Comm Med: Health Service Management

Front 1

Define management

Back 1

It is taking responsibility for the efficient use of resources to achieve objectives effectively

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Define effective

Back 2

Sth that produces intended results

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Define Efficient

Back 3

Sth that produces intended result at the least cost without wastage of resources

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Define goal

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End result of a mission or process

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Define Objective

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Process of achieving the goal

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Define Target

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Short term objective

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Define health service management

Back 7

The process of mobilising and deploying resources (human, material and financial) for the efficient provision of effective health services for the community

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Who is a manager

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Anybody in an organization that is in a position to control and direct others towards specified targets in the organization

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Management aims at increasing ___

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•Ability - what you are capable of doing

•Motivation - determines what you actually do

•Attitude - determines how well you do it

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Elements of the Managerial process

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•continuous decision making

•continuous problem solving (after problem identification and analysis)

•sequential processes of planning, implementation (organizing, staffing, leading/directing, controlling) and evaluation

•continuous communication

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Basic management functions

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1. Planning: setting objectives & choosing alternative courses of action towards their attainment

2. Organising: ensuring order in the deployment of resources

3. Staffing: ensuring that positions on the organizational chart are filled with adequate number of staff, with appropriate skills and attitudes

4. Leading: motivating personnel to work with sustained zeal towards organizational objectives

5. Controlling: surveillance to ensure that the work is done according to plan

6. Evaluating: assessing progress towards predetermined objectives

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Levels of management

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1. Strategic level (Top level)

2. Technical/ Tactical/ Administrative level (Middle level)

3. Operational and Supervisory level (Lower level)

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Strategic management

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Managers at this level include Ministers, CMDs, members of Board of management of Teaching hospitals, etc. The top level managers take decisions regarding ~Formulation of corporate policy, vision, mission, goals & objectives of the organization ~Strategic planning ~Resource mobilization & allocation ~Corporate evaluation

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Tactical management

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Managers at this level include heads of departments. Take decisions regarding ~Translation of policies formulated at the top and interpreting them according to the local needs. ~Definition of tactics of implementation. ~Structuring of Authority & Responsibility. ~Coordination of activities. ~Regional planning & evaluation.

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Operational management

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Decisions are concerned with ~Service processes (day to day activities)’ ~Service output. ~Activity scheduling (GANTT chart). ~Monitoring of performance. ~Utilisation of resources.~Inventory control.

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Define modern health planning

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Modern Health Planning can be defined as a systematic decision-making process of setting objectives and taking decisions on how, when, and where to deploy resources in order to achieve the objectives.

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Characteristics of a plan

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•It is very systematic. •It has to be carried out methodologically. •Information is vital. •Resources are needed.

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Merits of planning

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•It minimises the negative impacts of future uncertainty. •It focuses attention on the objectives to be attained and galvanises purposeful action towards the achievement of the objectives.• It minimises cost.• It facilitates control, monitoring and evaluation by establishing standards.

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Classification of health plans can be based on

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•flexibility

•duration

•nature & scope

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Classification of health plans based on flexibility

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1. Fixed Plan – Cover a rigid period of time, and have fixed objectives and resources, that cannot be maneuvered. 2. Rolling Plan – Flexible and continuously revised so as to remain relevant in view of prevailing circumstances. Resources and time frame are flexible.

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Classification of health plans based on duration

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1. Long term Plan (Perspective) – >10years. 2. Medium term Plan – above 2yrs but <10yrs. 3. Short term Plan – Lasts b/w 1-2yrs, could be fixed or rolling.

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Classification of health plans based on nature & scope

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1. Strategic Plan – It states priorities or general goals & strategies for general health devt, covers a large service area (a country) & is usually long term. It answers the following questions; •Where are we now? (Situation analysis) •Where do we want to be? (Goal) •How do we get there? (Objectives) •When do we get there? (Time frame) •How do we know we are on course? (monitoring & evaluation) 2. Operational Plan – It formulates detailed objectives and timed targets in executing health programs. Both strategic & operational plans are closely related for while one provides a general frame work, the other provides detailed operational & functional directives to specific targets.

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Components of the planning cycle

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Organising for planning -> Situation Analysis -> Ranging of Priorities -> Setting Objectives -> Specification of Technical Interventions -> Constraints Analysis -> Selection of strategies -> Detailed Programming & Resource Specification

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Organizing for planning

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Also known as “Planning the Planning” or “Pre-planning”. At this stage the planning team is assembled and prepared for the task ahead. The detailed composition of the team will depend on the level at which the plan is being formulated.

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Situation analysis

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Needs assessment

To determine the common health & health-related problems in quantified terms e.g infant mortality rate and factors aiding the devt of the problems e.g economy It is done by carrying out a descriptive survey or checking existing data. Information is collected about health policy, demographic, socioeconomic, geographic, epidemiologic and health resources situations.

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Ranging of Priorities

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This is crucial because of limited resources. Criteria considered include ~Disease incidence or prevalence. ~Social importance. ~Age grp affected. ~Sequelae of the disease. ~Ease and cost of control. ~Economic importance.

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Setting objectives

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Objectives set for each priority problem, must be •S - Specific •M - Measurable •A - Achievable/Attainable •R - Relevant •T – Time bound

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Specification of technical interventions

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At this stage you specify how the objectives will be achieved. For each desired objective, specify the technical interventions required to make the prescribed impact. These interventions should consist of appropriate promotive, preventive, curative and rehabilitative services which would result in the desired changes.

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Constraints Analysis

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For each technical intervention specified, the major obstacles, bottlenecks and constraining factors likely to impede its implementation are identified. Specify various management approaches and other strategies which could be used to neutralise the effect of the identified constraints.

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Selection of strategies

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Priority Strategies are selected on the basis of their perceived cost-effectiveness, feasibility, cost-efficiency, logistics etc. Economic evaluation techniques are invaluable tools for the objective selection of priority strategies. This stage marks the end of Macro-Planning.

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Detailed programming & Resource Specification

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Also known as Micro-Planning, Action/ Operational/ Implementation planning. Specified interventions and strategies are translated into specific Activities and Tasks using the techniques of Activity Analysis & Task Analysis. For each strategy, it is to be clearly specified what exactly has to be done, by whom, where it should be done, when & with what resources. Gantt chart.

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Causes of ineffective planning

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•Lack of real commitment to planning by managers at all levels.•Lack of meaningful, feasible and verifiable goals and objectives.•Lack of hierarchical approach to the devt of plans such that plans at different levels do not “fit” each other.•Non-participation in the planning process by relevant officers.•Failure to develop sound strategies based on an accurate scanning of the environment.•Excessive dependence on past experience and failure to take account of both current and future changes in the environment.•Resistance to change.

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What is evaluation

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This is the process of assessing progress towards predetermined objectives. It involves judgement of values or results i.e. comparing what you have with what you want It is an invaluable management tool for improved decision-making at all phases in the life span of a programme from the planning phase, through implementation and after implementation. Evaluation may be defined as the process of collecting information through various methods so as to determine the relevance, adequacy, progress, efficiency, effectiveness, and impact of planned activities. Evaluation aims at detecting the successes, the failures and the weaknesses in a health programme. During evaluation, the manager learns from past experience & from all the information obtained. The valuable lessons so learned are fed-back into the system in order to improve the system or to improve current programme activities &/or for better planning of future programmes, as appropriate. Evaluation thus enhances the attainment of effectiveness and efficiency in the use of scarce resources.

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Planning vs Evaluation

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There is an intimate relationship between planning and evaluation. They have been called the Siamese twins of management. An unplanned action cannot be properly evaluated and evaluation is impossible without objectives. Good planning results in the specification of objectives which are measurable/quantifiable These measurable objectives serve as Standards against which attainment of the programme are evaluated.

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Types of evaluation

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1. Pre-programme Evaluation. 2. Monitoring Evaluation. 3. Impact Analysis. 4. The Management audit. 5. The Medical Audit & the Clinical Audit

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Pre-Programme Evaluation

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Aka Input/Relevance Evaluation. It is an assessment of a planned programme before the commencement of implementation in terms of its relevance, appropriateness, efficacy, and adequacy with regard to the objectives of the programme and the needs which the programme proposes to address. It tries to answer the following questions; ~Are the inputs adequate? ~Are the proposed strategies likely to be effective? ~Is the programme needed at all?

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Monitoring Evaluation

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Aka Process, Progress, On-going, Output, Formative or Efficiency Evaluation. It focuses on the on-going processes of service delivery and on service output. It is an assessment of a planned programme during implementation. It ensures that a programme is implemented according to planned resource inputs and standards of performance. It ensures that service output targets are met. It is an aid to the rapid identification of operational problems. It enables the manager to keep the programme on course by making the necessary adjustments in programme inputs and/or service activities so as to attain operational target. It tries to answer the following questions; ~Are the activities undertaken in a timely manner? ~Are the specified procedures being followed? ~Are the resources being used economically? ~Are the expected services being produced in the right quantity, quality, and on time?

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Impact analysis

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Aka Outcome, Summative or Programme review Impact Evaluation. The major concern here is with the long-term effect of the programme on the health status of the population served. It is an assessment of the programme effectiveness in meeting stated long-term goals and objectives.

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Management Audit

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This is a comprehensive appraisal of the management of the health programme as a whole from planning to evaluation. It focuses on all aspects of the health services system. It consists of a check-list of questions relating to specific management functions; eg were there measurable programme objectives?; How competent was the manager?; etc It may be short and simple or very elaborate.

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The Clinical and Medical Audit

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A combination of Process evaluation and impact analysis. The Clinical Audit is a systematic critical analysis of the quality of patient care particularly the procedures used for diagnosis & treatment, the use of resources & the resulting outcome for the patient. It is designed to safeguard the quality of clinical care and to improve resource allocation decisions. It enhances clinical decision-making & quality-assurance in patient care. The Medical Audit is a more comprehensive auditing of all aspects of patient care, clinical & non-clinical e.g. catering services, house keeping etc. Regular analysis of the quality of patient care is done routinely in the developed world.

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The Evaluation process

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Decide what is to be evaluated. Establish the desired norms & standards. Select the indicators. Observe performance. Compare performance with the standard. Conclude i.e. judge. Decide what action is necessary. Quick feedback of decision.

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What is the first step in implementation

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The first step in implementation is to mobilise and deploy effectively all the detailed resources required for the implementation of the programme.

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What is the organising function concerned with

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The organising function is concerned with the development of a formal structure of relating people & other resources in such a way that they all contribute maximally & cohesively to organisational effectiveness.

Front 44

Order

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When more than one person is involved in achieving a common objective, their grp effort must be organised or pre-arranged if it is to be maximally successful. To ensure an equitable division of labour & co-ordination of the efforts of all members of the team for maximum effect, order is absolutely essential in the assembly of personnel. This order, the result of the process of organising human resources is the ORGANISATIONAL STRUCTURE or ORGANOGRAM.

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Merits of good Organization

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Good organisation reduces friction, promotes harmony, avoids duplication & conflict, optimises the utilisation of talents & facilitates the cost-efficient realisation of the organisational goals.

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Organizing function

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•Delineation of authority or power; •Delegation, the process of entrusting sub-ordinates with tasks to be carried out on behalf of their superiors, assignment or distribution of responsibility for carrying out specified tasks; •Deployment of the resources required for achieving the assigned responsibilities; •Development of formal mechanisms for co-ordination of the various activities; •Setting up of communication channels (organogram).

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Principles of Organization

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1. The Classical approach. •Fayol’s Principles of Organisation. 2. The Newer approaches; •The behavioural approach. •The decision-making approach. •The mathematical or biological approach.

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Fayol's Principles of Organization

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•Objectives. •Authority. •Responsibility. •Discipline. •Unity of direction. •Unity of command. •Subordination of personal/individual interest to cooperate interest. •Span of control. •Division of works/Specialization. •Order. •Short chain of command/hierarchy. •Equity. •Coordination – voluntary & directed. •Remuneration. •Stability of tenure. •Centralization/Decentralization. •Initiative. •“Espirit de corps” – Team spirit.

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Obstacles to effective organization

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~Failure to plan programmes and specify objectives & strategies. ~Failure to clarify organisational relationships & roles so as to avoid conflicts & inefficiencies. To avoid this, it should be ensured that the organisational chart/organogram is well understood by all personnel & use of clearly written job descriptions. ~Failure to delegate authority. ~Granting of responsibility without commensurate authority. ~ Over-organisation resulting in bureaucratic “red-tapism”.~Organisational rigidity even in the presence of a realistic need for adaptation to a changing environment and situations. ~Failure to design formal mechanisms for co-ordination of activities.

Front 50

Components of the staffing function

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•Procurement of staff through; ~Recruitment ~Selection ~Placement ~Orientation ~Transfers and Promotion •Preparation through; ~Appraisal ~Training and development •Maintenance through; ~Leadership and Control

Front 51

Effective leading requires ___

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Effective leading requires managers to design or create a work environment which will encourage the harmonisation of the needs of individual health workers with the demands of the health organisation.

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What is motivation

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This is the inner impulse that drives or moves a person to act in a particular manner.

Front 53

The Need-Want-Satisfaction chain

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Needs -> Wants (goals) -> Tensions (unfulfilled desires) -> Actions -> Satisfaction

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Maslow's Hierarchy of needs

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Primary/Basic: physiological necessity for water, air, food, shelter, safety etc ie need for survival

Secondary: need to satisfy the social needs for love, friendship and companionship

Tertiary: need for self respect, the respect of one's peers and need for self fulfilment through development of powers and skills

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Potent motivators and Dissatisfiers

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Potent motivators include self improvement, recognition, achievement, responsibility, advancement. Dissatisfiers include poor interpersonal relations, inefficient administrations, poor leadership qualities, inadequate pay, poor working conditions. Motivation will not be effective in the presence of dissatisfiers yet removing them will not provide positive motivation.

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Basic approaches to motivation

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•Paternalistic – if people are happy with work conditions they will respond by performing well at work. •Classical – ties rewards to performance. •Participative management – people are more highly motivated & committed to organisational goals if they are involved in decision-making.

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What is leadership

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This is the ability of a manager to influence people to work with a sustained zeal towards the achievement of organisational goals. Leaders place themselves in front of the grp so as to facilitate and inspire the progress of the grp towards its objectives. They do not stand behind to push forward. Very few employees work with sustained zeal in the absence of leadership. Effective leaders seem to have the ability to inspire and motivate their followers.

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Traits of leaders

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Some studies have indicated a significant correlation b/w effective leadership and the following traits;

•Intelligence. •Self confidence. •Initiative.

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Leadership styles classified on the basis of Authority utilization

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1. Autocratic (Exploitative/Benevolent Authoritative) – leaders have very little trust in the subordinates, limit decision-making to the top and engage in downward communication only. Tends to discourage initiative.2. Democratic (Participative/Consultative) – leaders have substantial trust & confidence in subordinates, seek their opinion & use their ideas, communicate in all directions & encourage decision-making throughout the organisation. Preferred by majority of people. 3. Anarchic (Laissez-faire) – leaders have complete trust in the subordinates who have complete freedom of choice and can do as they like. Situational factors determine which type of leadership is most appropriate. The work to be done & personnel expected to do it decide which style is suited. Highly technical tasks, emergency situations, unskilled & unreliable personnel require Autocratic style. Anarchic style may be deployed when leading a highly competent, reliable & dependable team. The skilled leader varies his style to adapt to the prevailing circumstance.

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Factors that enhance leadership effectiveness

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•An awareness of the factors which make for leadership effectiveness and the ability to put this knowledge to practice. •(Empathy) The ability to place oneself in the position of one’s subordinates so as to better understand their feelings, attitudes and perceptions.• Objectivity in their dealings with subordinates, an unemotional analysis of facts, restraint even under provocation.

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Attributes of a good leader

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•A good leader must be able to influence or inspire others to follow. •Must be able to motivate to work with a sustained zeal to attain grp goals. •Must be able to combine all the three leadership styles. •Should carry other personnel along in decision-making.

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Skills of the effective manager

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• Human skills : the ability to work effectively with people, to build cooperative effort & stimulate team work. Requires a deep perception of self, peers, subordinates & superiors, emotional intelligence, critical thinking as well as sociological, psychological & anthropological knowledge & intelligence. •Technical skills : knowledge, understanding & practical proficiency in the technical aspects of management. •Conceptual skills : ability to visualise the organisation as a whole, the interaction between it’s constituent parts as well as the impact & the relationship of the organisation with it’s external environment against the background of the organisation’s mission & vision.

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What is control

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Control is very important in any system b/c of the fundamental role it plays in the effective & efficient attainment of organisational goals. Control is any process that guides activity towards some predetermined goal. The plan of work to be done on a health programme provides an invaluable framework for controlling the activities of the health team. Control cannot be achieved without comprehensive plans.

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Reasons for control

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Control is undertaken in order to: ~Ensure that work is done in line with set objectives, activities planned within the allotted time & with resources provided. ~Ensure that resources provided are adequate and are properly utilised (no wastage). Identify causes of work deficiencies & take immediate remedial action. ~Recognize the gaps in knowledge.~ Recognize and reward good performance.

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The control process

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~Establish standards. ~Measure performance against standards. ~Feedback of information on deviations found. ~Correcting the deviations.

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What is Supervision

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Supervision is the process of keeping surveillance over the performance of assigned tasks. The effective supervisor supports his/her subordinates, facilitates and helps them by providing a supportive climate i.e. a helpful work environment.

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Content of supervision

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The content of supervision should include deliberate and specific efforts to: ~Listen attentively, share experience, offer advice and new ideas ~Train on the job, teach, explain, suggest ways to improve ~Analyse & interpret, resolve problems ~Confront and discipline only when absolutely necessary

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Traditional managerial tools for the control process

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•Work plan. •Written instructions. •Work schedules. •Job descriptions. •Staff lists. •Check lists. •Records of usage and activity. •Reports of progress and activity. •Supervisory visits - personal observations & consultations. •Budgets & Expenditure. •Operational (Internal) audit.

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Modern managerial tools for the control process

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•Operational Research. •Time – Event Network Analyses e.g. PERT (Programme Evaluation and Review Technique). •Standing orders.

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Causes of poor work performance

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•Insufficient training.•Insufficient resources.•No clear job descriptions.•Unclear instructions.•Lack of reward for good work.•Non-supportive supervision.•Inter-personal problems and conflicts.•Personal problems of the worker.

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What is economics

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Economics is the study of the proper allocation and efficient use of scarce resources to produce commodities for the satisfaction of unlimited needs and wants.

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What causes scarcity of resources

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Scarcity of resources is due to dwindling economy, lack of political commitment, mismanagement of available funds, varied interests etc.

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What is health economics

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Health Economics is the application of tools & principle of economics in the funding of health care services and programmes.

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Basic issues of health economics

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2 basic issues of Health Economics are scarcity of resources & efficient utilisation of these scarce resources.

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What is health care financing

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Strategies for paying for healthcare expenditures.Involves: •mobilization of funds for health care •allocation of funds to the regions and population groups and for specific types of health care •mechanisms for paying health care

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What are the health care financing options

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1. General revenue or tax based (Government) – royalties and fees from the oil sector; general tax revenue : VAT and General sales tax, non tax revenue 2. Individual consumer expenditure (Direct out of pocket payments).3. Social health Insurance – This is compulsory universal or employment group-targeted insurance system financed by employee-employer payroll deductions. 4. Private health Insurance – Financed through private voluntary contributions to for- and non-profit insurance organizations.5. Community Financing – Collective action of local communities to finance health services through pooling out-of-pocket payments that can include a variety of payment methods such as cash, in-kind and partial or delayed payment.6. Donor funding – Financial assistance given to developing countries to support socioeconomic and health development. From international organisations eg UNICEF, WHO, Bill Gates foundation etc.

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What is health insurance

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This is a health care risk spreading mechanism in which the sick benefit from the healthy, & the poor from the rich.It is a formal pool of funds.

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What is capitation

Back 78

A term used in health insurance. Capitation is the payment per person registered whether he or she uses the service or not.

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Goals of health insurance

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•Efficiency – available resources are judiciously used to procure services.

•Equality – every member contributing to this pool of funds should have equal right to it.

•Improvement of the health status of the population.

•Affordability.

Front 80

Benefits of health insurance

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•The working population and employers will by regular payments ensure continued access to health care for the workers.•Risks are spread between those with high needs for health services and those with low needs.•Employers will gain a healthier work force by paying part of the cost of health insurance for their employees.

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Benefits of health insurance

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•The working population and employers will by regular payments ensure continued access to health care for the workers.•Risks are spread between those with high needs for health services and those with low needs.•Employers will gain a healthier work force by paying part of the cost of health insurance for their employees.

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When did the document concerning National Health Insurance Scheme become a legal document

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The document concerning NHIS became a legal document in 1999.

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Principle of NHIS

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Principle : To pull resources together from the rich and the poor, healthy and sick.

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Goals of NHIS

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•To mobilise resources.•To fund health care services.•To enhance quality of health care services.•To ensure affordability of health care services.•To ensure accessibility to health care services.•To improve general health status of Nigerians.

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Beneficiaries of NHIS

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•Regular formal employees – Government employees at federal, state & local levels.•Employees in private sector.•Spouse and 4 children up to 18yrs, and those up to 25yrs in formal education.•Additional beneficiaries – unemployed, disabled, children <5yrs, self-employed, prisoners, inmates of institutional homes.

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Scope of capitation paid services to be covered by NHIS benefit package

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~Curative care – including curative drugs and simple diagnostic tests.~Maternity care for up to 4 live births.~Preventive services – immunisation, family planning, antenatal & postnatal care.~Visual test without procurement of spectacles.~Consultation with specialists.~Hospital care in a public or private hospital in a standard ward for the 1st 21 days in hospital.~A limited range of simple & inexpensive procedures~Treatment of cancer, DM, TB & other chronic diseases excluded.

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Players in NHIS

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•Government – the employers or Govt contributes 10% while the employee contributes 5% of his salary to the pool of funds on monthly basis. The govt is the “Watch-dog”.•Health Maintainance Organisations (HMOs) – Registered by the govt, can be public or private and manage the pool of funds.

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Benefits of NHIS

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•Provides pool of resources.•Provides health care services.•Spreads risk evenly among the rich and the poor, the sick and the healthy.•Improved quality of health care services due to competition among health care service providers.•Ensures equity and quality of health care.

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Features of economic evaluation

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It is characterized by 2 basic features: costs & consequences of activities and choices as a result of scarce resources.

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Uses of economic evaluation

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1. Planning •Choose between competing interventions or program.•Determine whether a program might provide good value.•Distribute resources efficiently between programs.2. Evaluation •Determine whether a program provides good values. •Decide whether to continue, expand, reduce or end a program.

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Basic types of economic evaluation

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1. Cost minimization Analysis (CMA) or Cost Analysis (CA)2. Cost-benefit Analysis (CBA) 3. Cost-effectiveness Analysis (CEA) 4. Cost-utility Analysis (CUA)

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Coat minimization analysis

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Costs and consequences (outcomes) of 2 or more alternatives (health care interventions) are examined. The outcomes are assumed to be equal or identical i.e. outcome difference of the interventions are non-existent or unimportant. E.g. Herniorrhaphy as a day case or admission. The Economic evaluation is based solely on comparative costs. What is the decision making rule? Choose alternative which costs least

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Cost benefit analysis

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Used to compare alternatives with different consequences. Measures both the costs and the benefits of alternative programs and interventions in monetary units/terms. Benefit (B) must be greater than Cost input (C): B – C > 0 or B/C >1. Present Value of Benefit (PVB) must be greater than Present Value of Cost: PVB/PVC > 1. The objective is to choose the alternative with the highest sum of net benefits.

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Net present value

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NPV is the amount that would have been saved. If there is unlimited funds, all projects with positive NPV are chosen. If there is unlimited funds but mutually exclusive projects, project with highest NPV is chosen. If limited funds and project not mutually exclusive, projects yielding greatest benefits per unit of expenditure (B/C ratio) are chosen.

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Cost effectiveness analysis

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Costs are related to a single common effect which may differ in magnitude between the alternative programmes. Outcomes are measured in natural or physical units (e.g. heart attacks avoided, health goods utilized, deaths avoided, reduced morbidity…). It enables the health researchers to determine the optimal strategy to meet an objective. Results are stated as cost per unit of effect /effect per unit of cost. Cost Effective Ratio (CER) = Net costs/Net health Effect. Programmes with the lowest CER are chosen.

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Cost utility analysis

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Outcomes are measured in healthy years, to which a value has been attached. Allows comparism of different health interventions because the outcome is not the same. Incorporates considerations of quality & quantity of life using a common unit. Outcome is measured in the number of life years saved adjusted to account for loss of quality- adjusted life years (QALYs) or for loss of disability- adjusted life years (DALYs). Interventions yielding the most QALYs per unit cost would be of high priority. Parameters – daily normal activities, occupation, marital functions, life expectancy etc.

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Categories of material resources

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1. Expenditure/Consumable/Recurrent materials: used up within a short period of time e.g. disposable syringes & needles, drugs, cotton wool etc.2. Non-expenditure/Capital/Non-recurrent materials: lasts for several years and needs proper care and maintenance e.g. hospital beds, wheel chairs etc.

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Procedures in material resource management

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1. Ordering2. Storing3. Issuing4. Controlling/Maintaining

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Ordering

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Usually done by a senior staff.It requires past knowledge of the use of the material and the ability to estimate for future use.Parameters include; exact type of material required e.g. 5ml syringe, exact quantity of required items, expected place of purchase.The officer must be able to balance the required with the available resources and make cost estimate (a priority list is generated due to limited resources).

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Storing

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Chikito:There are usually 2 storage places;1. Main/Reserve Store – where equipment is specially kept.2. Storage at the place of use for materials used everyday.Invoice or delivery note must be properly kept and new items entered into store book (The Ledger Balance). Contents of the Ledger are date of receipt, reference no, place of purchase, no of invoice, qty of items.Ledger balance must be updated regularly.

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Issuing

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Involves 3 paper-work procedure;1. The Ledger Record.2. The Voucher – states the date, item issued only, who is responsible for the use and signature of the receiver.

3. Inventory

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Controlling and maintaining

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Controlling is applicable to expenditure equipment, & is necessary to avoid wastages.Maintaining is for non-expendable equipment.The officer-in-charge must be able to ensure that equipment are clean & dry, defects are reported immediately, & equipment are always returned to the correct place after use.Use of inspection check-list & schedule; checking what is present against inventory list, check consumable frequently, non-expenditure can be checked yearly, breakable materials eg thermometer need regular and frequent check ups.

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Components of essential drug management

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•Selection

•Quantification

•Financing and Cost recovery

•Procurement

•Storage and distribution

•Rationale drug list

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Selection

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Essential drugs are drugs that meet the demands of majority of the population.They are drugs which are;

•Highly efficacious

•Safe

•Acceptable

•Available in simple doses

•With long shelve life

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Quantification

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This done by using any of the 2 methods;•Morbidity records – check the patients register to identify the most prevalent disease in the locality.•Consumption records

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Financing and cost delivery

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Via Drug Revolving Fund (DRF).Introduced in 1987 as Bamako Initiative.

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Procurement

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•Ordering of procedures.

•Open Tender.

•Closed Tender.

•Direct Purchase.

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Storage and distribution

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Chikito:Storage – Drugs are stored in a well ventilated room, properly arranged and labelled. Drugs with the same action are put in the same section. There should be proper records of how drugs are coming in or given out.Distribution – Done by “Pushing” or “Pulling”. Pulling is preferred. Use the principle of FIFO/FEFO. First in First out; First expired First out

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Rationale drug use

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•Accurate diagnosis.•Specific treatment.•Correct dispensing of drugs. •Encourage drug compliance and give clear instructions to end users.•Avoids poly pharmacy.

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Medical officer of health

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A MOH is a registered medical practitioner with a postgraduate qualification in Public health statutorily responsible for the administration of health and health-related events/activities within an area of jurisdiction defined as a Local Govt. Area.

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First MOH in Nigeria

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First MOH in Nigeria was late Dr Isaac Oluwole.

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Functions of MOH

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Functions of the MOH are classified into Managerial and Technical functions.

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Managerial functions

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•Administration of the Health Dept. of the LGA as HOD.•Serves as Secretary of LGA Primary Health Committee.•Identifies needed personnel and does staff recruitment.•Attends management meetings at the LGA as HOD.•Training and re-training of staff members.•Staff welfare eg provision of transport, recommendation of staff for promotion. •Advocacy and collaboration with other sectors in the LGA.•Formulates programme for the year in accordance with Local Govt. policy guidelines.•Solicits for financial support from within and outside the Local Govt.•Reports to Local Govt. Chairman through the Supervisory Councillor for Health.•Enforcement of PHC laws within the LGA.

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Technical functions

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•Implementation of the health policies of the Local Govt.•Execution of programme for the year.•Writes monthly, quarterly and annual reports of activities of department.•Training of all categories of staff – TBAs, VHWs•Keeps records of all vital statistics – births and deaths.•Control of epidemics – investigating, sending samples to Lab. And instituting control measures.•Oversees the Ward Health system of the LGA.•Attends to patients and also does outreach clinical services on specified days.•Responsible for abatement of nuisance in the LGA eg refuse and sewage disposal sites.•Ensures basic sanitation.•Ensures immunization activities are carried out including maintenance of Cold chain.

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Health management information system

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A collection of personnel, procedures, instruments and data bases organised to develop and utilise information to facilitate decision making.HMIS are made operational by indicators.An indicator is a measure of performance which enables the assessment of progress towards the attainment of defined objectives.Computation of indicators requires the collection of data.

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Monitoring and evaluation of health care

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For comprehensive M&E of health care, minimum categories of indicators include;•Health policy indicators.•Health status indicators.•Socioeconomic indicators.•Provision and utilization of health care indicators.

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Philosophy of HMIS

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The availability of accurate, timely, reliable and relevant health information is the most fundamental step towards informed Public health action.For effective, mgt of health and health resources, govts at all levels have overriding interest in supporting and ensuring the availability of health data and information as a public good for public, private and NGOs utilization.

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Six operational levels of HMIS

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1. Home-based records;•Child health card < 5 yrs.•Personal health card > 5 yrs. 2. Community-based records – •VHW record of work using pictorial tally sheet.3. Health facility records – health activities tally sheets are compiled daily, monthly, annually for activities like immunisation, ANC, Family planning, nutrition/growth monitoring, OPD attendance, in-patient admissions etc. These compilations are forwarded to the LGA PHC dept. at monthly intervals.4. LG PHC dept – collation, analysis and dissemination of information from all health facilities in their area at quarterly intervals to SMOH, DPRS, State HMIS unit5. SMOH, DPRS – summarizes returns from all LGAs in the State for onward transfer to the Federal NHMIS unit every 6 months. 6.At the federal level there is collating, analysing and interpreting of health and health-related data on a national basis. They also provide support to the state health authorities in the devt of their information system.

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Organogram for National health management information system

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FMOH DPRS (NHMIS unit) --> SMOH DPRS (State HMIS unit) --> LGA M&E/HMIS --> Health Facility --> Communities

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Challenges in developing NHMIS

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•Lack of Federal, State, but to a lesser extent, LGAs investment to ensure availability of health data for decision making.•Duplication in existing health data sub-systems.•Backlog of unprocessed health data.•Lack of/inadequate resources for HMIS activities.•Poor computerization.•Lack of support for a strong coordinating central body.