Organisational Capacity Building in Health Systems

Niyi Awofeso

• Publisher: Routledge
• Year: 2012
• ISBN:
  9781136224317
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

Capacity building – which focuses on understanding the obstacles that prevent organisations from realising their goals, while promoting those features that help them to achieve measurable and sustainable results – is vital to improve the delivery of health care in both developed and developing countries. Organisations are important structural building blocks of health systems because they provide platforms for delivery of curative and preventive health services, and facilitate health workforce financing and functions.

Organisational capacity building involves more than training and equipment and this book discusses management capacity to restructure systems, structures and roles strategically to optimise organisational performance in healthcare. Examining the topic in a practical and comprehensive way, Organisational Capacity Building in Health Systems is divided into five parts, looking at:

• What health organisations are and do
• Management and leadership in health organisations
• How to build capacity in health systems
• Building capacity in a range of health system contexts
• Dealing with challenges in building capacity and evaluating work

Looking at how to effectively design, implement and evaluate organisational capacity building initiatives, this book is ideal for public health, health promotion and health management researchers, students and practitioners.

Part I

Theories, typology and functions of organisations

1 Evolution of capacity building concept in health systems

While working as a volunteer infectious diseases physician at Kyrgyzstan’s prisons in 2007, I developed an epiphany on why the concept of ‘capacity building’ in health systems is so challenging, and yet so important. While Kyrgyzstan struggled to develop a new political framework following the implosion of the former Soviet Union, it had virtually lost control of the health and security management of its 16,000 prisoners. Criminal leaders transformed large sections of prisoners into armies in reserve. Violence, transmission of multi-drug resistant tuberculosis infection among prisoners and eventually from prisoners to their relatives and close contacts in the general community, were common. The tuberculosis control situation was so deplorable that two leading international non-governmental health movements – International Committee of the Red Cross and Doctors Without Borders – took over responsibility for prevention and treatment of tuberculosis and other public health problems in prison settings.

I realised that in order to restore normalcy to Kyrgyzstan government’s management of prison health services, it is important to develop indigenous capacity – i.e. enhance the capability of the people and government of Kyrgyzstan to undertake stated objectives – for effective management of prisons at institutional, human rights, judicial and public health perspectives. Institutional capacity building in Kyrgyzstan prisons’ context entails reforms of penal financing, infrastructure, personnel, security, corruption and dissolution of the ‘obshchak’ system of prison gang-led, violence-prone, prison management. At the human rights level, most incidents of violence and abuse inflicted by police and prison staff on inmates are apparently condoned by custodial authorities, and this has created a vicious cycle of payback violent attacks by inmates on other inmates and occasionally on custodial workers, including nurses and doctors. Training, employment and retention of health workers of the right mix, as well as equitable distribution of health workers and facilities within the prison system require carefully coordinated interdisciplinary capacity building efforts. Justice reforms include restoring the observance of the rule of law, especially by crime investigators, who are widely perceived as torturing crime suspects in order to obtain evidence. At the prisoner health care level, the fragile building blocks of health care delivery to prisoners – quality workforce, drugs and equipment, information technology, governance – crumbled with the demise of the former Soviet Union, and have been neglected since the late 1980s.¹

Although the decision by international non-governmental health-related organisations to address the worsening tuberculosis situation in Kyrgyzstan’s prisons was commendable and urgently required by prison inmates and staff at risk of contracting or dying from tuberculosis,² it addressed only a minor facet of the organisational capacity building processes required for transforming Kyrgyzstan’s prison system. It would have been impractical for health-focussed civil society groups to address non-health components of Kyrgyzstan’s prison capacity building components, but it is vitally important for all stakeholders to work in unison towards this goal, as piecemeal approaches to capacity building have, in general, unsatisfactory track records. Capacity development is a fundamental part of the mandates of many international organisations. Much of their activities aim to strengthen national capacities through training, technical advice, exchange of experiences, research and policy advice. Yet there is considerable dissatisfaction within the international community regarding the impact of many such interventions. Within the health sector, training-centred activities of international aid agencies have usually strengthened the skills of individuals, but have not always succeeded in improving the effectiveness of the ministries and other organisations where those individuals are working.³

For example, Haiti had about 5,000 non-governmental organisations working on various projects prior to the devastating January 2010 earthquake. Following the earthquake, millions of dollars were donated for emergency relief, and the number of civil society groups in Haiti increased to over 7,000. Yet, two years following the earthquake, there is estimated to be only one toilet for every 200 people in the Port au Prince metropolitan area. Water shortage is the norm. Electricity supply is epileptic. Poverty is endemic. Social services such as education and security are equally grossly inadequate or of substandard quality. In Africa, General Siad Barre was ousted as Somali president in 1991. While the lack of an existing political order and institutions of government (including administrative structures at the local, state and national levels) allowed authority to remain in the hands of competing warlords and clans, it became very difficult to meet the essential preconditions for effective post-conflict reconstruction and provision of health services in Somalia. Currently, Somalia is a failed state in the grip of severe famine, and its life expectancy at birth is estimated at 49 years. It has the highest rank for terrorism risk in the 2011 Maplecroft terrorism index. One lesson from the poor outcomes in relation to Haiti’s and Somalia’s reconstruction is that when a government is grossly ineffective, it needs to be reformed from bottom-up before reconstruction programmes can be successful. While short-term gains may be achieved within the health systems of failed states through vertical programmes, such as measles immunisation delivery, such vertical programmes are generally unsustainable and may further weaken vulnerable health systems. As Bill Gates perhaps belatedly realised following the resurgence of polio in Tajikistan and other Asian countries where it had been declared eradicated, and following two decades and $8.3 billion dollars to eradicate the disease:

Is humanity better served by waging wars on individual diseases, like polio? Or is it better to pursue a broader set of health goals simultaneously – improving hygiene, expanding immunizations, providing clean drinking water – that don’t eliminate any one disease, but might improve the overall health of people in developing countries? The new plan integrates both approaches. It’s an acknowledgment, bred by last summer’s outbreak, that disease-specific wars can succeed only if they also strengthen the overall health system in poor countries.⁴

From around the 1960s, ‘nation building’ was promoted by international agencies as a way to ensure that newly independent nations were able to develop appropriate social, legal, economic, health, judicial and political structures to facilitate long-term development. The conventional idea of nation building has always revolved around that of an externally driven top-down structure meant for the express purpose of state and administrative reconstruction. Especially in nations emerging from conflict or natural disasters, such nation building approaches tend to be of a ‘practical’ nature, focussing on infrastructural reconstruction, humanitarian assistance in terms of food and medical supplies, construction of roads, schools, health care provision, and expansion of water and sewage treatment facilities. Nation building in this context was thus viewed as a rehabilitation campaign which is expected to ‘provide the physical and organisational infrastructure populations need to re-establish normal lives’.⁵

For more stable, but underdeveloped, nations, the United Nations Development Programme (UNDP) promoted the concept of ‘Institution Building’ in the 1970s, as a platform for facilitating long-term prosperity, security and health outcomes. Keohane defines institutions as the ‘persistent and connected set of rules that prescribe behavioural roles, constrain activities, and shape expectations’.⁶ While specific institutions can be defined in the first instance in terms of rules, it should be recognised that their effects are also embedded in ‘practices’, i.e. manner of individual and administrative behaviour towards citizens and other agencies of government within the state. It became apparent to the UNDP in the 1980s and 1990s that it is possible that the prevailing institutional architecture could be the source of continued misunderstanding among stakeholders, in the same way that societal and cultural differences are. This made the top-down UNDP approach to development difficult to justify. The following quote, from East Timorese independence leader Xanana Gusmao, highlights the inherent contradictions of the institution building approach in delivering community participation in newly independent East Timor:

We are not interested in a legacy of cars and laws, nor are we interested in a legacy of development plans for Timorese … We are not interested in inheriting an economic rationale which leaves out the social and political complexity of East Timorese reality. Nor do we wish to inherit the heavy decision-making and project implementation mechanisms in which the role of the East Timorese is to give their consent as observers rather than the active players we should start to be.⁷’

The concept of ‘capacity building’ (otherwise stated as ‘capacity development’) replaced ‘institution building’ in the lexicon of international development organisations from the mid-1990s onwards. ‘Capacity building’ implies a focus on the existing capacities of governments and how these capacities can become strengthened on all levels – the individual, the organisational and the institutional, as well as the broader system context. Governments, donor agencies and international organisations involved in development are increasingly putting an emphasis on capacities as key to sustainable development. Capacity building entails the activities and structures that leverage existing resources in pursuit of some common objective(s), and which are sustainable over the long term. The process of capacity building is expected to improve the ability of a person, group, organisation or system to meet identified objectives or to perform better.

In the health sector, the concept of capacity building has gained increasing currency over the past decade. The United States Agency for International Development (USAID) capacity building for health framework focuses on the management, organisational and business planning competencies essential to sustainable health care organisations. It includes six core organisational competencies. Technical expertise: does the organisation have the technical capacity to carry out its mandate? This includes the ability to access tools and methodologies and a technically qualified workforce. Resource mobilisation: does the organisation have a business model that allows it to mobilise resources and be financially viable? Technical assistance and training: do local staff and consultants have basic skills in consulting and training to provide effective technical assistance and training? Management systems: does the organisation have the necessary management systems in areas such as financial management, procurement, human resources and administration to function effectively? Organisational development: does the organisation have the capacity to plan and manage its activities? This includes the ability to develop strategic and operational plans, provide effective leadership and management, build an effective team and create ...

Table of contents

• Cover Page
• Half Title page
• Series page
• Title Page
• Copyright Page
• Dedication
• Contents
• Figures
• Tables
• Prologue
• Part I Theories, typology and functions of organisations
• Part II Management of health organisations
• Part III Capacity building in health systems General overview
• Part IV Capacity building in health system contexts
• Part V Addressing obstacles, and evaluating capacity building activities in the health systems
• Index