Program Management in Sexual and Reproductive Health Services
Welcome to the programmatic area on program management in sexual and reproductive health (SRH) services within MEASURE Evaluation’s Family Planning and Reproductive Health Indicators Database. This is one of the subareas found in the service delivery section of the database. All indicators for this area include a definition, data requirements, data source(s), purpose, issues and—if relevant—gender implications.
- Good leadership and management are essential to organizational development, performance, and sustainability. An organization succeeds because of what it does (a shared commitment to accomplish something useful and important) and how it does it (the way it functions, decides, evaluates, adapts, and delegates). Good leadership and management are likewise essential to reproductive health (RH) programs and to the achievement of national RH goals.
- The indicators presented here describe attributes of a well-functioning system and generally measure progress in the use of a system, the effectiveness of individuals using the system, or the performance of the system.
Good leadership and management are essential to organizational development, performance, and sustainability. An organization succeeds because of what it does (a shared commitment to accomplish something useful and important) and how it does it (the way it functions, decides, evaluates, adapts, and delegates). Good leadership and management are likewise essential to reproductive health (RH) programs and to the achievement of national RH goals. Effective and efficient organizational performance is critical in the face of public health challenges (e.g., AIDS, tuberculosis), health-sector reform (e.g., decentralization, integration, financing), and the needs and desires of an ever-expanding number of clients of RH services from traditionally underserved groups (e.g., adolescents, rural and indigenous populations, men). The objective of management and leadership is to foster and sustain individual employee and organizational performance as well as overall program performance in delivering RH services.
As depicted in MSH’s Leading and Managing Framework, effective management and leadership consist of a series of essential functions, underlying dimensions, or elements. The functions of managing and leading are carried out simultaneously on a daily basis by multiple individuals at multiple levels of an organization, not just by senior staff.
In many instances, the “boundaries” between the management and leadership functional areas and other functional areas of RH service delivery overlap, because the management or leadership function spans each of the other areas. In other words, an organization’s or program’s success (or lack thereof) in performance in all of its areas of focus is at least in part attributable to a strength or weakness in its management and leadership.
Factors determining how an organization does its work or accomplishes its objectives:
- effectiveness and functioning of individuals at all levels of the organization;
- management systems supporting their work;
- organizational culture; and
- adequacy of human and financial resources.
Ideally, one should evaluate overall management and leadership capacity by taking a long-range view of the organization and the way it develops over time, evolving on the management development continuum characterized by four distinct developmental stages: emergent/initial, launch, consolidation, and mature. At the first stage, an organization begins to develop a particular management component. By the fourth stage, an organization operates extremely effectively with regard to the management component. Organizations (and the programs they support) pass through these stages at different rates, and evolve to the point that they have a clear mission, strong management structures and systems, and skilled leaders, managers, and staff who can effectively use these structures and systems.
Management systems or capabilities within a single organization will often be in different stages of development because some managment
systems will receive more attention than will others as the organization develops. For example, donors and the organization itself often focus on ensuring that a sound financial management system and practices are in place before they focus on developing an organization’s human resource management system. In such a case, the financial management system may be in a more advanced stage of development than is the human resource management system.
Organizational performance –which refers to what an organization does and how it does it — always includes some element of customer satisfaction. One evaluates what an organization does in relation to the goals and objectives it has established. Evaluators should therefore define measures or indicators in relation to the specific long- and short-range objectives set by the organization, many of which are presented in this database.
There are two distinct approaches to measuring management within RH programs. The first approach is to use a standard set of criteria based on national or international norms and standards. Some organizations in developing countries seek certification, for example, from the International Organization for Standardization (ISO), whereas others seek accreditation based on national standards. The second approach is to develop indicators for each management area and component in collaboration with the organization as part of an exercise to review and strengthen its management systems. This approach involves an assessment to determine the baseline stage of development of the organization. In this way, program managers and evaluators can tailor the standards against which organizational performance is being measured to the level of the organization’s development as well as the specific context in which the organization functions and offers RH services. The indicators presented here are derived from actual experience in designing assessments of RH programs in developing countries rather than from rigid standards that are applied to health care organizations.
Methodological Challenges of Evaluating Management and Leadership
- Self-assessment of performance generates ownership, but it may lack objectivity.
Organizations may assess their own performance in a participatory fashion, involving staff from all levels, including board members, with the assistance of an external facilitator or a highly skilled internal facilitator. This is generally cheaper and less time-consuming than external assessments. It allows for organization-wide ownership of the findings and commitment to action because it builds upon existing strengths and addresses major weaknesses acknowledged by the staff.
However, self-assessments can be subjective, unless the internal evaluator obtains hard data to verify the findings as part of the assessment process. Moreover, self-assessment requires careful and thorough consensus building among staff involved. External assessment, on the other hand, may be more objective, because it relies heavily on the review of organizational documents in addition to interviews with staff at all levels of the organizations. But it is likely to be time and resource intensive. Also, unless the assessment is carefully designed and implemented, the organization may not accept the findings or act on them.
Throughout this database, the term “evaluator” should be interpreted broadly to include both organizational staff responsible for internal assessments(also referred to as facilitators) as well as persons external to the organization.
- Many management indicators are not operationally precise.
Just as self-assessments can be subjective, so can the actual indicators for good management. Although efforts have been made to quantify and clearly define indicators, they are still subject to interpretation and varying points of reference.
- Evidence of the causal link between management and outcomes remains elusive.
Researchers have found it difficult to find conclusive evidence of a causal link between the indicators of program management/leadership and actual performance in developing country settings. For example, research from developing countries has yet to provide conclusive evidence that human resource interventions (e.g., leadership training) result in greater achievement of organizational objectives. The many intervening variables between human development and end results (e.g., shifts in internal and external conditions, market shifts) make these links difficult to validate. Links between management interventions and organizational outcomes are not clear-cut in research in the public sector, particularly in health care.
Organization of Indicators
The indicators describe attributes of a well-functioning system and generally measure progress in the use of a system, the effectiveness of individuals using the system, or the performance of the system. The indicators included in this section focus on four broad management elements found in all organizations: (MSH, 1999a).
- Mission: A statement of purpose that frames the values guiding the organization or program and that provides consistency and meaning to its actions. The mission statement answers the question, “What does the organization do and why?”
- Strategy: The approach that organizations and programs select to define the activities enabling the fulfillment of the mission. Strategy answers the question, “How will the organization get to where it wants to go?” Organizational strategies should help prioritize and focus the organization’s work, comply with its mission, and respond to the demands of the clients served and to the organization’s potential market (clients it has the desire to reach).
- Structure: Addresses roles and responsibilities, lines of authority, and distribution of responsibility, in alignment with mission and strategy. The structure answers the question, “What is the framework and decision-making structure within which the organization operates?” A well-defined structure encourages individual and team/ group initiative and provides staff clarity in terms of the decision-making authority.
- Systems: The interdependent management areas within an organization that allow it to do its work. Organizational systems answer the question, “How does the organization carry out its activities?” Key systems for health organizations and programs include human resource management, organizational planning, information systems, quality assurance, financial management, management of revenues, and management of supplies.
|Key Systems for Health Organizations and Programs|
The integrated use of systems, policies, and management practices to recruit, maintain, and develop employees in order to meet the desired goals of the organization. Effective human resource management supports employees in carrying out meaningful and satisfying work as well as help an organization to improve its level of performance and impact (FPMD, 1999).
A systematic process to review, modify, and align key elements of the organization’s mission, strategy, structure, systems, and program activities in light of changing internal or external conditions. Planning is an essential component in ensuring sustainability. Planning systems cover both annual and long-term planning that further the organization’s mission, strategy, and goals/objectives.
A set of components and procedures organized with the objective of generating information that will improve health care management decisions at all levels of the health system or organization. The MIS represents a key source of data for calculating indicators on service utilization, coverage, and overall performance; a comprehensive MIS includes distinct subsystems for management areas, such as human resources, logistics management, disease surveillance, finances, and workplan monitoring.
Improves service effectiveness and client satisfaction. Because QA emphasizes a process of constant improvement in operations, it requires long-term organizational commitment and teamwork (FPMD, 1993). Many elements of a high-functioning quality assurance system are embedded in other management systems.
Collects, records, and reports data on an organization’s financial situation. It provides information that helps finance, program, and senior managers to make decisions about allocating resources.
Planning for revenue generation and diversification of funding sources through constituency building among clients and donors (current and potential). Organizations tend to have greater success in this area if they have multiple funding sources (e.g., donors, government, third party payments, local community, sale of services/products).
Without a functioning supply management system, an organization cannot deliver quality RH services to its clients.
FPMD, 1993. “Using CQI to Strengthen Family Planning Programs.” The Family Planning Manager 2, No. 1. Boston, MA: Management Sciences for Health.
FPMD. 1999. “Human Resources: Managing and Developing your Most Important Asset.” The Manager 8, No. 1. Boston: MSH.