy of your management?

· Commodity shortages; infrastructure and lack of ownership of the program by the public sector

5. How can the Global Health Delivery Project address the challenges and barriers faced by those who manage delivery, especially at the frontlines? What kinds of resources or programs would be most helpful to you in your work?

· Adequate commodity supplies, accountability, improve infrastructure and staff motivation through mentorship, training, feedback and personal development.

Busi Mombaur Replied at 9:49 AM, 12 Sep 2013

Sandeep, I agree with you. But I think there are probably ways to harness the strength of effective private institutions to provide outreach to resource-poor settings. For example, I am trying to find ways for a private hospital to assist me with an outreach program for patients with neurological diseases. Initiatives that address inequity in health care delivery often require thinking out of the box in order to address specific gaps in resources. What I've learned in my limited experience is that when "senior" people do not display a commitment, then junior people can look for other avenues to effect change.

I think many people are willing to help, but cannot find avenues to contribute meaningfully, so they go on with their lives, turning a blind eye - uncomfortably - to issues of social injustice and inequity. Dr Paul Farmer calls this an "unintentional slide towards general anesthesia for the soul." The idea is to try to avoid this general anesthesia, and not give up on working to improve access to health care, whether there is institutional support or not.

Lubna Samad Replied at 10:06 AM, 12 Sep 2013

Great to see such an animated discussion underway. This is obviously a complex and multi-faceted discussion, and the solutions are bound to demand input at many levels. I think one of the key areas to focus on is building systems that are strong, that outlast the personalities or individuals. In our part of the world, we see many organizations that do excellent work but that are person led. If that person (either local or expatriate) is taken out of the equation, the initiative often collapses. Again, the importance of investment in systems cannot be over emphasized. Many donors and grants support activities but not infrastructural investments.

GHD's role: training people in different settings is a huge contribution. Perhaps hosting regional courses on a rotating basis will allow better participation due to decreased costs of travel and accommodation. Many participants face visa processing delays, that has affected their ability to attend the course even though selected. A regional approach would also encourage locally relevant solutions to emerge with the participation of people facing similar challenges..

Lisa Adams Replied at 10:22 AM, 12 Sep 2013

Thanks Rebecca for starting this important discussion. I completely agree with many colleagues who have commented on the need to engage the community in the evolution and delivery of heatlh care services. The importance of this is often acknowledged but execution is challenging so occurs much less frequently. I know there are examples (Rwanda being one of them) where this is put into practice at least at some levels at present. I also think task-shifting will be important as try to design efficient health systems - which is necessary now in all settings. I think of Aravind Eye Hospital's marvelously efficient system where they have shifted tasks to the person with the right level of training and skill - no more or no less which seems to lead to greater job satisfaction and very high quality of care. With so many issues in health care delivery being systems issues, there is a clear need for greater expertise in this area.

Marco Inzitari Replied at 10:30 AM, 12 Sep 2013

Dear participants in the panel,

I am a PhD geriatrician, now serving as the Director of Healthcare in a large monographic geriatric post-acute, rehabilitation and palliative care facility in Barcelona, Spain, which integrates bed-based (still the main activity), out-patients and home-delivered services. I come from the medical training, then complemented with aging research (with a PhD and a 1,5 years stay in the USA), and finally with two Master's degrees in Healthcare management, the last one from an international business school.

My dedication is now 90% management, 5% direct patients' care in a dementia outpatient, and 5% research. I'm in charge of about 350 professionals, and I participate in management activities assisting, as the maximum healthcare Dorector, my CEO.

Relative to your other questions, I think that the main focus in management has to be directed towards professionals and workers in general, together with protocols, procedures and orgazation, trying to facilitate their jobs and to add value to the talent and potential of the teams. In my view, workers and professionals are my "patients", in the sense that I dedicate my lidership and management skills to get imputs from them and help and facilitate them, with a close, listening and participative style, whenever possible and feasible.

I'm convinced that healthcare direct provision training, better if specific to the management position, associated with added management specific training, is clue for this type of job. In my personal experience, research training helped a lot in developing a analytic approach oriented towards outcomes measurement and follow-up.

For me, leadership of human resources is still the center of the business: building a successfull team, fostering team working and a participative strategic direction, with a constant dissemination of strategic challenges and goals, is pivotal. But, at the same time, it remains a challenge, mostly for the difficulty of finding the right way of communicating (what, when, to who first?).

Perhpas sharing cases of successful and unsuccessful management and delivery cases through GHD could be interesting as a training strategy, together with delivering short pills of innovation and research based experiences. Twitter and social networks remain a crucial vector for dissemination.

Marco Inzitari

Attached resources:

Robert Buxbaum Replied at 11:17 AM, 12 Sep 2013

This is a fascinating and productive discussion, and gratifying in the number, breadth, and depth of responses.

I would like to suggest that there's another potential area for discussion within this stream: the role of cooperatives.

The cooperative movement has a long and distinguished history, including its role in the development of health systems in the US, Of course, it's not at all limited to health initiatives (see Mondragon, in Spain as one of the most outstanding examples). Group Health of Puget Sound, a multispecality group practice, was founded by consumers of health, not physicians or health policy people.

For starters, I suggest taking a look at the Rochedale Principles (you can google this) and see whether you think these apply to health delivery systems.

Cheers --

Bob Buxbaum, M.D.
Associate Clinical Professor of Medicine
Harvard Medical School

Aliya Yamin Replied at 11:55 AM, 12 Sep 2013

Dear Rebecca and all, thanks for asking us to join this rich discussion. After all, we do learn from each other's experiences.
I am an Internal Medicine physician currently working with Public Health. My patients in communicable disease branch are diagnosed with TB or TB/HIV. TB management over here is a team work of clinic, outreach, surveillance and management staff.
I firmly believe that whoever is engaged in delivery of public health needs to keep up to date with recent advances in medicine. I have attended both in-house trainings offered through the health department as well as refresher courses in TB/HIV management and treatment through outside sources. Other sources of information are medical journals, webinars and in person consultation with clinical experts. There are state TB consultants, ones from CDC and others from your regional centers, all there to assist you when an expert opinion is needed.
While Working with public health one needs to learn how to cope with the departmental policies and management bureaucracies, when trying to deliver the best possible, as it may be challenging at times.
When we think about the global health delivery we need to consider wellbeing of all the stakeholders, whether it be the providers, patients or their family members. Because if we attend to one and tend to ignore the others, it will not give us the optimal outcome.
Areas where health care needs improvement is the cost of delivery and provision of care to general population, especially in underserved areas which are devastated by ongoing wars and troubling economies. Countries like Syria, Iraq, central Africa,Afghanistan and Pakistan need urgent attention.

LORENZO DORR Replied at 12:02 PM, 12 Sep 2013

1. What kind of management duties or responsibilities do you perform in health care delivery or see others perform?
a) Develop plans, contribute to proposal writing and budget development
b) Provide direct supervision and monitoring of supervisors
c) Provide technical oversight of the program
d) Ensure coordination between Merlin and County Health Team program teams
e) Ensure timely collection of monthly reports and submission of quality monthly and quarterly donor reports
f) Manage operating program budget
g) Writing month , quarterly program and end of project reports
h) In the absence of Health Coordinator, perform the functions of Health Coordinator

2. How important is management (of people, processes and resources), compared to other issues or challenges in health care delivery?
a) People management is very essential and is a difficult task. The delivery of health care is dependent on people. To be able to provide or deliver quality health care, the right people must be recruited at the right time and placed in the right positions. Managing people means understanding them as they are. Because they have different mindsets, different behaviors and attitudes, and they come from different schools of thought, and have different beliefs and a philosophy, understanding them is very paramount to achieving the organization objectives and goal. Motivating your team is also crucial to meeting your targets. However, you cannot motivate people without understanding how they operate taking into account amongst other things, characteristics mentioned above.

People want to identify themselves with successes and not with failures. They are happy to contribute to the growth of the organization or team. Delegating responsibilities to members help them to appreciate their own potentials and values and this motivate them to share in the journey/tasks.

Managing people means leading them. Good leadership is needed to line manage people. A good leader is one who leads by example. Leadership is 80% decision-making and 20% implementation. There are times when you are required by situation or condition or circumstance to hire or fire the people you lead or manage. This sometimes comes about when systems are not followed or are breeched.
b) Processes and resources- Process management is important to control the quality of a product. In this case, regarding the provision of health care services, we must ensure that the systems and processes developed are adhered to and followed. Process influences implementation and determines its outcome. A well managed process will produce quality product/outcome. Resources on the other hand are materials, tools, and instruments required to effect needed actions and steps. In order to effectively and efficiently manage resources, limited or adequate, there must be well developed and defined processes that can be utilized to derive our desire outcome.
Concluding, good people management lead to better process and resource management and generate the desired outcomes.
How do you prioritize this element of your work?
a) Work with staff to set working objectives
b) Work with staff to schedule performance appraisal interviews and share information with management
c) Ensure the appraisals are conducted as scheduled
d) Work with staff to schedule annual leaves and ensure that staff take their leaves as scheduled
e) Coordinate daily attendance and ensure absences of people I line manage are approved by me since I am accountable for the staff.
f) Identify human resource gaps in program and communicate to management for actions.
g) Recommend staff for trainings, promotions, demotions and or redundancy as per their performance appraisal outcomes.

3. What core skills do those who manage delivery need to be effective?
a) Supervisory skills
b) Monitoring, evaluation and analytical skills
c) Skills to build the capacities of others
d) Good communication skills
e) Excellent interpersonal skills
f) Team building skills
How did you or others gain these skills?
I gained the skills through my openness to lack of knowledge and skills, willingness to learn new skill and to adapt to change, application of new learnt skills, learning from others in the team, reading for self-development and personal growth, coaching and mentorship from line managers, and through formal trainings (organization-sponsored and self-sponsored).
Are management training or capacity building opportunities available in your work? Training opportunities are only available to staff through e-learning. Opportunities for senior level management trainings are rarely offered. I had to seek sponsorship from friends to attend GHEC at Harvard during the summer of 2012. My office, even the organization, could not support the trip nor was it willing to pay the tuition and other fees.

4. What factors in health systems, organizations or communities impacts the work of those who manage delivery?
1. Health system:
a) Weak systems such as logistics system, Human Resource system, Communication system, and financial system.
b) Lack of training for staff
c) Poor management &weal logistics systems- poor supply chain management result to frequent stock-out of drugs and supplies
d) Lack of clear policies
e) Governance structure and system
a) Organization:
a) Failures to invest in human resource- most organizations are donor-driven. Training budget is often chopped
b) Weak logistics systems-delay ordering and delivery of drugs and supplies
c) Donor restrictions- Most organizations are not allow to procure drugs in country, and considering the long delays in international procurements, particularly for short and medium –term (6-12months) projects, commodities sometimes arrive in country at the end of projects.
d) Orientation on government’s policies
e) Limited funding but so much activities with no budgetary implications
f) Weak /inappropriate project designs
g) Poor project management
h) Failure to recognize communities as major partners
i) Staff retention and turnover
b) Community:
a) Lack of orientation about health- low education status of community dwellers
b) Misapplication of power/authority- manipulation of the community by people of influence and affluence
c) Discrimination with lack of team spirit-marginalization of groups based on tribes, religion, sex, gender, political affiliation, etc.
d) Failure to exercise ownership of the health system- dependency syndrome
e) Financial insecurity of community dwellers- community is not able to pay for health care services due to low or lack of income, and lack of medical insurance for non-income/unemployed community dwellers
f) Environment issue- there is lack of roads, limited service delivery points
g) Lack of standardized incentive scheme for frontline health workers/Community Health Volunteers-some FHWs/CHVs are paid monthly incentives while others work as volunteers.

What are the main barriers to improving the efficacy of your management?
a) Lack of formal training opportunities
b) Difficulty finding qualified staff who are willing to take up assignment in rural areas
c) Staff retention and tunover
d) Lower financial incentives for staff
5. How can the Global Health Delivery Project address the challenges and barriers faced by those who manage delivery, especially at the frontlines?
Global Health Delivery Project or through its affiliate organizations/projects at national levels should consider the following options:
a) Pressurize or work with national governments to create the necessary environment that would provide the impetus to improve the lives of its people
b) Advocacy to ensure the equitable distribution of resources, particularly financial resources with increase spending on health in national budgets.
c) Provide opportunities for training of health professional, particularly mid-level health workers through scholarships and grants.
d) Work with national governments and local partners to develop programs aimed at developing a trained workforce prepared to work across all spheres of national development, and creating the platform for good governance-not based on theories only but with practical demonstrations.
e) Work with national governments and partners to develop programs aimed at mitigating the challenges and barriers encountered by those working at the frontlines. These challenges include lack of standardized merit-based motivational packages for health workers, low monthly salaries/incentives, lack of medical insurance benefits, lack of housing facilities, etc.
What kinds of resources or programs would be most helpful to you in your work?
a) Capacity-building program – I must be afforded opportunities to external formal trainings to enhance technical and managerial skills
b) Internship mentoring through staff exchange across sister organizations
c) Provision of required working tools such as SPSS and STATA to enhance my efficacy and proficiency monitoring and evaluation. I received a month-long training in Monitoring and Evaluation at African Medical Research Foundation (AMREF) in Nairobi, Kenya in 2011 and one month training in Epidemiology and Biostatistics and Introduction to Global Health Delivery at Harvard School of Public Health, Department of Global Health in July 2012.

LORENZO DORR Replied at 12:15 PM, 12 Sep 2013

Dear Rebecca,
Thanks for the engagement and for affording me the opportunity to be a part.

Keri Wachter Replied at 12:57 PM, 12 Sep 2013

Hello all,

It's been fascinating to follow this discussion. Thank you for all of your contributions. I wanted to share this timely article in Harvard Business Review by Michael Porter and Thomas Lee which highlights some of your strategies as managers:

In the "Next Steps: Other Stakeholder Roles" exhibit on pg. 15, Porter and Lee write, "The transformation to a high-value health care delivery system must come from within, with physicians and provider organizations taking the lead. But every stakeholder in the health care system has a role to play in improving the value of care." They then provide 6 next steps that all stakeholders--including board members, patients, and health plans/employers--can seek out, which I've pasted below.

Do these resonate with you as managers? How would these agenda items be helpful to you in your daily work?

1. Organize into integrated practice units
2. Measure outcomes and costs for every patient
3. Develop bundled prices for care cycles
4. Integrate care delivery systems
5. Grow excellent services across geography
6. Build an enabling information technology platform

Look forward to your responses.

Keri Wachter
Program Manager, GHD Project

Attached resource:

Ellen Munemo Replied at 1:09 PM, 12 Sep 2013

I am a chief lab scientist working in a TB culture lab. I can tell you that it is not easy to motivate someone to come and work in TB culture lab in these days of MDRTB. We need people to work in the labs but how. Being in a management position in such an institution involves a lot of negotiations. 

Sent from Samsung Mobile

spero HOUNDENOU Replied at 1:15 PM, 12 Sep 2013

Dear All
thank you everyone for your contribution to this exchange week.

Am the medical director of AEDLidaw (a Togolese NGO founded by PLWHA in Kara, Togo) and HTH (Hope Through Health is a US based NGO that works in partnership with community based initiatives and the public sector to expand access to quality health care) clinical center at Kara in Togo. we offer HIV prevention and education, voluntary counseling and testing, medical and psychosocial consultations, provision of medications to treat HIV and associated opportunistic infections, home visits by trained community health workers, prevention of mothertochildtransmission and programs to treat pediatric HIV/AIDS.

I took a real pleasure to read your various comments. For my part, managing health care delivery, we must first do a diagnosis of the weakness and strength of our care Systems, then you must define the goals (clinical quality improvement,for exemple) and finally identifer a theoretical framework that allows you to carry out reforms to achieve principal goals. we need also to difine what is global health for us.this is a difficult task but is essential if we want to go towards quality improvement and / or Quantitive health services.

It is my modest contribution to this week's discussion and I still read with great interest your comment.Actualy in our clinic we are using the care delivery value chain (CDVC) framework applying to HIV in Resource Poor Settings.

Dr Spéro HOUNDENOUMédical Director of AED-lidaw/HTH CenterKara, Togo

Ellen Munemo Replied at 1:15 PM, 12 Sep 2013

Dear colleagues.
My name is Ellen and I am a chief scientist in a TB Lab. I can tell you that most managers in the health delivery system find themselves in a management position and then see how tough it is. My advice would be for such people to take an initiative and attend management courses. Because we are in the science field, we need leadership courses to help us tackle some HR, marketing and financial issues.

Sent from Samsung Mobile

spero HOUNDENOU Replied at 1:19 PM, 12 Sep 2013

Dear All

thank you everyone for your contribution to this exchange week.

Am the medical director of AEDLidaw (a Togolese NGO founded by PLWHA in Kara, Togo) and HTH (Hope Through Health is a US based NGO that works in partnership with community based initiatives and the public sector to expand access to quality health care) clinical center at Kara in Togo. we offer HIV prevention and education, voluntary counseling and testing, medical and psychosocial consultations, provision of medications to treat HIV and associated opportunistic infections, home visits by trained community health workers, prevention of mothertochildtransmission and programs to treat pediatric HIV/AIDS.

I took a real pleasure to read your various comments. For my part, managing health care delivery, we must first do a diagnosis of the weakness and strength of our care Systems, then you must define the goals (clinical quality improvement,for exemple) and finally identifer a theoretical framework that allows you to carry out reforms to achieve principal goals. we need also to difine what is global health for us.
this is a difficult task but is essential if we want to go towards quality improvement and / or Quantitive health services.

It is my modest contribution to this week's discussion and I still read with great interest your comment.
Actualy in our clinic we are using the care delivery value chain (CDVC) framework applying to HIV in Resource Poor Settings.

Médical Director of AED-lidaw/HTH Center
Kara, Togo

A/Prof. Terry HANNAN Replied at 3:44 PM, 12 Sep 2013

I am travelling extensively at the moment so I have been basically reading these extensive and informative inputs. Alice Ojwang's comments have encouraged me to make a short response from my limited facilities.
A physician health commentator in Sydney stated many years ago that the health of a nation despite the presence of war, pestilence, famine, is directly related to the "literacy of the mothers". To ensure this we need to create, design and deliver cost effective information and knowledge management tools to ensure this literacy.
As an aside I have in the last week seen a powerful documentary film "Fire In the Blood". It documents the socio-political role of large pharmaceutical companies in preventing access to affordable medications in both developing (more so) and developed nations. In the film I saw people in South Africa with whom I have worked and one strong woman gave me the term "economic apartheid". From the film a new term "pharmaceutical genocide" through the prevention of access to affordable medications.
I believe google has the world wide roll out of this film.

A/Prof. Terry HANNAN Replied at 4:07 PM, 12 Sep 2013

Busi, have you read L. Leape "Five years after To Err is Human. What have we learned?"
And also.....
2000-To Err Is Human Building a Safer Health System. INSTITUTE OF MEDICINE.
2005 -Leape, L.L. and D.M. Berwick, Five years after To Err Is Human: what have we learned? JAMA.
2011- Health Information Technology Institute Of Medicine, Health IT and Patient Safety Building Safer Systems for Better Care, The National Academies Press: Washington D.C.
2011-Jha, A.K. and D.C. Classen, Getting moving on patient safety--harnessing electronic data for safer care. N Engl J Med.

karen Suva Replied at 4:31 PM, 12 Sep 2013

Thank you for the opportunity to participate in this interesting discussion. I am a health care management professional who has been working for an NGO that strengthens the health system in Haiti.

It is clear that the participants in this discussion feel that management is of utmost importance. My observation is that the most common reason for interventions and projects to fail is the failure to manage people, processes and/or resources. Yet it is often hard to get funding for this type of capacity building. Antonia’s example of the EKG machine is so true. There are often funds for the EKG machine, trauma unit, pediatric wing, etc., but just as often there is no funding for the systems needed to get it up and running and to keep it functioning effectively.

In the public sector in Haiti, I think it is the civil service system that is the most significant barrier to improving the efficacy of management. There may be a motivated leader, but he/she has no formal responsibility or authority for the supervisors or front line staff who have life-time employment through the ministry of health. Human resources in the public system are limited as it is and made more scarce by people who have no goals, objectives, formal job descriptions, incentives to come to work, etc. It would be very helpful if the GHD Project could facilitate discussion of how to effect positive change in systems beset by a sclerotic civil service system.

Attached resource:

Blessings Banda Replied at 4:57 PM, 12 Sep 2013

3. The core skills that those managing delivery need are a lot but looking at a few we should seriously consider decision making skills, financial management skills, economics, communication, conflict management, leadership skills, monitoring and evaluation and mostly motivation skills. In the developing world it may be a challenge to have all of these but they are equally important to look at when managing those in health care delivery.

I gained skills through peer interaction, reading a lot and through organized training's that are done at District, National and International level. Capacity building programs are very minimal but available at our organization and they provide a depth of demanded trainings that we request. Those managing health care delivery need to have a better understanding of management principals aside meeting a patient.

Vannak Chrun Replied at 9:34 PM, 12 Sep 2013

Dear All,

The first of all, I would like to thank you so much for your comments/ sharing experiences related to the health care system, in particularly in NGO sector. I would few question related to coordination/cooperate with counterparts( government sectors), Based on your experiences 1)- how would you do to achieve your objective from the top to bottom of counterparts?.2)- how you measure the accomplishment that you had been done?, 3)- do you have M&E framework? if so, how you develop it? could you share us?

Thanks in advance for your kindly participation, Dr. Vannak

Brook Courchaine Replied at 10:50 PM, 12 Sep 2013

Keri, the 6 points you list seem more applicable to US scenarios, than to underserved areas of the world, at least in our case in Honduras, but I may be wrong.
I agree with you and so many others who know that we have to work WITH IN the local systems to make headway on successful healthcare delivery. This is why the Carrizo Project has begun a program to invite Honduran doctors for a two week visit to the US to observe clinic, hospital and home care setting with US colleagues. We believe this will be a way for Honduran practitioners to see what other systems could work in their own environments. This interchange will not only allow the doctors to see actual systems but they will be able to learn how various successful delivery systems work. We predict dialogs and relationship that will develop from these visits will create and on-going resource for both the US and Honduran practitioners.
First and formost healthcare providers (from administration to "in-the-trenches" practicitioners) need to know what practices are even out there to emulate.
But equally important for the visitors is the need to be empowered to return home and develop and utilize these new (better?) practices. What better way than to see first hand?

Bistra Zheleva Replied at 12:22 AM, 13 Sep 2013

It has been very interesting to read all the comments and learn about the work different members are doing. I think we need to make a distinction between people management and process management. People and organizations management is a science and can be learned and its basic principles can be applied to many industries, including health care. Health care management and organization is are certainly a problem but the underlying issue in the developing world is still the lack of trained personnel to provide the care. Most public health care workers are severely overworked and underpaid and don't have time to think about process improvement. For example, in my work we find that even in advanced tertiary institutions people have poor concepts of what quality improvement is until they are shown what to do and how to apply those concepts. They need QI mentors. So Brooke, I think Keri is right, these principles are all applicable but there is lack of resources and appropriate understanding to apply them. We may have a self-selected community here that understands them, but in general the knowledge on QI is low. Or take data collection - everyone thinks it's important, yet the answer we keep hearing is - we don't have money to hire a database person.

I think all interventions in this area have to be linked to the principles of adult learning theory and preceptorship - problem-based, collaborative, rather than didactic. I am sure there are opportunities for GHD Online to assist in this. Webinars? Case studies? Still someone has to teach them and make that personal connection Dr. Gawande was talking about. So maybe taking the GHD intensive around the world? MSH is working on a health care leadership project and have had fantastic results, we should all use their resources.

Debashish Naik Replied at 1:19 AM, 13 Sep 2013

"As we continue the conversation this week, we encourage everyone to
consider our final two questions for discussion:"

Q1) What are the barriers in health systems, both in the private and public
sectors that impact managers role and performance?

Ans: My point of view to the above question: There will always be external
challenges such as infrastructure, govt policies and support, economic
conditions, conflicts among the stakeholders, lack of skilled resources,
lack of respect etc...

Considering such challenges as reality and assuming that bringing changes
take its own time, and understanding that "the Role of Manager is to
improve its area of Responsibility", *o**ne of the barriers* *I perceive is*
*"Self- i.e a close mind, lack of thinking skill, and lack of mental power
& patience" (may not be for all bot for many).*

Q2 ) how the Global Health Delivery Project can address the challenges and
barriers faced by those who manage delivery - what kinds of resources or
programs would be most helpful to you in your professional roles

Ans: The managers should measure their performance from a leadership
perspective, who has to design and implement simple solutions to
continuously improve the area of her/his responsibility in healthcare
delivery. This needs a mindset, attitude, and a continuous self development
in skills and competencies appropriate for the specific environment.

GHD may develop a leadership competency framework considering the required
skills and competencies for managers in this challenging environment and
pilot its execution with a group of managers and evaluate the result.

In addition GHD may also look for technology and methodology for
implementing the framework to develop the required managerial competencies
for managers across the world who are interested to improve their ability
and also working in the the healthcare specific challenging environment.
One of the thing can be part of methodology is having a mentoring system
where the experienced managers can mentor the new managers. The other could
be problem solving where the managers who are interested can reach to other
managers to get their help on a one on one basis.

Blessings Banda Replied at 3:19 AM, 13 Sep 2013

5. Global Health Delivery project can address challenges faced by those who manage delivery at the front lines in a way that trainings on resource management should be provided, decentralize the GHD project so that the training should be available locally. This may be achieved by providing a Training of Trainers of Global Health Delivery at as the training offered at Harvard University may be expensive, if self sponsored, for someone who lives in a developing world like Malawi. A lot of people who may wish to gain experience and skills from attending this training do not afford to it.

Apart from resource management and GHD Training, the project can also act as a communication medium for different sites and try to link managers of different sites according to common interests. For instance, if the Malawi project is implementing Malaria treatment activities and the same succeeded in Nigeria, the too sites should be able to be linked by GHD to learn the best practices from each other. This may be followed by exchange visits and twining of projects with similar programs and challenges.

Another challenge faced by those managing delivery is retention of health care providers and program managers. This is due to the less income that providers get at the end of their duties and may not be compared to other organizations and companies locally and outside the country. This can be prevented by advocating better packages for care providers and program managers as well as negotiating for better government policy on income.

Vannak Chrun Replied at 3:43 AM, 13 Sep 2013

Dear Sir or Madame,

I'm Vannak, MD, working with URC_Cambodia.
Thanks for your posted/share knowledge related to HIV at community with counterparts. based your existing program, could you share me about the successful project/ lesson learn related to how make a good collaboration/ cooperation with local authority/ local health government staff where your communities has worked?

Thanks in advance for your kindly share.

Gaddo Flego Replied at 4:28 AM, 13 Sep 2013

Dear all,
for K. R. Amico and others who could be interested in the HTA approach to priority setting and disinvestment I referred to in my previous message, this is the link to a WHO publication on the subject
It refers to medical devices but "health technology" is usually meant in a broad context, including drugs, procedures and organizational models of care delivery. One of the dimension considered, along with effectiveness, impact on the organization, financial implications/sustainability, is the "patient perspective". In our experience it is quite difficult to approach this, as usually care providers, especially doctors, tend to act as patients proxy ("I know what they like, or is good to them, don't bother to ask"), and even patients o consumers organizations may carry interests different from the expression of patients/consumers point of view. So this is a subject worth for further analysis, maybe in Latin America we can find models of community involvement in health promotion and care that have proven some efficacy and that would be interesting to hear.
To underline the fact that high efficiency in health care delivery and great avalaibility of resources alone do not automatically lead to good results in terms of population health, I add a link to a 2009 paper by Atul Gawande on Mc Allen, Texas.
Thanks to all, Gaddo.

Corine Karema Replied at 5:30 AM, 13 Sep 2013

Dear Rebecca and all,

Thank you for enriched discussions

Most of the challenges of our health systems have been pointed out here like understaffing, no priority for health challenges, etc

However for me the critical element is leadership and clear vision of a country, it's leaders from top to community health workers.
Poor leadership leads to miss management, waste of resources and so on. this impact on the performance and expected targets of programs as well as the delivery of health care to the patients.

Rwanda is a live case of what leadership and accountability with insufficient resources , a country can achieve good performance in the health sector and implement innovations to strengthen it's health system.

The global health delivery project is a unique opportunity to share live cases( what is real on the ground) to program managers, health providers for them to adapt in their context ,this from the creation, scaling-up, and replication of programs and services.

The GHD while documenting the experiences of health care programs and organizations in the field, and examining the role of diverse factors ( including socioeconomic and political ) on program strategy, design, and implementation, help health providers/ leaders and managers to first understand what has happened and how this can be replicated.

Thank you

Miguel Antonio Salazar Replied at 6:11 AM, 13 Sep 2013

Good day, I work for a local NGO in the Philippines as a project officer and we have a project where we build community health centers in geographically isolated and depressed areas. I managed the community based health program of the project. We developed the concept and implemented the project. Management is very important in my job in terms of assessing the needs of the community and planning activities that address these needs. As a technical advisory group to the local health unit our job is to empower each village to improve health outcomes. But in our pilot village we did a more in depth engagement in that we did capacity building for the health workers in skills and service delivery.

Management in terms of planning and execution of these plans are important but in the end the community health team will ultimately implement the health services. This is the main limitation in our work. We have to work with the staff that is already there. There is a limitation in not having the full control of the implementing health staff. We ave to work around this limitation by inspiring them to do more than what they are used to.

I came from a clinical background prior to this work thus I had to learn on the job. I had no formal training in management. But through some courses from partner NGOs in project design, implementation, management, monitoring and evaluation I was able to appreciate the complexities of management. Online courses through Coursera, Global Health Learning, and the World Bank E-Institute helped in getting adjunct learning for work.

The Global Health Delivery Project can help in giving more innovative practices or best practices that can be duplicated in different communities around the world. Here we can be exposed to new developments as they happen in other areas across the world. This can greatly benefit health managers in municipalities in the Philippines.

Rick Botelho Replied at 7:06 AM, 13 Sep 2013

Dear All,

Leaders and managers face major challenges of increasing capabilities and capacities to address health problems. This creates a huge innovation opportunity. This abstract (just submitted) encapsulates the cutting-edge of my current work. It is about creating learning networks and communities on open innovation.

What if GHD organize an MOOC (massive open online course--no cost) for this community that showcased cutting edge work of individuals working within their particular areas of expertise? This could help to develop a more robust and invigorating community of practice. Maybe this idea has already been done or is in the work --- if so, I missed it and apologize...

Designing Catalytic Innovations for Population Health Improvement:

A Learning Process for Faculty Development

Goal: Enable teams to design a catalytic innovation

Content: Most faculty have had little formal training in designing catalytic innovations. These socio-behavioral innovations promote healthy habits, prevent diseases, and co-manage common illnesses, mental illnesses and chronic diseases. These innovations go beyond the constraints of clinical encounters and evidence-based guidelines by creating positive social networks of reciprocal coach-coachee relationships. Using self-reflective learning exercises, peers coach each to research, author and share their own health improvement stories. Story-telling creates personal evidence that breaks through the evidence-based ceiling of organizational performance.

Method: Pre- and post-workshop assignments will prepare teams to discover their own learning outcomes. Using a three-phase learning process, the teams will design a prototype innovation

Outcome: Self-assess and peer evaluate the learning experiences of faculty

1. What is this session about?

Dr. Botelho has designed this workshop with Dr. Peter Jones (Associate Professor in the Strategic Foresight and Innovation program, OCAD University, Toronto). His recent book, Design Care: Innovating Healthcare Experience describes current research methods and clinical design concepts for developing healthcare innovations.

Improvement science techniques have been widely deployed in healthcare, but messy complex problems cannot be solved by improvement sciences alone. This 3-phase innovation model provides an alternative approach.

Problem framing phase involves using human-centered research methods to understand the nature and different perspectives about the innovation challenge
Innovation development concept phase uses design research, creative design thinking and co-creative processes and methodologies adapted from business and service innovation to develop rapid cycle prototyping and piloting to assess what works and what fails.
Acceleration phase involves using techniques to assure adoption, iterative evaluation, improvement and spread of the innovation
The epidemics of unhealthy habits and mounting burdens of chronic diseases present huge innovation opportunities. We can design proactive lifelong learning health programs. This calls for creating radically new ideas for developing catalytic innovations that have large-scale population health impacts. These socio-behavioral innovations use self-reflective learning and peer coaching processes that are inexpensive, convenient, accessible and widely available to anybody, any time, any place. They innovations are designed to:

· Promote healthy habits, happiness and well-being

· Prevent diseases, preserve and restore function

· Treat, self-manage and co-manage common illnesses, mental illnesses and chronic diseases

· Deliver social interventions, such as community of solutions.

Collaborating together to share our lifelong learning journeys, we can enhance our decision-making capabilities and develop our collective health literacy.

An effective catalytic innovation is ensured by:

· Starting with a commitment for making a significant difference in a problem area

· Organize a multidisciplinary team to research and address the problem

· Develop institutional and community support to evaluate, improve and sustain the innovation

· Integrate the emerging new practices into the existing infrastructure of information technologies and clinical workflows to ensure its sustainability

Lachlan Forrow Replied at 7:30 AM, 13 Sep 2013

This is a vitally-important discussion. As we think together about how to move forward effectively, I am especially interested in Questions 3 and 5:

3. What core skills do those who manage delivery need to be effective? How did you or others gain these skills – are management training or capacity building opportunities available in your work?

5. How can the Global Health Delivery Project address the challenges and barriers faced by those who manage delivery, especially at the frontlines? What kinds of resources or programs would be most helpful to you in your work?

My own experience in Africa has been entirely focused on Gabon, through the Albert Schweitzer Hospital, where in July 2013 we organized a symposium of Nobel laureates, scientists, and others from around the world, hosted by Gabon President Ali Bongo Ondimba, celebrating the 100th anniversary of the Albert Schweitzer Hospital in Lambarene. The symposium culminated in a "Lambarene Declaration" (see attached), which emphasizes the urgent need to strengthen African science and health worker training in the fight against the "Triple Epidemic" (HIV/AIDS, TB, and malaria). To help concretely with this, Gabon is completing construction of a new research/training campus in Lambarene, adjacent to the grounds of the Schweitzer Hospital, which will include creating of a new Albert Schweitzer School of Public Health. The goal is to create a resource for Africa, including curricula and training programs available at little or no cost to anyone in Africa and beyond. We have the great opportunity, since we are starting from scratch, to do things right. We also need to figure out how to maximize synergies with other efforts, and not re-invent any wheels that already exist.

As we are thinking about what the new Albert Schweitzer School of Public Health might try to accomplish, two questions seem crucial:

a. What exactly are skills/competencies that people need to develop in order to be most effective in achieving impact in health?

b. How can we best support people in developing these -- what kinds of on-line learning resources are truly valuable to the user? what kinds of learning reallly requires on-site time together with faculty and co-learner?

The better we understand these, the more likely that we can design activities of the new Albert Schweitzer School of Public Health in Lambarene that really contribute to strengthening the workforce of people working in Africa.

Thanks in advance for any ideas, which I hope will feed into the Second Annual Albert Schweitzer Global Health Symposium we will hold in Gabon in 2014 (tentatively July).

For those interested, the program and high-quality videos from all of the sessions of the July 2013 First Annual Albert Schweitzer Global Health Symposium are available at

Lachlan Forrow, MD
Immediate Past President (2010-2013), Hopital Albert Schweitzer
Associate Professor of Medicine
Beth Israel Deaconess Medical Center
Harvard Medical School

Attached resources:

Julie Rosenberg Replied at 10:07 AM, 13 Sep 2013

Thank you to everyone who has contributed to this incredibly rich discussion. We at the Global Health Delivery Project are so grateful to learn from your experiences and insights and are excited about the prospect of translating them into change.

In thinking about the current state of management and leadership in health care, I am curious to learn more about how you think we got here. How did those of you who currently hold management positions get to where you are? What was your career path? How did your managers or others who manage get where they are? What training or understanding of management do you or they have?

Hopefully looking back will also provide us some insight about what is needed moving forward.

Many thanks again!

ALICE OJWANG Replied at 11:22 AM, 13 Sep 2013

Thank You Terry Hannan,
I must say that I learn soo much from all these contributions from GHDonline members.
I have watched the trailer of the blood line and will get the movie.
Thank you all soo much for your contribution sand to the moderators for your good JOB AS WELL.

ALICE OJWANG Replied at 11:37 AM, 13 Sep 2013

Hello Sandeep,
what I have seen happening in my country is some consultants  travel to a medical center in a remote clinic and run a clinic on diabetes, neurology clinic, antenatal and and many more. In fact it is walking so well in some areas. Its not enough but its a start.
So maybe if the consultants can be requested to go visit a remote are once a a while, it will be a start to a good project.
at the moment, my family started a small health center in my village, which is about 20km form any health facility. we have been able to get health professions from the nearest health facility to come to the village and run a clinic, for now, its a nurse who comes and see all children and expecting mothers. We have talked to a consultant, who has promise to be coming. All we have to do is take care of there transport. Its all we can do now, but eventually, we hope we can get more funds and employe health professional.

Thank you.

harry strulovici Replied at 11:48 AM, 13 Sep 2013

Dear Rebecca and all participants:

I have been following these discussions over the past few days and am very impressed with the range of topics explored as well as the contributors to these discussions. I have many thoughts about what's been said albeit I will only expand on a few of them. I believe our main objectives are to improve access to health services which will hopefully lead to better health outcomes in developing countries.

How to achieve this goal is the question. There is no magic bullet to solve all the issues involved. Without having had 'boots' on the ground it is impossible someone to offer solutions. Having worked in rural Uganda for years and walking door to door alongside community health workers (CHWS) in all types of conditions (severe rains, mud roads, etc.) one only begins to appreciate all the challenges involved that women and their households endure to access services. However, one should not be cynical regarding achieving meaningful results. I founded an international NGO--Life for Mothers in late 2008 and since then we completed a Phase l Pilot project to determine if CHWs could be rapidly trained using mHealth technology to register women and households into electronic database. We found out that this could be done and also learned that there was a huge gap in service delivery (see the draft report-- but this work required on-site monitoring as well as management skills.

Working presently as a consultant to the Price Center a division of the UCLA Anderson School of Management I am aware that on a yearly basis they run a week-long management training seminar in Sub-Saharan based in Nairobi, Kenya for all residents of Eastern Africa.

Many participants during the past few days have referenced have Dr. Gawande's article from the New Yorker. Certainly his point about going out into the field was certainly important however, it was somewhat simplistic to believe that that was the prime mover which would create a paradigm shift in improving health outcomes. (I did comment on the piece in a letter which was published in the subsequent issue.) Albeit my comments were edited my letter emphasized the need for political will, good governance and stewardship for outcomes to improve. Again, much of this involves having management skills. The NY Times published an editorial on September 11th acknowledging the need to improve Global Health in developing nations. Again, many excellent points were made. However, the need to strengthen health systems cannot be understated. Without horizontal integration of health services (HIV and maternal/reproductive/neonatal) outcomes will remain stagnant. I believe that we have reached a tipping point whereby the focus must be placed on repairing non-functioning systems. This will entail a holistic and comprehensive strategy. Of course many of these factors will not be 'fixed' quickly, e.g. cultural influences, women's empowerment, male partner involvement, etc. We must be realistic but appreciate that this can be done. Having worked on the ground I believe this wholeheartedly. Each country and even each district has their own particular context that must not be ignored. Yet there is a fundamental strategy that applies to all these settings.

Kind regards,

Harry Strulovici, MD, MPH
Founder and Consultant
Life for Mothers

Blair Gifford Replied at 11:55 AM, 13 Sep 2013

A group of health administration faculty are putting together a text on global health management. If you or a colleague would be interested in writing a chapter for this text, please send a note about the content that you would like to cover so that it can be considered for inclusion. We want to make sure that the group of authors for the text has a strong international orientation.

Please send your information in a private email to . Thanks.

Blair Gifford, PhD
Professor, Global Health Management
University of Colorado Denver, USA

Monica Adhiambo Onyango Replied at 12:29 PM, 13 Sep 2013

Hello everyone: I have followed the discussions on this topic over the last few days and have really enjoyed them. I am a nurse midwife from Kenya although at present I am a faculty member at Boston university school of public health. As we discuss this important topic, it is worth noting that nurses are also leading in providing health care to displaced populations around the world, following man-made and natural disasters. I just got back from South Sudan where we visited four refugee camps. A few nurses I spoke with find themselves in an environment where they manage everything from design of the clinic and everything that goes with construction to caring for patients with diverse health care needs. The health systems in these situations are not well established and therefore has its own challenges. These nurses mostly work for aid agencies whose priorities also vary. In response to Q#5, maybe GHDonline could find ways of reaching out to these nurses so that we can understand more some of their challenges and most importantly the kinds of help they need to manage effectively. Thanks,

Monica Adhiambo Onyango
Assistant Professor
Boston university school of public health

dian marandola Replied at 1:51 PM, 13 Sep 2013

In recognition of the Declaration of Alma-Ata (1978) , the Ottawa Charter for Health Promotion (1986) and various regional and global resolutions of WHO Committees and Health Assemblies aim to strengthen political commitment at all levels to the values and principles of primary health care. I would be interested in working with primary care providers around the world to present a chapter on essential role primary care primary care plays in health systems. My global perspective is from Phillipines primary care project based in Dumaguete.
Dian T. Marandola APRN,MSN,MPH
Pediatric Nurse Practitioner.

Ferdousi begum Replied at 1:54 PM, 13 Sep 2013

Thank you Dr. Rebecca, I am honored and delighted to be included in this
panel. I am a health program management expert working at FHI360,
Bangladesh with a mandate to manage Food and Nutrition Technical Assistant
(FANTA) Project. Following are my responses:

1. What kind of management duties or responsibilities do you perform in
health care delivery or see others perform?

I am responsible to manage FANTA project in Bangladesh being a country;
managing partnership with 8 partners in Bangladesh who are responsible to
execute policy work with parliamentarians and bureaucrats (policy
maker),conduct national level mapping, develop national basic training
modules and program implementation related to nutrition

2. How important is management (of people, processes and resources),
compared to other issues or challenges in health care delivery? How do you
prioritize this element of your work?

Management of people, processes and resources is key to achieve goal of the
program compared to other issues or challenges in health care delivery.
Having right partners and skilled people on board are always remain on the
top of in my priority list as it is time bound project.

3. What core skills do those who manage delivery need to be effective? How
did you or others gain these skills – are management training or capacity
building opportunities available in your work?

Key skills are essential to manage any program are:

- Team building

- Establishment of strong, transparent and accountable supervision and
monitoring system to track progress

- Time management to ensure quality deliverable

- Functional MIS system in place

- Partnership management

- Proper delegation of work with authority

We regularly organize monthly meeting with partners and team members to
track the progress, also identify the gaps and their TA needs and finally
develop joint action plan accordingly to address those.

4. What factors in health systems, organizations or communities impacts the
work of those who manage delivery? What are the main barriers to improving
the efficacy of your management?

Following factors we always consider to see the impact:

- Need assessment

- Equip the team to deliver quality delivery as per the need of the
organization or communities

- Timely delivery of quality services

- Marketing and doing advocacy at same scale to have the funding commitment
and sustain the programes

- Ownership development and keeping sustainability option from the 1st day
of work

- Using local expert and local resources

- Sustainable GOB commitment

Main barriers are:

- Time bound project

- No grantee of continuation of project even though we manage the project
best way and create all positive evidences as every 4 to 5 years we need to
participate in the bidding process

- Change of government commitment some time create huge problem for many

- Ensuring equal focus on marketing of program and at the same time
advocacy for continuous funding

5. How can the Global Health Delivery Project address the challenges and
barriers faced by those who manage delivery, especially at the frontlines?
What kinds of resources or programs would be most helpful to you in your

- Sharing of our feeling, observation and finding with all key players

Most useful program for Bangladesh would be having a project which will
have long term continuation rather then change the key players every five
years but will have strong M&E system build in within the project, so that
project can get right TA from the donor end not only the fund.

dian marandola Replied at 2:17 PM, 13 Sep 2013

Dear Dr. Srulovici,
You mentioned that Dr. Gwande's important article could not have made a paradigm shift. But what if it did? It is often said that "One person can make a difference" . I hear his article referenced when organizations are preparing for Accountable Care Systems, in discussing issues of quality of patient centered systems and in discussing the patient centered medical home as an infrastructure to improve the model of primary care which includes enhanced access to care, coordination of care, tracking referrals, patient educations and programs of improvement to manage population outcomes of care delivered. A recent blog posting noted population health outcomes (among populations or individuals) are influenced by multiple determinants such as social, environmental, resources, most of which are beyond health care ( Unpacking the Triple Aim Dr. Gwande's article speaks to his patients multi-determinants of health. It is time that we incorporate the full scope of his published story into the transformation of health systems in the US.
Thank you for your time. Dian (APRN,MSN, MPH- peds nurse practitioner)

dian marandola Replied at 2:43 PM, 13 Sep 2013

I apologize for the typo- It should be Philippines.

Barbara Waldorf Replied at 3:12 PM, 13 Sep 2013

Dear All,

I appreciate the perspectives and suggestions of so many who have responded. I am the executive director of a small non-profit who's mission is to advance the role of nursing in global health. I have had to get "on the job training" in management principles and practice as my education in nursing and public health did not go into this area with any depth. We are very fortunate to have a consulting group ( give us pro-bono assistance in board creation, alignment and ongoing management. This assistance is invaluable in growing the organization, as well as creating, structuring and delivering our programs.

This experience has made me consider the need for this type of education in nursing and public health programs as well as for short, focused online education to be available outside of a degree program. GHDonline could address this need by supporting online courses, and by acting as a resource for collaborations between management organizations and those who are working to deliver health care globally.

Thank you for creating such a useful discussion topic and for posting articles and resources that address these needs.

Barbara Waldorf BSN, MPH
Executive Director
Global Nursing Caucus
Advancing the role of nursing in global health practice, education and policy through advocacy, collaboration, engagement and research.

Mark Rosenberg Replied at 4:10 PM, 13 Sep 2013

My team works to help distribute about 80 million treatments for the prevention of blinding trachoma. We are trying to understand how to better manage supply chain logistics so that we can track the delivery of these treatments to the end of road where they are actually given to community members on mass distribution days.

Mark Rosenberg Replied at 4:13 PM, 13 Sep 2013

We are interested in the experience of other mass distribution programs and descriptions of how they accepted this program and their success in acheiving distribuiton goals and tracking and monitoring the treatments that actually were delivered and swallowed and how they reduced the amounts that were diverted.

Mark Rosenberg Replied at 4:32 PM, 13 Sep 2013

I found the individual notes very interesting but as a newcomer to this dialogue it was hard to follow the string running through the notes. Is there a way to identify the strings or themes that run through the different notes, so that one could follow a particular theme, like the need for management skills to manage the development of effective programs? I certainly agree that management is most commonly the missing ingredient in effective program delivery.

Tess Panizales, DNP, MSN, RN Replied at 4:52 PM, 13 Sep 2013

*Thanks for the invite to provide expertise in this discussion.*
*On being a leader*: Reflecting on past experiences and to the present,
provides me with the simple way of saying that a leader must be a creative
visionary, honestly committed and dedicated to the cause of the chosen
service. In my prior roles in community program development
(Philippines) and later in corporate management (USA), there is always the
time to be with the people you work with and the people you serve.
Visibility in being a leader and sharing equal goals are important, a
leader is also a follower - you can be behind and at times you may have to
take the lead. Empowering the staff and people you serve with skills and
education of the issue and skills necessary to help alleviate the problem
or tackle the problem

*What are the barriers in health systems sectors that impact managers role
and performance?*
Incongruent vision and goals to that of the community being served;
un-involvement of the program recipients.
Poor support in program implementation from higher leadership and staff;
poor infrastructure within the organization and the community or country at
Poor commitment and buy-in of a leader to the program being implemented or
the work one does.
Poor communication and education/training of staff.

*How the Global Health Delivery Project can address the challenges and
barriers faced by those who manage delivery - what kinds of resources or
programs would be most helpful to you in your professional roles.*
GHD has come a long way and have hosted multiple opportunites for us to
learn, I have seen it grow since the first time it was conceived - thanks a
lot - I wont forget the conversations along the way.

It can continue to host specific online discussions from experts lead based
on collated suggestions, share research materials and articles that will
help its audience. GHD can probably feature country by country focus
discussion on the wonderful projects and how challenges were met.

Rebecca Weintraub, MD Replied at 5:16 PM, 13 Sep 2013

Dear colleagues,

As this panel comes to a close, we are inspired and humbled that so many of
you have taken the time to participate. Our deepest thanks for your

In the coming days, we will share a brief summary of this discussion to
highlight the common threads and key issues raised. We will also create a
permanent webpage on GHDonline that contains the various tools and
resources you have all shared. If you have any additional resources to
share (ie, links or documents), please do so and we will include on this
resource page.

Also, please note: the Global Health Delivery Project offers a 3-week
intensive summer course in Boston to provide management training for those
working in health care delivery. We have been fortunate to have many alumni
from this course join us in the discussion this week. If you are interested
in pursuing management training opportunities further, we invite you to
learn more about the course by visiting:
Applications open this October and close in February 2014.

Please feel free to share any final thoughts or reflections over the
weekend. We look forward to hearing from you again and are eager to build
the future of GHD together.

In gratitude,

ndahiro emile Replied at 5:55 PM, 13 Sep 2013

Emile Ndahiro,MD

Much as we are very concerned about Global health delivery, the entire world needs also to consider on the advocay for international and domestic peace in most parts of the world in order to facilitate this health delivery issue. Am emphasing on this point due to cosntant lose of lives of health care givers in most troubled regions of the world and in particular the Darfur region of Sudan where am presently working as a medical officer.

Christophe Milien Replied at 7:52 PM, 13 Sep 2013

One important point is to avoid bureaucracy as a manager. Everyone needs to know how things going on in his department and that will permit to know the needs of your department what improvement that you have to do. Your relationship with your team will be better by talking to them about their work. People in the department must have a good comprehension of the mission and the vision of the department. Objectives must well define and it will be better 3 to 5 objectives. A strategic plan must be established for arriving to the gold.
Employees must fill the department is theirs.

Patrick Jouissance Replied at 8:31 PM, 13 Sep 2013

Hello everyone,
First of all I want to thank you very much Rebecca for the opportunity to be part of this panel on the management of health care delivery at the global level.
My name is Patrick Jouissance and I am currently serving as the associate director of the family practice residency program that is being developed jointly by the ministry of health and PIH at the St Nicolas Hospital located in St Marc , Haiti.
In addition to clinical duties, management responsibilities play a prominent on my day to day routine. These managerial tasks can be split between basic administrative work yet more importantly the management of residents on training as well as their trainers and additional personnel.
If one’s to be successful, management of people, processes and resources are supposed to be at the center of any program. Since our residency program is a relatively new with limited material resources , and processes under development , we are putting a lot of emphasis on human resources management and development .
In order to be effective, I sincerely think , that one of the most important skill that need to be developed is the ability to put human resources at the center of their strategy. Valuing everyone contribution within the team is the door of success, understanding everyone specific abilities in building the program is the key to success.
We also need to add that since formal management training is limited, these aptitudes can also be developed through common sense, observation, and appropriate readings.
We also have to acknowledge that in addition to material resources , the delivery of appropriate care also require the ability to find skilled human resources as well as the development of strategies to retain them in the needy areas .
Hence, the advocacy role that the GHD project is called upon to play for the future of health care delivery worldwide.
Although a great deal has been done by this project already , more emphasis will probably be needed in order to facilitate formal training for managers, while developing retention plans as well as giving them the basic material means to perform effectively.

Jay Bhatt Replied at 8:33 PM, 13 Sep 2013

This has been an inspiring and humbling discussion.

I am a Geriatric Medicine Fellow at the University of Michigan and much of
the leadership in caring for our patients in the ambulatory enviornment
comes from the broader microsystem which includes security, front office
staff, call center, medical assistants, providers, and trainees.

During this discussion there have been references to the distinction
between leader, leadership and management. In my view, a leader plays a
role but leadership is exercised and is a practice. There are technical
solutions that draw on our know how and then there are adaptive solutions
that require a change in culture, value, attitudes, and beliefs to close
the gap between the reality and the aspiration.

Thank you again for such a thoughtful discussion. It was a pleasure to hear
from folks all over the world!

Dave Wyant Replied at 9:47 PM, 13 Sep 2013

I've enjoyed the discussion.
Given some of the comments, some of you may be interested in a free course available over the web in Health information Technology. The development of the course was financed (primarily) by the Health Information and Management Systems Society (HIMSS). It is available on the website of the Association of University Programs In Healthcare Administration (AUPHA). The purpose was to help graduate level management programs. Frequently such programs use an adjunct to teach HIT, and the idea was to help the adjunct develop a full course.
The course is named HIMSTA and is available at
There are 14 modules, each with several powerpoint lectures that have voiceovers. There are also syllabi for each module, and some exercises.
It should not be looked upon as a stand alone course, but a number of US programs have used it and reported it was helpful. I was one of the group that worked on the project that developed it over the last 4 years. We hope people use it. At the next HIMSS conference there will be a train the trainers session to help programs that want to use it. That will be Sunday Feb 23 in Orlando. But I believe it is fairly straightforward. You are free to use any of the materials, but please attribute back to the project.
I teach in the Healthcare MBA program at Belmont in Nashville. My main areas are Healthcare Finance, Economics and HIT.

Dave Wyant

Sheila Davis Replied at 11:30 PM, 13 Sep 2013

Dear Colleagues,
Great discussion thus far and it has been very enlightening to hear about everyone's diverse experiences and expertise. I am the Chief Nursing Officer at Partners In Health (PIH) and am part of the clinical leadership team managing our clinical programs in all of the PIH country sites. I have worked in the field of HIV/AIDS for over 25 years both in the US and in a number of other countries and joined PIH in October of 2010. I continue to practice a few days a month at Mass General Hospital in Boston in the Infectious Disease department as a Nurse Practitioner but the vast majority of my time is spent on developing, implementing and evaluating a variety of clinical programs at PIH and no longer in direct patient care. With a recent restructuring of our clinical team I have taken on more supervision of staff locally and remotely and this can be very challenging to 'manage from afar'. I agree with many of the other participants about the need for clarity and communication with all levels of management. Although leadership and management can often not be prioritized in care delivery in resource limited settings-- it is even more important to be able to provide quality care tied to measurable outcomes when you are dealing with scarcity.
With numerous competing priorities, management can often feel like dealing with crisis all day and one can fall into the trap of jumping from one thing to another and not prioritizing the development of systems. The best strategy I have attempted to implement for myself is to try and devote a certain percentage of my day/week on the system development and refinement, even if that means letting some other things fall down to the bottom of the to-do list.

I look forward to learning more from all of you,
Take care,

Sheila Davis, DNP, ANP
Chief Nursing Officer, PIH

YAP BOUM II Replied at 12:43 AM, 14 Sep 2013

Dear all

What a great sharing of expertise in diverse environment .
I am the Director of MSF/Epicentre Research Base in Uganda.
I agree with you that the human resource should be at the centre of any management and leadership ... But I even think the patient should have a bigger place!!!

Like management by Quality the client/customer is at the centre of the system the patient must be at the centre of our management and we should always ensure that they are satisfied... Even with our limited resources.

Health workers sometimes focused too much on themselves and disrespect patients who are mainly poor and most of the time in a position where they can't complain.

As leader we should make a must to ensure patient satisfaction is our ultimate goal and that our human and material resources are dedicated to them!

Nice weekend


Aamer Ikram Replied at 2:22 AM, 14 Sep 2013

Very impressive; it has been an excellent opportunity provided yet again by GHD. The discussion has been versatile with lot of learning. Thanks Rebecca and her team.

Frank NDUU NAWEJ Replied at 4:12 AM, 14 Sep 2013

Thank you Dear Dave for your contribution, i h am going now to the link you showed.
Now , i want to answer to the question number 1 ans 5.
1. As the manager of a dialysis clinic, my duties or responsabilities are included in this mission: to let patients getting safe and improved healthcare. So some of my duties are to lead and motivate the staff, to monitor the finances process, to manage data, etc.
5.Ressources or programs which would be helpfull to me in my work are specially continuous formation and ressources on management operations on these topics: health human ressources management, healthcare imrpovement (the role of the board), the financial managment including the budgets, marketing and procurement.

Alvin Marcelo, MD Replied at 4:29 AM, 14 Sep 2013

Dear all,

My two cents:

1. The best way to learn how to manage our team is to know how to manage ourselves. We should also nurture our staff to manage themselves. Self-management is the key to effective group management.

2. Theoretical frameworks and case-based learning are tremendous sources of knowledge in management. Without these frameworks, we will repeat the mistakes that some other people had committed and had already shared for others to learn from.

3. Networks like GHD are good sources of these theories and cases. The network becomes more powerful and effective the more people share their stories and lessons.

4. Inter-networks provide the diversity of domains and could add depth to the knowledge exchange. The Asia eHealth Information Network for example dwells on health information management ( and support for national efforts on health information systems development (pardon the plug).

Alvin Marcelo

Gini Williams Replied at 5:46 AM, 14 Sep 2013

It has been very enlightening to see how this discussion has developed and expanded over the week. The sheer volume and detail of the posts shows just how an important management is and how many different areas of concern there are. Health Systems Strengthening has been listed as one of the priorities for Global Health for a number of years but it seems clear from this conversation how far we have to go. One of the challenges is the variety of issues raised from the management of care, to the management of personnel, to the management of resources and supply chains to the management of programmes to mention just a few. This makes it difficult to frame the the discussion and draw a line through it as someone suggested.
I wholeheartedly agree with Yap Boum, that the patient, should be at the centre of our management and leadership and it is clear to me that, where this is the case, outcomes are better and providers are happier. The problem is that we cannot expect nurses and other health care workers (HCWs) to provide patient-centred care if they have nothing to offer beyond tests and tablets, which is where the management of resources and inter-agency working comes in. Nor can you expect nurses and HCWs to use this approach when they are stretched to breaking point and feel under-valued and over-looked by the people they work for.
Taking a broader perspective a major part of way health systems are managed, is based on a biomedical response to a particular health problem or disease. The education and investment then follows this approach and focuses on the technical, rather than the social, environmental and human aspects of care. For instance in each of the 18 countries where we provide training for nurses to improve care for people affected by TB, the most frequent comment we get during the evaluation is that this is the first training the nurses have received which takes their role as nurses and their practice environment into account. "You have reminded us that patients are human beings and we need to think about more than just getting them to take their tablets" (Lesotho). "You have revived for us what it means to be a nurse" (Colombia).
As has already been mentioned in a previous post, we need a serious paradigm shift from a global to a local level to put people at the centre and build systems around the needs of the community being served. We have time, as many of the health problems we face are not going to change very quickly, and we have models of primary and community care which can help us make the shift. How we achieve the shift at the level of major global donors is another question. What we can do is rethink who needs to be sitting around the table to achieve the community-driven, interdisciplinary and inter-agency response required to make the shift and finally achieve health for all.

Edwin Vicente Bolastig Replied at 7:10 AM, 14 Sep 2013

Dear Colleagues,

This might come late but I would like to join in the rich discussions anyhow. Hope you still find my insights useful and relevant. As they say, better late than never! Here goes:

1. What kind of management duties or responsibilities do you perform in health care delivery or see others perform?

Graduating from medical school in the Philippines, I started out as a Municipal Health Officer seeing about the management of the various essential public health functions of a resource-constrained, doctorless municipality. This experience has served to broaden my perspective on the various roles that health workers play, aside from just providing clinical care. My medical school has trained us to be five-star physicians: clinicians, educators, researchers, leader-managers, and social mobilizers rolled into one. This has guided me throughout my career as I moved up from community-based public health practice to hospital-based residency work, to academic medicine, national health policy and management, and onto international health policy and systems pedagogy, practice and consulting work.

Being currently involved in teaching Health Policy, Health Systems, Health Planning and Primary Health Care to Masters in Health Administration (MHA) students who are themselves middle to top level managers in various disciplines of the Trinidad and Tobago health sector, I can see them involved in carrying out key functions from managing MOH departments, Regional Health Authorities, health facilities, programmes and services in both the private and public health sectors, to policy and standards development, to strategic planning, research, monitoring and evaluation, among many other functions.

2. How important is management (of people, processes and resources), compared to other issues or challenges in health care delivery? How do you prioritize this element of your work?

Management serves as the “hub” that connects all the different spokes of the health system wheel that is comprised of various sub-systems. Looking at the health system as a complex adaptive system, management serves as the “glue” that keeps the whole organization, programme or service running smoothly, with all its elements working together to achieve the desired health outcomes, while continuously learning lessons from its day-to-day operations.

3. What core skills do those who manage delivery need to be effective? How did you or others gain these skills – are management training or capacity building opportunities available in your work?

For a manager to be effective, these are some of the core skillsets they need to possess: a.) analytical and assessment skills, b.) leadership and systems thinking skills, c.) policy development and strategic planning skills, d.) financial planning and management, e.) communication and interpersonal relationships skills, and f.) community and cultural competency skills.

In our case, the MHA programme provides training and capacity building to health professionals on all of these aspects of health leadership and management.

4. What factors in health systems, organizations or communities impacts the work of those who manage delivery? What are the main barriers to improving the efficacy of your management?

The organizational culture speaks a lot about the way health managers behave and run their business, so to speak. The level of technology also dictates as to what type of services could be provided and how. The availability, training, competency levels and distribution of health providers also affect the managers’ ability to effectively address the population’s health needs. In addition, changes in the political climate could also affect motivation of health workers and strategic direction of the health sector.

Deficiencies or negative developments in the above areas could serve as barriers to effective management.

5. How can the Global Health Delivery Project address the challenges and barriers faced by those who manage delivery, especially at the frontlines? What kinds of resources or programs would be most helpful to you in your work?

The Global Health Delivery Project could address these challenges by equipping managers in the health sector with additional skills that would enhance their problem-solving and conflict management capacity, especially in resource-constrained environments, taking into account the complexities of managerial issues as well as variations in the political and socio-economic landscape of the health sector. Online-based learning opportunities such as webinars, virtual management courses and other such methods could have the widest reach. Organized in-country capacity building programmes and sponsored regional/international health leadership fellowship programmes (for free or at minimal cost) could also help.

sulaiman Kawooya Replied at 9:17 AM, 14 Sep 2013

Dear all GHDonliners,

Warm greetings from Masaka,Uganda.

Am a medical Director of a rural based HIV/AIDs Treat program,located in masaka regional referral Hospital with 10,345 clients actively in care.
looking at the deliberation that are busy transpiring, i think it adds up quite a number of text books.
personally i think that i always look at all concepts around people,process and resources
management in this way.
4's of management s1-Strategic planning that consists of the health care aspects of vision,mission,goals,aims,core values.
s2-Structures such as institutional positions and also physical structures.
s3-Staffing. all aspects of human resource are this is really the oil that drives and health related discourses.
s4-Systems. this the last of these 4's that links up all the above issues and example of these systems are information/data management systems,logistics and supply systems,financial systems(engulfing critical aspects of cost evaluations,cost-Benefit analysis,value for money,return over investments)

At the centre of our working is the key issue of QUALITY.
QUALITY = Inputs(universal basic concepts,principals,guidelines,SOPs),Resources +Processes,clinic systems +outputs(results-patients waiting time,effectiveness,efficiency)

Total Quality Management(TQM)= Continuous Quality Improvement (CQI)+Work Environment Improvement(WEI)

But WEI= you cant talk about quality when your place of work is wanting;therefore we ought to these 5s of wei such as Sort,Set,Shine,Sustain and standardize.
TEAM WORK-we operate as a star team other-than a team of stars.

Sandeep Saluja Replied at 11:11 AM, 14 Sep 2013

Alvins 2 cents are worth dollars

Imran Mirza Replied at 2:58 PM, 14 Sep 2013

Dear GHDOnline team members,

Thanks for the opportunity to participate in this forum. I sit on the board of a not-for-profit company that is involved in setting up centers for care of diabetics in Pakistan.

1. What kind of management duties or responsibilities do you perform in health care delivery or see others perform?
I do work full-time for a healthcare organization and volunteer my time on the board of The Diabetes Centre ( As a founder member, it has been a challenge to set up the company with other partners, craft a strategy, identify resources to deliver on our mission, and manage all this while not being in Pakistan.

2. How important is management (of people, processes and resources), compared to other issues or challenges in health care delivery? How do you prioritize this element of your work?
People management has been the greatest challenge. To keep our expenses low, we have relied significantly on volunteers. Whereas the quality of work by some of the volunteers has been exceptional, it has been a challenge to get the work done by most. With our busy personal and professional lives, it has not been easy for anyone of us. As a board, our foremost priority has been generation of funds to support our organization.

3. What core skills do those who manage delivery need to be effective? How did you or others gain these skills – are management training or capacity building opportunities available in your work?
Training and Education are key to get the work going. Going forward, patient experience and business review of performance metrics are the key issues that we will be focusing on. I have had some Executive level training in leadership and management and the memberships of American College of Physician Executives ( and Canadian Society of Physician Executives ( have been of value.

4. What factors in health systems, organizations or communities impacts the work of those who manage delivery? What are the main barriers to improving the efficacy of your management?
The major factor having impact on the work is the lack of patient-centeredness in our approach, procedures, processes and workflows. The provider-centered approach of delivery of care has been clearly shown to be ineffective; however, this message has not percolated to middle and low-income settings.

5. How can the Global Health Delivery Project address the challenges and barriers faced by those who manage delivery, especially at the frontlines? What kinds of resources or programs would be most helpful to you in your work?
A number of open source tools and programs are available. However, not many are aware of those resources. GHD can continue to make sure that the knowledge and resources remain available and easily accessible to the GHD community. Additionally, GHD can facilitate sharing of the best and safe practices from all practice settings.

Attached resources:

Glenville Liburd Replied at 8:14 AM, 15 Sep 2013

I am an Anaesthetist /Intensivist doubling up as a Family Physician on an island of 12000 inhabitants. It has truly been an amazing experience over the past 17 years since returning home from training abroad. My Prime specialty training has truly equipped me with the managerial skills even though they were acquired informally to be an effective agent of change. I would not burden this forum with the many challenges faced to care for patients in a resource limited environment. Patient Advocacy is an essential skill. Fairness of Mind is also vital as well as good oral and written communication skills... We mus not forget as patient Advocate and Provider "Evidence Based" propositions are essential to effectively mobilse resources to help our patients.

Michael Goodson Replied at 11:48 AM, 15 Sep 2013

I am a healthcare supply chain subject matter specialist and owner of an organization that provides assistance in optimizing healthcare facility and/or operating room materials management business processes, whether enabled by technology or not.
Healthcare is delivered by employing medical supplies, equipment and trained human resources. Although good can be accomplished through altruistic efforts of trained medical professionals, provision of healthcare services can become more effective and cost efficient though optimization of processes.
Every individual who has an interest the effective delivery of healthcare services must have representation on a work team which will determine how to accomplish the optimization of the process. Executive leadership must be in agreement that the goal is critical to the mission of the organization. There must be consensus within the team on the goal to be accomplished and agreement on how to measure when success is occurring. Baseline metrics of current efficacy must be measured and the team must consistently employ continuous measurement of whether or not the optimizing process is moving the team toward or away from the mutually agreed upon goals. The movement indicated by the metrics must be communicated to all team members on a regular and continuing basis.
Leading practices must be established to identify whether or not each step of the current healthcare delivery process is adding value to achieve the mutually agreed upon goal.
Each step in the delivery process must be defined and responsibility for each step must be assigned to an individual or group. The individual or group must agree that they are the correct individuals to accomplish the assigned task and that the timelines for doing so are reasonable.
Someone must be responsible to monitor the agreed upon steps on as frequent a basis as necessary to assure that the steps are being successfully executed in a timely manner. The status of the effort must be communicated to all stakeholders on a regular basis.
Having the correct supplies on hand in sufficient quantity to meet the demand requires either knowledge of the rate at which the supplies are needed (the demand) or an informed estimate of the number of procedures that are expected to be performed over time. The team must also know the lead time between when the need is recognized that specific supplies are needed and when the supplies have been procured and are ready for use. When the demand rate and the lead time are known, optimal levels of supplies to meet demand can be mathematically calculated to have sufficient stock available without tying up funds unnecessarily.
These are the techniques to assure work is accomplished and these techniques can be easily taught.

Maggie Sullivan Replied at 1:50 PM, 15 Sep 2013

Though I am contributing late in the conversation, I still wanted to add my two cents, which I learned from Sandeep Saluja, are worth dollars :) Also, I wanted to commment that going through these questions has been a very helpful exercise for myself professionally. As a clinician, I came to management sideways, so this is very useful for me to think about critically.

1. What kind of management duties or responsibilities do you perform in health care delivery or see others perform?
• Get to know personally/build relationships with the front line/clinical staff.
• Look for my own opportunities to learn from the front line/clinical staff.
• Help front line staff trouble-shoot clinical problems related to patient care.
• Provide face-to-face supervision and clinical observation of front line staff.
• Provide constructive feedback regarding clinical skill and decision-making.
• Seek funding opportunities/apply for grants.
• Pursue collaborative relationships with entities with overlapping missions.
• Develop clinical algorithms to streamline clinical care provided by front line staff.
• Precept volunteer medical/nursing students who travel to clinical sites with me.
• Attempt to maintain communication with clinical staff, even when I’m not able to be on site.

2. How important is management (of people, processes and resources), compared to other issues or challenges in health care delivery? How do you prioritize this element of your work?
Before doing this work myself, I would’ve said management was definitely a clear second priority. However, after being involved in global health delivery for some years now, I believe management to be a definite first priority. Having/being an excellent manager makes or breaks health delivery. I could have the best medicines, clinical skills and equipment, but without management of people, processes and resources, all of this may go to waste. Ironically, management is not something in which I was trained, so making mistakes on the job has unfortunately been my learning curve. I feel like this element prioritizes itself, there’s nothing I need to do to push it to the top. Management issues crop up frequently and regularly. To not notice or pay attention to this would be akin to standing by and watching the project slide away.

3. What core skills do those who manage delivery need to be effective? How did you or others gain these skills – are management training or capacity building opportunities available in your work?
• Communication and documentation skills
• Mediation/negotiation
• Efficiency and follow-through
• Problem-solving, creativity and resourcefulness
• Initiative, willingness
• Flexibility
I guess in writing this, these are more traits and characteristics than core skills. In re-thinking, core skills may be:
• Recruiting, interviewing and hiring staff
• providing staff development opportunities
• supervision
• money management/accounting
• the ability to cut your losses and move on (including letting people go)
I learned this through doing and through observing my own manager/supervisor. Fortunately for me, my supervisor is an excellent manager so I’ve had a good example to try and follow. Otherwise, no, there are not any management training and capacity building opportunities through my work.

4. What factors in health systems, organizations or communities impacts the work of those who manage delivery? What are the main barriers to improving the efficacy of your management?
• MOH/public health system beaurocracy and profound lack of resources
• Cultural differences in professionalilsm and work norms/expectations
• Cultural perceptions of health, wellness and illness
• Interpersonal politics of small rural communities – regardless of country
• Lack of infrastructure in communities (ie transportation, roads, internet access)
Barriers to improving the efficacy of my management:
• My own lack of management training
• Lack of institutional support: as a nurse, I work in clinic for an organization that allows me to travel, though there is no financial support for my global health work. I use either vacation time or unpaid leave. Overall lack of institutional support also contributes to my needing to work multiple jobs/long-hours, wearing multiple hats and being my own HR/administrative assistant, all of which compounds time constraints.
• And the usual suspects of time and money/resources

5. How can the Global Health Delivery Project address the challenges and barriers faced by those who manage delivery, especially at the frontlines? What kinds of resources or programs would be most helpful to you in your work?
• Firstly and importantly, GHDonline already helps to overcome some of these barriers by facilitating a communication platform for managers to speak to one another.
• Perhaps create a new managers forum, where resources are catalogued by the necessary core skills (recruitment/hiring, how to provide supervision, what works and doesn’t work when collaborating with MOHs, managing supply chains, etc).
• Advocate for greater institutional support of clinicians/clinical managers

Barbara Meyer Replied at 3:03 PM, 15 Sep 2013

One resource that has been very helpful at a hospital in Lesotho is the Open School. They have courses on quality improvement that can be taken at one's own pace and the courses are free in many low resource countries. I worked in Lesotho for two years as a Peace Corps volunteer, primarily with the Quality and Infection Control nurse. We created a management learning group using ihi (Institute for Healthcare Improvement) courses and book discussions. The group enjoyed the book "First Break All the Rules: What the World's Greatest Managers Do Differently" and found it helpful.
A resource that looks very good, though I had no personal connection with it, was the Lean Institute of Africa in Cape Town, South Africa. They say they give discounts for public hospitals. Here is a link to their page on public sector projects:

Attached resources:

Violet Chaka Replied at 5:01 PM, 15 Sep 2013

This has been a great panel! I have worked in 2 countries, Zimbabwe and Namibia as a medical technologist. Over the years I have realized one common aspect of managers in the public health sector. Most are thrust into management without any prior managerial experience or expertise. You learn as you go and are expected to solve a lot of management issues. I think it's about time our training institutions incorporate management courses or modules which will be invaluable post qualification. Or if that cannot be done in the short term, then ministries or organizations need to enroll their managers into management courses or at least offer support to those who are enrolled in such programs (e.g. study leave).

Best regards,

Der-Ming Liou Replied at 9:24 PM, 15 Sep 2013

I totally agreed with Michael Goodson. I used to be the Chief Information Officer of Taipei City Hospital where we merged 10 hospitals and 17 clinics into one hospital. The difficult part during the merging process is to manage the medical supplies and equipment. Each individual hospital had different coding schema for the medical supplies, equipment, drug and others. To unify the coding schema and to verify each medical supply spent a lot of time. It is important to have the correct and exact supplied on hand, otherwise, there can be happen some medical errors.

Jose Luis Sebastian Mesones Replied at 12:49 AM, 16 Sep 2013

Good night, I work as country coordinator in Peru, for AIDS HEALTHCARE FOUNDATION. We are currently in the process of implementation of country office and the development of strategic alliances with local NGOs and MoH. We are dedicated to promote early diagnosis of HIV infection and early initiation of antiretroviral treatment, for that train to health workers and community workers in screening for open community spaces, mainly with vulnerable populations, also helping to strengthen the local state health system.
For this we are using the lessons and experiences learned during the 10 years that we play work as national director of the HIV program of the Ministry of Health of Peru.
An important point that we are working on the foundation is to strengthen the diagnosis and appropriate treatment of TB-HIV co-infection, which is the major cause of death from HIV in Peru. To achieve success of these interventions must ensure active participation and commitment of the community and state support, to compromise the transfer of achievements and help improve the quality of life of people.

Heidi Behforouz, MD Replied at 11:31 AM, 16 Sep 2013

Shared Decision Making a la conversation Rivet started in # 63
Highly recommend looking at Dartmouth Hitchcock's Center for Shared Decision Making
They have great resources for patients/professionals alike

Marie Connelly Replied at 5:47 PM, 16 Sep 2013

Dear colleagues,

We would like to thank you all for following and participating in this discussion - we have been inspired to hear from colleagues in 74 different countries and over 130 organizations this past week. Your insightful comments have been shared with more than 10,000 members here on GHDonline, as well as several thousand visitors who came to the website last week, and we have all learned so much from your contributions.

While we were truly thrilled to see such a rich discussion unfold amongst our colleagues around the world, we know this Expert Panel generated an unprecedented number of email notifications. We appreciate everyone's patience with this influx of emails, and thank you all for so actively engaging with the responses from your colleagues.

In an effort to minimize these emails moving forward, we will begin sending out a single daily email with updates on any additional responses to this discussion. Of course, you can always review your email settings at any time by visiting your GHDonline profile, and we encourage you to contact us directly with any questions:

Thank you all again for such a rich discussion - we welcome any additional thoughts or insights you wish to share in the coming days and weeks, and look forward to sharing our Discussion Brief summary with all of you shortly.

With thanks,

Allison Squires Replied at 6:11 PM, 16 Sep 2013

Dear Colleagues,

I’ve followed the discussion with great interest as a US-based nurse and
health workforce researcher with research experience in 30 countries. I
write from a symposium in Ottawa on Health Workforce Migration ( where the role of management as a driver
of migration, from organizational to international, is quite apparent.

It strikes me that the single best measure of management performance, from
the unit/ward level through the upper levels of an organization, is
Turnover Rate. That concept has positive, mixed, and negative aspects to
it that may predict a lot about manager performance. For example, drawing
from the evidence you can sort aspects of turnover in the following ways:

Positive turnover: Employees leave for career advancement reasons (internal
or external), termination of incompetent or toxic personalities that affect
the overall work environment, retention of a minimum number (to be
determined by the organization) of experience personnel who can mentor or
precept new hires (experienced and inexperienced alike). [These suggest a
supportive working environment that promotes retention.]

Mixed turnover: Internal organizational transfers to another ward/unit (may
be a passive aggressive indicator of dissatisfaction with direct supervisor
but could also be for career advancement).

Negative turnover: High rates of new graduate or new hire turnover; low
rates of experienced nurse turnover, suggesting career stagnation or a lack
of support for career advancement; employee left the organization but
stayed locally; high burnout or emotional exhaustion rates reported on the
unit; toxic personalities or poor quality relationships pervade the unit
per staff feedback.

Data is the big piece that is missing from most organizations’ ability to
accurately measure turnover as an indicator of management performance.
Most of the focus on manager performance is on how well they manage their
budgets, supply chains (when part of the job description), patient
complaints (when those systems exist), and implementation of QI/QA programs.

The aspects of turnover I wrote about likely have more dimensions, but I
hope they present a useful contribution to the dialogue.

Thanks again to all for the engaging discussion that has so beautifully
illustrated our common challenges in health services delivery.

Best, Allison


*Allison Squires, PhD, RN*

Assistant Professor, New York University College of Nursing – Global

Research Assistant Professor, New York University School of Medicine

726 Broadway, 10th Floor

New York, NY 10003

Tel: 212-992-7074


Health Worker Migration:

Timothy Simard Replied at 11:07 PM, 16 Sep 2013

I have a background in SCM for many years which I now apply to SCM of human capital - delivering and "unlocking idle IQ" of healthcare workers based on condition, therapeutics or geographies- global 24x7.
BTW - I 'm a problem solver and technology person not a clinician.
Anyways, Scalable solutions of healthcare delivery is my passion I suppose. If I can help or know someone I will do so.
How do you do it now? What have you tried before? What are the biggest problems? What geographies do you focus on - percentages are helpful.
RFID is perhaps not grandular enough? Not sure.

Vinitha kadamkode Replied at 11:53 PM, 17 Sep 2013

Hi, I am vinitha, a beginner in Diabetets research. I am very excited to be part of this expert panel. Research is accentuating the importance of physical activity and diet in diabetes managemnet and prevention. Community health practices are very much effective in disease control and prevention. In India such community programs are in very nascent stage, but more actvities are sprouting these days. I would like to share the healthy school initiative program "MARG", one of the largest helathy scholl initiative in south East Asia. The team lead by Dr Vanish Nambiar is doing an excellent job to inculcate helathy eating habits and lifestyle changes in school kids.Please go through this link for further details

AMINA HAMZA Replied at 9:02 AM, 19 Sep 2013

I am an architect working with NPHCDA an agency under the Ministry of Health in Nigeria
saddled with responsibility of providing primary health care services to the nation at the ward level.

we design and built the primary health care centers (PHCs), routine immunization, community health services to mention a few. i participate in the design and supervision process of the PHCs

currently we are about to start building 156 PHCs nation wide which happens every year. For just this aspect of serves we provide it is very important you know how to manage the people, the processes and the resources involved.due to the involvement of different profession in other to achieve the best result.

Thomas Flood Replied at 11:54 PM, 19 Sep 2013

If you need any assistance with operating rooms let me know.

Menyanga Abu Replied at 4:24 PM, 20 Sep 2013

·   To manage health care service delivery effectively, one should understand  the components of health care servicesas  mentioned above

*  Health
services delivery/Health infrastructural facility
*  Health
workforce(human resources)
*  Health
information system
* Medical
and pharmaceutical products, vaccines and technologies
*  Health
*   Leadership
and governance
*  Clients/patients/community
For the
health system to provide qaulity health care services and  achieve its goals , all the components have to carry out some
basic functions regardless of  how they
are organized. Health system makes sure that quality services are provided,
develops  appropriate health workers ,
mobilizes and allocates funds  and other
resources , ensuring health system leadership and mobilizing and educating
clients/communities for health servicesup-take.

(1)Services delivery/Health infrastructural
Good health
service delivery system should provide effective, safe, quality personal and
non-personal health interventions to those who need them when and where needed
with minimum waste of resources. In the provision of health, the
roles of public, NGOs, donor agencies and private sector in supporting service
delivery should be well spelt out. The care networks i.  e the referral system should be strengthened
making sure that decentralization does not negatively affect the service
delivery system and should go beyond structural arrangement to actual provision
of health services at the various tier of the system. Special provision should
be made to ensure outreach to special Population. Adequate infrastructural
facilities should be provided for effective and quality health care services.

workforce  (human resources)   
There should
be health human resources strategic plans for equitable distribution  of human resources. In-service training and
workshops should be organized to keep the health workers abreast of the  development in the health technology.
Training and retraining is the key issue. Solid arrangement for in-service
training, pre-service training and capacity building of the training institutions
should be put in place . The capacity of the training institutions should be
strengthened to provide medical, pharmaceutical and nursery education to meet
the health care demand of the future  and  to improve the quality of
clinical education  and care.
(3)Health information   
A well
designed and functional health information system  ensures the production, analysis ,dissemination
and use of reliable ,accurate and timely information on health determinants ,
health system performance and health status. Planning, monitoring and evaluation,
improved delivery services including M&E, drug resistance surveillance,
pharmacovigilance , death registry ,quality assurance and data for decision
making should be strengthened.

(4)Medical, pharmaceutical products and
Drugs and
heath commodity supply cycle  should  be well managed to prevent stock-outs and
waste. Using morbidity and consumption data, appropriate forecasting should be
made as regard selection and quantification of required medical, pharmaceutical
and other health commodities. Effective supply management system should  be established. Functional and effective
rational drug use strategy should be developed to promote  rational drug use and minimize inappropriate
use of drugs and health commodities.

(5)Health financing 
A good
health financing system raises adequate funds for health services in a way that
ensure people can access and use needed services  and are protected from financial catastrophe
or impoverishment associated with having to pay for the services . Mechanism
should be developed to create sustainable health system financing model that
entrenches transparent management of health funds and budgets. Government and
donor agencies should not only fund health sector adequately but should also
put in place strategies that will ensure  effective and efficient use of such funds with transparency and

(6)Leadership and governance
should take the stewardship of the various activities in the health sector
making sure that strategic policy frameworks are developed and are combined
with oversight, coalition building and the provision of appropriate regulations
and incentives

play important role in the production and consumption of health services.
Community system is complimentary to and closely connected to health system and
services delivery. Advocacy, community  mobilization
, accountability, demand creation and linking community to appropriate
services  plays a key roles in health
promotion and delivery as well as in monitoring health system for equity  and  quality of services. Community system strengthening is an approach that
promotes the development of informed, supportive- community and community-based
structures that enable them to contribute to longer-term sustainability of
health and other interventions at the community levels.

Marie Connelly Replied at 3:29 PM, 26 Sep 2013

Many thanks once again to all of our colleagues here in the community for taking the time to share such important insights and expertise during this Expert Panel discussion.

We have summarized some of the common themes and key points shared here in a new Discussion Brief, which can be accessed on the GHDonline website by visiting:

For those interested in further reading on this subject, we have also shared a bibliography of literature on health care delivery in resource-limited settings.

We encourage everyone to continue sharing examples of beneficial training programs for managers in health care delivery, as we are working to create a resource page on GHDonline to disseminate these tools and resources more widely.

Attached resource:

ReLAB Bamenda Replied at 5:55 AM, 20 Dec 2013

Hi Ivahn,

Very interested in this. Apparently I am also an administrator working in a TB lab in Cameroon. I could really use any experience you might want to share on inventory management. My personal email is <mailto:>

How successful has this pilot in Guinea been? Hope to hear from you soon.

Anne Marie Hvid Replied at 11:12 AM, 28 Jan 2014

HR Management is critical for health service delivery. The USAID | DELIVER PROJECT has published two innovative toolkits to help strengthen human resources for public health supply chains in developing countries.

The Human Resource Capacity Development in Public Health Supply Chain Management: Assessment Guide and Tool presents a structured, rating-based methodology designed to provide a rapid, comprehensive assessment of the capacity of the human resource support system for a country’s supply chain. Data are gathered from a document review, focus group discussions, and in-country stakeholder interviews to identify the strengths, areas for improvement, opportunities, and challenges for a wide range of human resource inputs and components. The findings are transformed into specific recommendations and strategies for action based on an understanding of country priorities and programming gaps. The toolkit also includes Word templates, a PowerPoint template, and an Excel-based Diagnostic Dashboard.

Recruiting Supply Chain Professionals: A Ready Reference Guide for Finding and Selecting High Performers leads users through the steps required to hire the right supply chain professionals, in the right quantities, with the right skills, in the right place, at the right time, and for the right salaries. It also includes templates that will be helpful at each stage of the process.

To access the toolkits, please visit

Sriram Shamasunder Replied at 2:00 PM, 11 Mar 2014

Based on what many of the experts in this group have said in this forum, University of California at San Francisco along with PIH are putting on a 4 day bootcamp in Global Health Delivery from October 2nd-5th 2014. Many of the participants in this forum may find this bootcamp useful so I thought I would share more details. Please see below. There are a few scholarships for our international colleagues that may require some financial assistance to participate.

Announcing UCSF Bootcamp for Global Health Care Delivery
October 2nd-5th, 2014 in San Francisco, California

The UCSF Global Health Core is offering a Continuing Medical Education (CME)/ Continuing Education (CE) immersion program for early to mid-career health professionals interested in serving globally and committed to incorporating global health care into their career path.

Taught by over a dozen experienced global health experts, the Bootcamp will use hands-on small group workshops and simulations to teach health system design and delivery, value chain mapping, leadership training, ethics and quality improvement principles tailored for resource-constrained settings. In addition, participants will have ongoing opportunities for longitudinal mentorship for one year following the Bootcamp.

Bootcamp faculty include Ambassador Eric Goosby, former head of PEPFAR, Joia Mukherjee, CMO of Partners in Health, Raj Panjabi, Founder of Last Mile Health, Sheila Davis, Chief Nursing Officer of Partners in Health, Tina Brock, UCSF School of Pharmacy, and International colleagues from Haiti and Liberia to lead small group sessions and case-based scenarios. For the full list of guest speakers, Click Here. For the full list of UCSF faculty, Click Here.

The President of the World Bank, Jim Kim, MD has said “the barrier to global health care delivery is not necessarily funding or knowledge of how to deliver health care: it is the ability to implement.”  The ability to implement in resource poor settings entails not only the will to serve, but also the expertise. The Bootcamp for Global Health Care Delivery will increase participants’ readiness for work in resource poor countries. 

The Bootcamp for Global Health Care Delivery will be limited to 36 participants so early registration is encouraged. To register for the Bootcamp, Click Here.

More information can be found at:

Questions should be directed to Manisha Singh at

Organizing Committee:
Phuoc Van Le, MD MPH DTM&H
Division of Hospital Medicine. UCSF School of Public Health, UC Berkeley
Sriram Shamasunder, MD DTM&H
Division of Hospital Medicine, UCSF
Madhavi Dandu, MD MPH
Division of Hospital Medicine, UCSF
Global Health Sciences
Ethel Wu, MD
Division of Hospital Medicine, UCSF
Karen Duderstadt, RN PhD, 
School of Nursing, UCSF
Tina Brock, BA BSPharm MS EdD
School of Pharmacy, UCSF

Attached resource:

This Expert Panel is Archived.

This Expert Panel is no longer active as of December 2018. Thanks to those who posted here and made this information available to others visiting the site.