The limits of externally supported institution building
A Hospital under Resource Constraints
Von Rudolf Fischer / SolidarMed
We are all aware of the limitations of the purely "technical" approaches in health development. Good governance and effective leadership and management have been on the development agenda for some time now. The hypothesis is that technically improved services need to be embedded in a conducive institutional context to ensures effective, targeted and equitable delivery. However, this is not a magic bullet, and prevailing expectations may be too high.
Since the mid-nineties, SolidarMed has been concentrating on effective leadership and management in its co-operation with partner hospitals in Lesotho. The strategy we have been following could be called "institution building". The stated aim is to empower partner institutions and their key staff to manage operations successfully and to develop planning and problem solving skills which will enable them to master future challenges to their institutions thereby enhancing sustainability of health services.
The approach has been one of strengthening governance and management functions in three ways:
- By supporting the development of procedures and instruments financially and through dialogue, coaching and provision of external expertise
- By financing key investments in training, infrastructure, equipment and software
- By tying financial support for 1) and 2) to submission of proof for discharge of core governance and management functions. We do not require them to deliver specific reports to the donor, we rather "force" them to go through the yearly governance and management cycles according to their own rules and regulations. We accept as proof of delivery their routine documents such as minutes of board meetings, reports on annual internal performance reviews, work plans, budgets and externally audited financial statements.
Building on comparative advantages?
In the late nineties SolidarMed offered the partner hospitals an opportunity to develop a mid-term strategic business development plan with professional external assistance. These strategic plans are broken down into yearly plans of operation in a planning exercise attended by board members, key management and staff representatives. Our financial support is then negotiated on the basis of the yearly plan of operation approved by the board.
One would expect that such a strategy should be fairly successful since our partner institutions in Lesotho, which are church hospitals, have a number of comparative advantages over public hospitals in Lesotho and other countries in Eastern and Southern Africa when it comes to developing good governance, and accountable and effective management.
- They are fairly autonomous in that they have a board of governors which may, theoretically, be answerable to the owner, usually a bishop, but in practice the boards have full responsibility for running the institution. And some of them have a fairly good community representation on them. This is not far removed from the kind of decentralised decision making and accountability Health Sector Reforms all over Africa are striving to establish.
- They are also autonomous in their crucial management operations such as hiring and firing which has traditionally not been the case with government institutions and has always been an impediment for the establishment of an effective work discipline.
- They are free in procurement and other core administrative functions.
However, as you will see, results of this institution building strategy are mixed. St. Joseph's Hospital in Roma, Lesotho, is one of SolidarMed's partner institutions in Lesotho. It has, by any standards, a fairly good board with a number of competent and well connected members. Over the past years, the hospital has been suffering from persistent problems in the area of labour relations and from a negative image in connection with perceived low quality of services in general and patient care in particular. About a year ago, the board of governors of the hospital therefore decided to have a management audit performed. The board entrusted the mandate to the "Institute of Development Management". The IDM is a reputable regional organisation with offices in Lesotho and Botswana. It specialises in management services and management training for both public and private institutions.
I now want to share some of the findings and conclusions of this management audit with you. I am sure they will provide food for thought. I am not going to summarise and comment, rather, I am going to provide you with a number of quotations from the original text, because I believe that they speak for themselves.
The case of St. Joseph's Hospital at Roma, Lesotho,
*Input by Rudolf Fischer, Ph.D., Executive Director, SolidarMed, for the session “Take care of your money – and of people! The role of Governance and Stewardship“ at the MMS Symposium 2003. Contact: firstname.lastname@example.org.