Vol.3, No.6, 343-356 (2011)
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Assessment of strategic management practice of
malaria control in the Dangme West district, Ghana
——Article submitted to the West African College of Nursing for the award of a fellow
Adelaide Maria Ansah Ofei
School of Nursing, University Of Ghana, Legon, Ghana. adelaideofei@yahoo.com
Received 23 February 2011; revised 1 April 2011; accepted 6 April 2011.
Strategic management (SM) practice was as-
sessed in all HCFs both in the public and priv ate
and some chemical shops within the Dangme
West district using semi-structured question-
naires. In-depth interviews were carried out with
healthcare managers in their clinical setting.
The study utilized both qualitative and quantita-
tive methods in describing the SM practice.
Healthcare managers were using all the ele-
ments of SM in the management of malaria but
these were not holistically coordinated. Present
were short ranged informal planning based on
the objectives of NMCP and day-to-day opera-
tion of the HCFs especially with Ghana Health
Service facilities. Due to homogenous nature of
Dangme West district, management of culture
wasn’t given much attention by healthcare
managers though healthcare providers were
acutely aware of its importance to quality ser-
vice delivery. Competition was woefully absent
in the healthcare environment. No formal struc-
ture has been created for the management of
malaria control activities with the exception of
the involvement of Community Based agents.
The district was widely implementing all the
strategies of the NMCP with favourable outcomes.
Keywords: Assessment; Strategic Management;
Practice; Malaria Control; Dangme West
1.1. Background
The healthcare system in Ghana is con fro nted with the
formidable task of improving and guaranteeing the
health and well-being of all people living in Ghana. Such
a broad goal encompasses many specific objectives for
individuals and populations, e.g. increased life expec-
tancy, reduction in avoidable deaths and improvement in
quality of life. Recognizing that resources are never
adequate, a rethinking and restructuring of priorities is
inevitable at all levels. Thus, the health care system has
since independence gone through series of progressive
reforms intended to develop and improve public health
practice in Ghana. Prominent among these reforms, are
the adoption of Primary Health Care (PHC) concept,
creation of the Ghana Health Service by an act of par-
liament (Act 525), development of the Medium Term
Health Strategy (MTHS) and a 5-year Programme of
Work (PoW). In all these developmental approaches
malaria control has been given some form of promi-
Malaria as a public health challenge seems to be on
the increase globally with over 1 - 2 million deaths each
year. Over 90% of these are African children who due to
poor access to health care facilities and local perceptions
about the disease fail to seek prompt help. Indeed, ma-
laria is accredited to be a major cause of poverty and low
productivity especially in poor countries [19]. It is esti-
mated that the annual economic burden of malaria in
Africa is about US$ 1.7 billion or 1% of the Gross Do-
mestic Product. In Ghana, malaria is hyper-endemic and
accounts for more than 44% of reported out-patient visit
and an estimated 22% of under-5 mortality. Reported
cases however, represent only a small fraction of the
actual number of malaria episodes in the population be-
cause the majority of people with symptomatic infec-
tions are treated at home and not reported [11].
Malaria is a life threatening disease in individuals
with low or impaired immunity, but malaria is both pre-
ventable and curable. Ghana therefore, has identified
Malaria as one of its priority diseases targeted for con-
trol in the medium term. Resources are sent directly by
the National Malaria Control Programme (NMCP), with
support from the Global Fund, Development Partners,
etc. to the district for the management of malaria and
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other diseases of public health concern to help strengthen
decentralization (MTHS, 1995). For instance available
data at the NMCP office showed that from 2004 to 2006
first quarter, a total of thirty thousand and one dollars,
ninety seven cents ($30,001.97c) was sent to the
Dangme West district health directorate for malaria con-
trol activities. The issue is, what management processes
have these healthcare managers (HCMs) put in place to
cope with the increasing trend of morbidity and mortal-
ity associated with malaria? Strategic management (SM)
according to Duncan [10] is a major thrust that would
guide the management of healthcare organizations to
anticipate and cope with the variety of external forces
operating beyond their control.
“Strategic” is the most overused word in the vocabu-
lary of business. Frequently, it is just another way of
saying, “this is important”, but the aim of true strategy is
to master environment by understanding and anticipatin g
the actions of other economic agents, especially com-
petitors [16]. A strategy to a program is amongst other
things a plan of how the program can achieve its goals
and objectives [6,26]. It is a ‘commitment of present
resources to future expectations’ [9]. The aim of SM is to
decide on program goals, the means of achieving those
goals, and ensuring that the program is sustainably posi-
tioned in order to pursue these goals. Furthermore, the
strategies developed provide a base for managerial deci-
sion making [3,32,31].
1.2. Statement of the Problem
As GHS continues with its decentralization process,
resources are being disbursed directly to the district for
the delivery of healthcare services. For example, finan-
cial data at the Dangme West DHD showed that between
2005 and 2006 firs t quarter the NMCP/Global Fund sent
twenty thousand, six hundred and thirty dollars, seventy
six cents ($20,530.76c) to the DHD for malaria control
activities. It is however, uncertain what structures the
districts have developed to manage the health system in
coping with the increasing malaria morbidity and mor-
Malaria is a public health problem which no doubt
accounts for a substantial disease burden in the Dangme
West and for many years various control measures have
been undertaken with limited success. The percentage of
reported cases of febrile illness presumed as malaria at
the OPD has consistently risen over a period of five
years (2002-2006) with annual OPD reported cases of
17,675 to 30,070. Current percentage rate of reported
cases of febrile illness presumed malaria at the OPD was
51 percent [8], which was just the tip of ice-burg be-
cause most people managed uncomplicated malaria at
home. What management processes have the HCMs
practiced all this while and how have they managed in-
creased morbidity and mortality in malaria control?
What are the outcomes of the efforts exerted by HCMs
in malaria control?
This study describes the extent to which SM process
is being used to manage malaria control in the Dangme
West district. There are numerous decisions and actions
that managers and administrators take in the course of
operating a development program. While all of them
have an impact on the direction of the program and its
outcome, certain interventions by the government and
the program leadership is critical in that they prov ide the
basic framework for operational decisions and set the
pace for program performance. This means that for ef-
fective and efficient malaria control, we should go be-
yond the leadersh ip, reso urces and political commitment
bit and use holistic approach or the SM approach in the
management of malaria within the district as suggested
by Paul [30].
Pertinent questions that need to be asked in this study
are what management processes have the district devel-
oped for malaria control and how has management
thought their way out to cope with increasing morbidity
and mortality of malaria? The reason for using the SM
model was that this area has not been studied in depth
although it is a promising area.
1.3. Objective
To evaluate the extent to which the practice of SM is
fully integrated into the management principles of GHS
at the district levels and to make recommendations for
1.4. Significance for the Study
SM when applied at th e district level will give a holis-
tic approach to management such that malaria control
programmes can wholly be linked to their environment
with realistic objectives and packages that can always be
verified. It will also ensure appreciable handling of the
three major spheres of administrative responsibility of
HCMs namely, day-to-day operations, management of
the culture of the healthcare facility (HCF) and man-
agement of strategy. All th ree must coexist and synergize
each other for optimal performance or output.
The district is the operational level of the GHS. It is
the operational level where all decisions concerning the
delivery of healthcare are implemented. The study will
provide knowledge about issues and needs of district
health system management and directions for SM in
malaria control. It will let the membership of district
health management team (DHMT) appreciate the im-
portance of their environments especially, the concept of
A. M. A. Ofei et al. / Health 3 (2011) 343-356
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competition. Develop a common sense of purpose and
shared values with the community thus, improving ef-
fectiveness and efficiency of malaria control program
within the district since malaria is a developmental issu e.
It will encourage management training for all healthcare
providers regardless of the size and site of the HCF.
Furthermore, it will provide literature for further studies
in this area.
1.5. Literature Review
SM can be defined as a continuous, iterative process
aimed at keeping an organization as a whole appropri-
ately matched to its environment [5]. It is a process of
making explicit the goals of the enterprise, the environ-
ment in which it operates, the strategies, and finally the
feedback loops that tell the firm whether each of these
steps has been identified correctly [37]. One important
element of SM process is the development of a vision for
the organization by top management. SM is in large part,
a decision-making activity. Strategy therefore, is the re-
sult of a series of managerial decisions often supported
by a great deal of quantitative data. Strategic decisions
are fundamentally judgemental and generally the more
important the decision, the less quantifiable it is and the
more it is reliant on opinions of others [10].
Vision according to Hussey [20] is an expression of
hope and is simply regarded as statement of basic prin-
ciples that governs the direction in which a program
seeks to develop. Critical to management is the choice of
objectives which provides guidance and unified direction,
facilitates planning, inspires motivation and commitment,
and promotes control [17]. Multiple objectives are usu-
ally pursued in a homogenous environment whereas sin-
gle-service strategy is pursued in diverse environment
where uncertainty in relation to market or public re-
sponse is high [30]. Mintzberg [26] acknowledged that
informal planning is an implicit strategy worked out by a
dominant leader without the support of a formal process
which is a highly ordered logical process developed
purposefully for developmental programs. Formal plan-
ning becomes increasingly important to programs when;
their markets stop growing, there is increase in competi-
tion and the rate of environmental change is dramatic
[10]. Hussin [18] asserted that long-range planning and
strategic thinking is common to most HCMs but not SM
which is still vague to many managers. External envi-
ronmental analysis is a process for understanding the
external environment of organizations and acts as a
window through which, HCMs can view external envi-
ronment for information and/or issues [10] and develop
packages to satisfy consumers.
Internal involvement of staff in the exposition of the
planning processes and inter-institutional communica-
tion patterns between top and bottom layers of the HCFs
according to Hussin et al. [18] are strategies used to re-
duce resistance. Implementation is critical, in that if
planning is creative and brillian t but strateg ies are poorly
implemented, little is likely to change. Technical and
financial support to districts for situation analysis ac-
cording to Teklehai manot [38] is to ensure that interven-
tions will be adapted to local needs which will be sus-
tained after RBM support. Interventions required ade-
quate resources but Duncan et al. [10] acknowledged
that although financial resources are important reality
checks to strategic decision making, the vision of man-
agement should not be limited by the financial resources
available. Duncan et al. [10] reiterated that there are
dedicated personnel whose attraction to the field goes
beyond monetary rewards and is mostly focused on
some of the “strategic uniqueness” of healthcare. These
strategic unique characteristics of the healthcare are in-
spiration-related currencies, task-related currencies, po-
sition-related currencies, relationship-related currencies,
and personal-related currencies.
As malaria morbidity and mortality continues to in-
crease in most countries in Africa, international agencies
and malaria control program managers have identified
the strengthening of program evaluation as an important
strategy for improving the efficiency and effectiveness
of malaria control programs [4]. Evaluation helps man-
agers to account for the investment made, refine strate-
gies and identify and correct flaws in program imple-
mentation. It provides decision-makers with the required
tools for refined planning and modified strategies by
updating on progress, as well as any problems or con-
2.1. Study Area
The Dangme-West District is located in the south-
eastern part of Ghana, in close proximity to Tema, the
country’s largest seaport, and Accra, the capital city. It is
the largest district (about 1,700 square kilometers) in the
Greater Accra Region and its capital is Dodowa. The
district is one of the two rural districts in the Greater
Accra region which has not yet been caught up by the
rapid urbanization of the peripheral areas surrounding
the city of Accra. The Dangme West district according to
Ghana Statistical Survey [13] is extremely poor and pre-
dominantly rural with both poor socio-economic and
infrastructural development [22] making financial access
to health quite difficult. The district is sparsely popu-
lated with most inhabitants living in scattered small
communities less than 2,000 people, sometimes with
very poor road access which gets worse in the rainy
A. M. A. Ofei et al. / Health 3 (2011) 343-356
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district reports and documents for the past five years to
enrich information for the study.
season. The district was selected for the study because it
is among the first 20 districts that implemented the RBM
programme suppor ted by the Global Fund. 2.3. Stud y Population
2.2. Stud y Design The study population was all persons who provide
healthcare services in the Dangme West district. All
HCFs in the district; both public (n = 10) and private
(n = 5) and all chemical shops (n = 25) in the district.
All HCMs in the 15 HCFs took part in the study. Pur-
posive sampling was used to select 17 chemical sellers
out of 25 chemical shops from the communities se-
lected for the study due to the vast nature of the district
and money constraints. The list of chemical shops in
the district was collected from the president of the
chemical sellers association in his pharmacy shop at
Dodowa. Those who couldn’t participate were shop
assistant or attendants who could barely write and/or
had little or no knowledge on current trends in malaria
control practices.
The study was a cross-sectional exploratory descrip-
tive study of the processes for the management of ma-
laria control activities in the Dangme West based on the
conceptual model (Figure 1). The stud y used both quan-
titative and qualitative methods of data collection in as-
sessing strategic management practice. The researcher
held semi-structured in-depth interviews with all the in-
charges of HCFs and operators of chemical shops. These
respondents were termed as HCMs for the study. Fur-
thermore, discussions were held with the district phar-
macist, the Global Fund representative of the district and
the Public Relation Officer at the district assembly to
gather information on managerial support to malaria
control. Additionally, there was desk review of annual
Status of key malaria control
Vision of NMCP,
Mi ssi on/ Op era t io na l g oal s
of NMCP,
Objectives of NMCP
External an alys is of the
(Opportunities and threats)
Inte rn al analys is of
heal t h ca re facili t y
(Strengt hs and weakness)
Pla n ning pr oc e s s f or ma l a r ia co nt rol program wou ld gen er a te
strategies a nd activities for the program
Promotion of N MCP objectives
Implementation of planned strategies and activities of malaria control
Monito ri ng and eva luation of s t rategies and
activities of malaria control
Figure 1. The conceptual framework.
Openly accessible at
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2.4. Data Analysis
Analysis of data was both qualitative and quantitative
using the SPSS 12.0.1 for Windo ws, (2003 ) and Epi-info
™ version 3.3.2 for windows, (2005). Qualitative data
was analyzed manually by grouping, themes, sub-themes
and trends after collating all data. After the question-
naires have been checked for consistency, they were
coded and entered primarily into Epi-info. The Epi-info
data was later transferred into the Excel Spreadsheet
then to SPSS software for analysis using a number of
descriptive statistical techniques such as, cross tabula-
tion, simple frequency tables, means, bar charts and pie
chart to describe the various dimensions of the SM
2.5. Ethical Consideration
At the district, consent was sought from all those who
were involved in the study particularly from the DHA,
chiefs and opinion leaders of the selected communities
and the district assembly. Confidentiality an d anonymity
was maintained throughout the study.
Out of the 32 HCMs 16 (50.0%) were chemical sellers,
whereas, 8 (31.3%) were nurses, 34.7% of the HCMs
were beyond the age of 50 years. The conduct of the
situational analysis involved both internal and external
analysis of the HCFs and is the building blocks of stra-
tegic planning for managing malaria control activities in
the district. Information presented below informs the
HCMs on the strengths and weaknesses of their HCFs
and the opportunities and threats within their environ-
ments. This is used to formulate strategies towards
management of malaria control within the district. Out
of 32 HCMs interviewed, all the 10 in the public HCFs
representing 41.7 percent could state the vision of
NMCP, again, all 5 (20.8%) in the private HCFs knew
about the vision of NMCP. Whereas, out of the 17
chemical sellers interviewed, 9 (52.9%) knew the vision
of NMCP. Vision of the HCFs was found displayed in
only 2 facilities and it was a replica of the vision of the
parent organization.
Though an operational strategy hasn’t been developed
by many of the HCMs, but because malaria is a house-
hold or common disease, intuitively they effectively
communicated their ideals through the following strate-
gies. Out of the 32 HCMs, only 5 (15.6%) have devel-
oped operational strategies for the control of malaria.
None of the 17 chemical sellers have developed opera-
tional strategies for malaria control because they were
interested only in selling their drugs and not p articularly
interested in any one disease condition. Operational
strategies developed by the HCMs for management of
malaria vividly expressed the intent of management to-
wards healthcare delivery. The HCMs acknowledged
their desire to give quality care to their clients, ensuring
that all the tenets of NMCP were strengthened. The op-
erational strategy of malaria control was given by Miss
Cee HCM in a private-not-profit facility as:
To provide quality care in the most effective and in-
novative manner especially in the areas of curative,
preventive and promotive health care to the community
we serve at all times acknowledging the dignity of the
Similarly, Madam Aggie, HCM of public healthcare
facility stated:
To give quality care, education and effective manage-
ment, and to ensure all cases are treated with Artesu-
nate-Amodiaquine and encouraged children under five
and pregnant women to sleep in ITNs.
Communication of operational strategies has been
outlined below and the media was sparingly used as
compared to the other mediums of communication.
The NMCP have designed a set of objectives to ensure
uniformity in the organization, coordination and imple-
mentation of the activities of malaria control within the
districts. There was keen interest of HCMs in both pub-
lic and private HCFs in meeting these objectives. The
implementation of these objectives was ardently super-
vised by the district health administration regularly.
The Ta bl e 1 shows that the most common tools used
in the planning process were community assessment
(68.8%), objectives set by the NMCP (56.3%), SWOT
analysis (40.6%), make reference to previous objectives
with some analysis (50.0%), information technology,
expert opinion and finally through scenario building.
This indicated that management of malaria in the district
was both community and NMCP related.
Out of the 32 HCMs, 56.3 percent (18) used objec-
tives set by the NMCP for their planning process; 9 (50.0
percent) from the public, 4 (22.2 percent) from the pri-
vate and 5 (27.8 percent) from the chemical sellers. Ad-
ditionally, out of the 32 HCMs, 40.6 percent (13) used
the SWOT analysis; 7 (53.8 percent) from the public, 3
(23.1 percent) from the private with 3 (23.1 percent)
being chemical sellers.
Environmental factors were analyzed by HCMs to
identify opportunities and threats within their environ-
ment. Whereas HCMs in both public and private HCFs
were really concerned about the socio-economic back-
ground of healthcare consumers, ironically the chemical
sellers were not bothered. The concept of competition
was nonexistent for the HCMs, even the chemical sellers
who were business entities. I would recount an amazing
incident that chan ced during the interview of Miss Bee a
HCM and her colleague at Osudoku sub-district:
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Table 1. Management tools used in the situational analysis.
Tools Percentage Public Private Chem. shop
Information technology 32 (100%) 8 (25.0%)
Scenario building 32 (100%) 3 (10.7%)
Expert opinion (Consultants) 10 (31.3%)
Make reference to previous objectives with some analysis 16 (50.0%) 8 (50.0%) 2 (12.5%) 6 (37.5%)
Make use of objectives of NMCP 32 (100%) 18 (56.3%) 9 (50.0%) 4 (22.2%) 5 (27.8%)
SWOT analysis 32 (100%) 13 (40.6%) 7 (53.8%) 3 (23.1%) 3 (23.1%)
Community assessment 32 (100%) 22 (68.8%) 10 (45.5%) 4 (18.2%) 8 (36.4%)
Source: Healthcare facility survey
Having just answered in the negative about competi-
tion, a drug peddler carrying his wares passed by. The
peddler took some time in exchanging pleasantries with
the healthcare manager before continuing on his mission.
Then I asked her: You claimed there are no competitors
here, what about the peddler who just passed by? Is he
not offering some form of healthcare? Don’t you have
chemical sellers around? Are they not treating malaria?
All these questions were answered in the affirmative. She
then admitted that both the activities of chemical sellers
and drug peddlers posed a great challenge for malaria
contro l within the community.
Generally, the HCMs utilized most of the environ-
mental factors especially the political, social, regulatory
and epidemiological factors in coming up with plans for
malaria control. Opportunities identified by HCMs
within their environment that enhanced malaria control
were generally community participation, interpersonal
relationship between staff and clients, extensive use of
ITNs, research on rectal Artesunate for children under
five and involvement of CBAs in home-base care. Teyi,
a HCM of a private HCF in the Prampram sub-district
recalled opportunities as:
Good interpersonal relationship between staff and
clients urged them to openly discuss their problems,
there were also organized groups such as churches,
youth clubs, schools, etc., which makes BCC a whole lot
easier. Finally the involvement of community based
agents in home-base care greatly influenced incidence of
malaria in the under fives.
Miss Adotey a HCM of a public HCF on her part
Community members’ are always in haste to identify-
ing health problems for healthcare providers to solve
and their eagerness to learn innovative ideas concerning
malaria control. There is again, overwhelming collabo-
ration between the healthcare facility and the communi-
ties, extensive use of ITNs, communal spirit of most
communities, and research on rectal Artesunate for chil-
dren under five years by the HRU; and administration of
rectal Artesunate suppositories to under five-year olds
by the CBAs.
Whereas Mr.Kweinor a chemical seller at Ayikuma
Education of the community on home-base care by the
DHD, education of market women and the HE-HA-HO
programme by the NMCP on radio have increased the
knowledge-base of the people on malaria. Environmen-
tal cleanliness is also encouraging.
Threats basically were challenges that impinged on
the success of intended objectives. Generally threats
identified by the HCMs ranged between environmental
sanitation to unemployment, poverty and illiteracy.
Threats as retorted by Dr. Kwei a HCM in Prampram
sub-district were abound and he remarked:
Since this community is still growing, new buildings
are springing up with open trenches all over the place
which collect water when it rains thus, creating a con-
venient environment for the breeding of mosquitoes.
Again, there are no toilet facilities in the communities,
so individuals dig holes which become breeding places
for mosquitoes.
Miss. Ayi also in the Prampram sub-district described
threats identified as:
The activities of chemical shops and drug peddlers,
unemployment, poverty, increase in the premium of the
National health insurance scheme; high illiteracy rate,
lack of transportation and portable water in some com-
Similarly, Miss Lee at Osudoku sub-district re marked:
The rice farms in the community breed a lot of mos-
quitoes. The choice of medicine to use for malaria is
crucial since there are several options at the chemical
shops that are relatively cheaper than the recommended
drug for malaria by the government.
Mr. Tetteh a chemical seller in the Ayikuma sub-dis-
trict declared:
Unemployment with its associate effects of poverty
has been a major hindrance in the purchasing of rec-
ommended drug Artesunate-Amodiaquine which, they
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considered expensive. There are a lso pit latrines all over
the communities and these are potential places for
breeding of mosquit oes.
At Old Ningo Mr. Agyeman a chemical seller had this
to say:
There are no gutters in the community thus; there are
pools of standing water all over the community with
reckless disposal of refuse also compounding the already
compromised situation. Most people are illiterates and
there is no communal spirit.
Mr. Akoto also a chemical seller acknowledged that:
The choice of medicine to be used is a major threat to
the control of malaria. Clients always come with their
demands and preferences, which usually depend on af-
fordab ility. They reckon ed that the recommended drug is
too expensive for the ordinary man hence, their reliance
on other equally efficacious alternatives such as the
herbal preparations.
Methods used for assessing strengths and weakness
within the HCFs and conducting community assessment
are outlined in Table 2.
Facility strengths identified by HCMs generally were
availability of recommended drugs for the management
of malaria, relatively moderate fees charged for service
delivery, promotion of the tenets of NMCP and knowl-
edgeable staff. This was expressively put by Dr. Nartey a
HCM in Prampram as:
We are always ready to receive clients and there is
good relationship between clients and us. We charge
relatively low fees and clients spend less time at the clinic.
Again, we have in stock most of the drugs for malaria.
Similarly Miss Agartha, a HCM in Ayikuma remark-
We have adequate logistics; provision of free ITNs,
provision of free folic acid, and Artesunate Amodiaquine
for one year. Additionally, we have stocks of antima laria
drugs e.g. Quinnee, Artesunate and Amodiaquine.
Mr. Dakey a chemical seller in Asutuare said:
The experience gained from persistent training en-
sured delivery of quality service to clients and I have in
stock adequate drugs for the management of malaria.
Miss Adotey a HCM in Dodowa declared:
Our staff ensures that clients receive quality care thus;
there is good staff-client relationship. We have available
all malaria drugs and laboratory facility for confirma-
tion of the diag nosis of malaria.
Facility weaknesses identified by HCMs were inade-
quate quality and quantity of staff; inadequate logistics;
no definite plan for the program; inadequate finance;
inadequate motivation of staff; insensitive attitude of
some staff; infrequent in-service training for staff; and
lack of privacy. Attitude toward risk was non existence,
and all 32 HCMs declared they did not encounter any
risk in either planning or implementation. Almost all
staff especially those in the public HCFs were involved
in the planning process whereas in the private and
chemical shops only the HCMs did the planning.
Out of the 32 HCMs, 3 (9.4 percent) did have formal
plans, 18 (56.3 percent) had informal plans whereas 11
(34.4 percent) had both formal and informal plans. Even
the 3 HCMs with formal plans could not readily produce
their plans.
Table 2. Methods used for internal auditing.
Type of healthcare facility
Method Public Private Chemical shop
Total (n = 32)
Utility rate 6 (46.2%) 5 (38.5%) 2 (15.4%) 13 (40.6%)
Government assessment 8 (42.1%) 5 (26.7%) 6 (31.6%) 19 (59.4%)
Measuring the market share 5 (38.5%) 3 (23.1%) 5 (38.5%) 13 (40.6%)
Studying the gap 9 (50.0%) 4 (22.2%) 5 (29.4%) 18 (56.3%)
Benchmarking other facilities 4 (40.0%) 2 (20.0%) 4 (40.0%) 10 (31.3%)
Perception testing of key constituency groups 8 (53.3%) 3 (20.0%) 4 (26.7%) 15 (46.9%)
Community assessment
Activity parameters of the facility 5 (50.0%) 4 (40.0%) 1 ( 1 0 % ) 10 (31.3%)
Simple on-going conversation 7 (33.3%) 5 (23.8%) 9 (42.9%) 21 (65.6%)
Informal gathering of local leaders 6 (40.0%) 4 (26.7%) 5 (33.3%) 15 (46.9%)
Structured questionnaire 4 (36.4%) 2 (18.2%) 5 (45.5%) 11 (34.4%)
Focus group discussion 6 (46.2%) 3 (23.1%) 4 (30.8%) 13 (40.6%)
Healthcare facility’s discharge data 9 (56.3%) 4 (25.0%) 3 (18.8%) 16 (50.0%)
Traditional database and health statistics indicators 4 (44.4%) 2 (22.2%) 3 (33.3%) 9 (28.1%)
Source: Healthcare facility survey
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Out of the 32 HCMs, 17 (53.1 percent) developed
plans for malaria every year. 6 (15.6 percent) asserted
the duration of their plans were two years while 2 (6.3
percent) had five-year plan for their HCFs. The remain-
ing 8 (25.0 percent) HCMs declared they neither had
plans nor duration for their plans. The mean duration
period was 1.5years. Out of the 32 HCMs, 2 (6.3 percent)
had annual planning meetings. 1 (3.1 percent) had semi-
annual meetin gs, 9 (28.1 percent) had quarterly meetings
while 10 (31.3 percent) had monthly meetings. For 10
(31.3 percent) of the HCMs however, planning meetings
were contingent and usually ensued as situation de-
The first barrier towards implementation in any de-
velopmental program has been resistance to change. Out
of the 32 HCMs interviewed, 4 (12.5 percent) admitted
to facing much resistance to change, 9 (28.1 percent)
claimed they faced little resistance, while 15 (59.4 per-
cent) asserted to facing no resistance during implemen-
HCMs remarked that factors relevant to implementa-
tion of malaria control were leadership, training, ade-
quate resources, and organizational culture. See Ta bl e 3
for detailed description. The factor that ostensibly im-
pacted on implementation of malaria control was lead-
ership; the use of non coercive influence to shape the
HCF’s goals, motivate behaviour towards the achieve-
ment of goals and help define organizational culture.
Out of the 32 HCMs, 23 (71.9 percent) had their staff
trained and delegated the authority needed to produce
the quality of healthcare services demanded. All the 10
(43.5 percent) public HCMs had their staff trained, 4
(17.4 percent) of the private HCFs also had their staff
trained whereas, 9 (39.1 percent) of the chemical shops
had their staff trained too. 9 (29.0 percent) HCMs had
adequate number of qualified clinical staff on duty at all
times to ensure that clients receive prompt and high
quality healthcare services. Frequency of In-service train-
ing offered to staff to upgrade knowledge, skills and at-
titude ranged between quarterly 9 (28.1%), annually 8
(25.0%), twice a year 7 (21.9%), weekly 2 (6.3%), thrice
a year 1 (3.1%), twice in three years 1 (3.1%) to none 4
(12.5%). Most of the chemical sellers either had annual
training 8 (47.1%) or had training twice a year 5
Out of 32 HCMs, 15 (46.9 percent) had flexible cul-
tures, 4 (12.5 percent) had very flexible cultures, while
the 3 (9.4 percent) had a rigid, and 1 (3.1 percent) had
very rigid cultures. 9 (28.1 percent) had somehow neu-
tral culture for malaria control. Leadership style pro-
moted in the HCFs according to the 32 HCMs were
management team leadership style 18 (56.3 percent), and
the combined style of leadership 12 (37.5 percent). An-
other fact was that all HCMs who pursued a combined
style of leadership also had flexible cultures. The chi-
square was 13.338 with a p-value of 0.345. F-statistics
was 3.937 with a p-value of 0.047, and a correlation co-
efficient of –0.207.
Implementation of malaria control within the facilities
was done through the assignment of responsibilities for
each aspect of the plan 13 (40.6 percent), trust and open
communication 12 (37.5 percent), establishment of rela-
tionship among people 11 (34.4 percent) and finally
delegation of authority 6 (18.8 percent). Management of
malaria control was carried out in such a way that it pro-
vided staff with a sense of security, au tonomy and at the
same time motivation (91.7 percent). This was done by
giving incentives, open recommendation of staff, re-
warding extra work, and verbal encouragement of staff.
Arguably almost all the HCFs had in place similar moti-
vational strategies. One important factor was the zeal of
healthcare providers to see that everything was in order,
thus, even when there were no incentives, work was ac-
complished without any hindrance. The regular work-
shops on malaria organized to upgrade knowledge, skills
and attitude equally enhanced competence, commitment
and confidence. Furthermore, appraisals and good inter-
personal relationship between management and staff
ensured contentment among colleagues.
Table 3. Factors that impact on implementation of malaria control.
Factor Most imp. Imp. Least imp. Total
Leadership 19 (59.4%) 7 (21.9%) 6 (18.8%) 100
Training 19 (59.4%) 7 (21.9%) 6 (18.8%) 100
Motivation 10 (31.3%) 10 (31.3%) 12 (37.5%) 100
Adequate resources 15 (46.9%) 5 (15.6%) 12 (37.5%) 100
Need to build Information sys tem 16 (50.0%) 6 (18.8%) 10 (31.3%) 100
Organizational culture 10 (31.3%) 7 (21.9%) 15 (46.9%) 100
Organizational structure 11 (34.4%) 8 (25.0%) 13 (40.6%) 100
Source: Community Survey
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Out of the 32 HCMs, 18 (56.3 percent) had their staff
trained on the strategies of NMCP, basic S&S and man-
agement; 9 (50.0 percent) from the public HCFs, 5 (27.8
percent) from private with 4 (22.2 percent) being
chemical sellers. 17 (53.1 percent) out of the 32 HCMs
did also involve opinion leaders, district assembly and
religious institutio ns in their BCC; 8 (47.1 percent) from
the public HCFs, all the 5 (29.9 percent) private HCFs
and 4 (23.5 percent) from chemical shops.
Out of the 32 HCMs, 14 (43.8percent) had standard
case definition of malaria developed and pasted at van-
tage points within their HCFs; 8 (57.1 percent) from the
public, 4 (28.6 percent) from the private and 2 (14.3
percent) chemical sellers. 18 (56.3 percent) HCMs out of
the 32 persistently carried out BCC on malaria preven-
tion within the communities; 9 (50.0 percent) from the
public HCFs, 3 (16.7 percent) from the private HCFs
whil e 6 (33.3 percent) were chemical sellers.
Out of the 32 HCMs, 14 (43.8 percent) would request
for laboratory test for confirmation of diagnosis; 7 (50.0
percent) were pu bl i c HCFs , 5 (35. 7 p ercent) were private
HCFs while 2 (14.3 percent) were chemical shops. Other
measure identified was the requisition for blood film for
malaria parasites (BF) for pregnant women before SP
was given when clients develop malaria by 1 public
healthcare manager. 14 HCMs representing ( 43 .8 percent)
out of the 32, acknowledged the involvement of school
children in their BCC; 7 (50.0 percent) from the public
HCFs, 3 (21.4 percent) from the private HCFs while 4
(28.6 percent) were chemical shops. 12 (37.5 percent)
HCMs out of the 32, developed and distributed simpli-
fied case definition of malaria leaflets to households; 7
(58.3 percent) from the public, 1 (8.3 percent) from the
private HCF whereas 4 (33.3 percent) were chemical
Systems developed to ensure appropriate response and
referral has been enumerated in Ta bl e 4. Prompt atten-
tion to emergency cases and provision of approved
treatment was important to the groups. In almost all the
HCFs visited, protocols for case management of malaria
were visibly displayed on the walls. Some HCFs had
drugs such as Artesunate suppositories, Folic acid and
iron tablets free for children under five-years and preg-
nant women. See Table 5 for detailed description.
Table 4. Systems developed for appropriate response and referral.
Type of healthcare facility
System Public
(n = 10) Private
(n = 5) Chem. shop
(n = 17)
(n = 32)
Protocol for malaria case management in al l c l i n ical areas 9 (60.0%) 4 (26.7%) 2 (13.3%) 15 (46.9%)
Provision of approved malaria treatment in the facility 9 (50.0%) 4 (22.2%) 5 (27.8%) 1 8 (56 3%)
Prompt attention to emergency cases 9 (42.9%) 5 (23.8%) 7 (33.3%) 21 (65.6%)
Effective system of referral 9 (56.3%) 5 (31.3%) 2 (12.5%) 16 (50.0%)
Source: Survey of Healthcare Facilities
Table 5. Measures for delivering quality healthcare services.
Type of healthcare facility
Measures Public
(n = 10) Private
(n = 5) Chem. shop
(n = 17)
(n = 32)
Effective use of performance appraisal to identify Staff needs for
subsequent training 4 (50.0%) 2 (25.0%) 2 (25.0%) 8 (25.0%)
Patients are given prompt attention 9 (37.5%) 5 (20.8%) 10 (41.7%) 24 (75.0%)
Patients are always given all their treatment at the facility 10 (52.6%) 5 (26.3%) 4 (21.1%) 19 (59.4%)
Improved staf f at ti tu de t o cl ie nt s 8 (44.4%) 4 (22.2%) 6 (33.3%) 18 (56.3%)
Horizontal integration with some agencies within the community to
ensure easy access to resources 1 (20.0%) 3 (50.0%) 1 (20.0%) 5 (15.6%)
Provision of incentives 1 (16.7%) 4 (66.7%) 1 (16.7%) 6 (18.8%)
Open recommendation of hard working staff 7 (46.7%) 5 (33.3%) 3 (20.0%) 15 (46.9%)
Source: Facility Survey
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HCMs asserted that clients’ concerns were acknowl-
edged through friendly attitude of staff towards clients
which coaxed them to air their grievances to them when-
ever possible; they also questioned clients about effec-
tive use of drugs or provision of other services. Addi-
tionally, complaints were sometimes lodged with opin-
ion leaders or the assemblymen, following-up of cases,
and open discussions during staff or advisory board
meetings. Apart from Dodowa HCF that had a sugges-
tion box, the remaining HCFs basically resorted to in-
formal measures in soliciting for clients’ concerns.
Qualitative data suggested that home-based manage-
ment of malaria was essentially carried out by education,
counseling and home visits to ensure that mothers did
the right thing however; others have not been doing
anything. Wh ereas, the HCMs in both the pubic and pr i-
vate resorted to BCC on care of children at home to care
takers, the chemical seller largely engaged in talking to
clients on how to take medicine. Namely, mothers were
trained to tepid sponged their children when there is fe-
ver and to give Paracetamol before sending them to the
CBAs for rectal Artesunate, they were also encouraged
to use ITNs especially for children under five years and
to give ORS when there was diarr h oea a nd vomiting.
Qualitative data suggested that although, HCMs were
not aware of what they have been doing, maintaining
competitive edge was essential to all the HCFs. They
ensured prompt attention to clients to avoid client frus-
tration and maintained cordial staff-clients’ relationship
to enhance maximum satisfaction. Occasionally, mass
educational campaigns were carried out, canvassing
community members to use their HCFs. Offering of
24-hour quality service to clients and ensuring that cli-
ents receive all treatments at the facility. Fees charged
were relatively moderate and clients have been encour-
aged to join the NHIS to be able to always patronize
their services.
Qualitative data indicated that special efforts adopted
in both public and private HCFs to enhance NMCP
strategies were Behavio ur Chan ge Commu nic ation (BCC)
which was carried out both massively and individually.
These educational campaigns emphasized multiple pre-
vention strategies such as the use of ITNs, IPT and en-
vironmental cleanliness. HCFs also had in stock recom-
mended drugs. Staff especially, those in the public HCFs
have all been trained in current trends and training was
carried out periodically to update skills, knowledge and
attitude of staff. Distribution of ITNs to children less
than two years was on-going in all the public HCFs, to-
gether with the administration of SP. The chemical sell-
ers on the other hand, have embarked upon education
and counseling of customers.
Multiple strategies adopted to reduce the occurrence
of malaria within the district by HCMs were basically
promotion of insecticide treated materials, liaising with
the district assembly for educational campaigns, en-
couraging communities on good environmental sanita-
tion and administration of chemotherapy to pregnant
24 (75.0 percent) HCMs out of the 32 encouraged the
use of insecticide treated materials in combating malaria;
apart from 9 (37.5 percent) chemical sellers, the 15 (68.5
percent) were all HCMs from both public and private
HCFs. Out of the 32 HCMs, 13 (40.6 percent) liaised
with the district assembly for health educational cam-
paigns; 7 (53.8 percent) from the public, 3 (23.1 percent)
from the private and 3 (23.1 percent) being chemical
sellers. 22 (68.8 percent) out of the 32 HCMs, did en-
courage drainage, mosquito proofing and general sanita-
tion through education campaigns in the fight against
malaria; 9 representing 40.9 percent were public HCMs,
4 representing 18.2 percent were from the private and 9
(40.9 percent ) be i n g c hemical sellers.
Administration of chemotherapy to pregnant women
was carried out by 14 (43.8 percent) out of the 32 HCMs;
9 (64.3 percent) from the public, 3 (21.4 percent) from
the private, with 2 (14.3 percent) being chemical sellers.
Additionally, residual spraying was carried out by 6
(18.8 percent) HCMs out of the 32, while larviciding
was done by 5 ( 15.6 perc ent) HCMs.
HCFs are primarily community assets thus, the com-
munity 32 (100 percent) partner whatever the HCMs
embarked upon to ensure their effectiveness. Equally
important in this partnership was the religious institu-
tions 20 (62.5 percent), educational institutions 13 (40.6
percent) and the district assembly 10 (31.3 percent).
Partnering the religious institutions were 7 (35.0 percent)
from the public, 5 (25.0 percent) from the private and 8
(40.0 percent) chemical sellers. Partnering educational
institutions were 7 (53.8 percent) from the public, 3
(23.1 percent) from the private and 3 (23.1 percent)
chemical sellers. Partnering the district assembly were 6
from the public, 3 from the private and 1 chemical seller.
The activities of NGOs 5 (15.6 percent) were not wide
spread within the district, apart from the World Vision
International who was assisting in staff training; the
Catholic Church was also assisting with the financial
management of one HCF. Hence, community participa-
tion in malaria control was exceedingly important to the
HCMs and every effort was being used to sustain it.
The health system in the district has been using the
integrated approach to public health diseases in the
management of malaria. Thus, there has not been any
structural change within the HCFs for the sole manage-
ment of malaria. Qualitative data suggested there have
been the creation of community based agents (CBAs) in
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the communities. These volunteers have been identified
and trained to administer rectal artesunate supposito ry at
the community level. They have been giving artesunate
suppositories to be used as first aid in the management
of malaria in the under fives.
Caretakers were instructed to rush their infants to the
CBAs for insertion of the suppository before taking them
to HCF for treatment continuation. However, because
the rectal artesunate was free, many caretakers preferred
going to just the CBAs for the free rectal suppository
without going to HCFs for further management due to
cost. The CBAs have also been trained in the principles
of IPT; they roamed the community to ensure that all
pregnant women attended ANC. The defaulters were
then referred to the HCFs for antenatal care and SP. The
midwives would then issue these women chits to be
given to the CBAs so as to ensure constant communica-
tion between the CBA and the client.
The reporting system used sporadically to co nduct the
control process indicated that out of the 32 HCMs, 50.0
percent (16) followed a quarterly control approach
whereas 6.3 percent (2) had an annual approach. The
remaining 9.4 percent (3) of the HCMs conducted it
monthly while 12.5 percent (4) did interfere immediately
when the need arose. 7 (21.9%) did not have any control
mechanism in place. Ta ble 6 depicts the control process
for malaria activities. The process which is common to
all the groups was studying, analyzing and evaluating
the outcomes and taking corrective measures where
necessary (62.5 percent).
Informal processes such as feedback through conver-
sation, frequent team meetings, direct contact and inter-
views were used in all the HCFs. There was no doubt
that the HCMs’ ability to orchestrate planning and im-
plementation in the light of changing conditions was
greatly strengthened by the operation of this sensitive
process. Use of feedback in supervision was mainly
verbal and immediate or during staff meetings.
Partners involved in the management of malaria
within the district were the Health research unit, NGOs
such as World vision international and the Catholic
Church, the district assembly, educational and religious
institutions, opinion leaders and the community as a
whole. These agencies carried out periodic researches,
pilot surveys; provided assistance for BCC, distribution
of ITNs, training and organized communal labours. Most
of these partners were members of the DHMT; they
communicated constantly to plans and constituted a core
group within the d istrict helping to reduce morbidity and
mortality attributable to malaria. Partnership according
to HCMs was maintained by constant communication.
The DHMT for instance would confront them with their
problems after receiving quarterly reports. Challenges
were addressed by these partners through dialogue and
feedback on how resources have been utilized.
Conduction of situational analysis was prevalent
though, the researcher couldn’t really fathom usage of
information generated from the analysis. There was no
formal documentation of any conduct of situational
analysis; as formal plans were infrequently used in the
management of HCFs. Data presented therefore, were
simply perceived conduct of situational analysis by the
HCMs. The vision of NMCP was widely known in both
private and public HCFs. The high knowledge of the
strategic vision could be due to the increased in-service
training and promotion of malaria control within the
district by the health directorate. Dangme West typically
being an indigenous district, her environment was natu-
rally uncompetitive [10], all the HCM were pursuing
multiple goal and multiple service strategies as ac-
knowledged by Paul [30] for better outputs of malaria
control. As suggested by Hussey [20] and Senge [34]
knowledge of the vision, mission and objectives is criti-
cal because it would guide the direction of the program
and create energy for changing reality which ensure
higher performance and disciplined program.
It is very sad though, that none of the HCFs could
boast of a computer, which is very basic to effective
planning. The development of timely, accurate, system-
atic, consistent and useful information system is crucial
for analysis of dynamic forces of the environment for
efficient planning as noted by Sprague and McNurlin
[35]. Therefore, to have a structured plan the DHD
should endeavour to equip the HCFs with computers to
facilitate planning.
SWOT analysis according to Duncan et al. [10] is an
essential logical element that combines analysis with
judgment in planning. HCMs constantly carried out
SWOT analysis to enhance collaboration with the com-
munities as indicated by both Bopp [1] and Ofosu-
Amaah [29]. Community participation in malaria control
was important to global RBM [8] and frantic efforts
were being made by the HC M s to enhance this objective.
Opportunities identified were overwhelming collabora-
tion between HCFs and the communities, extensive use
of ITNs, increased communal spirit in some communi-
ties and research on rectal Artesunate for children under
five years by the health research unit (HRU). The activi-
ties of the HRU kept malaria control active in the district
which confirms the assertion of Paul [30] that integration
of pilot projects enhances program effectiveness and
keeps it reengineered.
Threats identified included unemployment, high illit-
eracy, poverty, and poor environmental conditions which
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challenged the control process. The district is predomi-
nantly rural with poor socio-economic and infra-struc-
tural development; hence, in some communities the
NHIS was initiated and sponsored by International La-
bour Organization, this encouraged many residents to
utilize the HCFs. After the project residents simply
stopped using the HCFs due to finance. This is of im-
mense concern to the management of malaria. A peculiar
situation captured during the study, was a virtually
empty HCF during working hours. Explanation given
was that residents were looking for money to pay-up
their prem i ums.
Conventional methods were used in assessing strengths
and weaknesses. Common among them were govern-
ment assessment, perception testing of key constituency
groups and studying the gap, which were mostly used by
the public HCFs because of centralization of administra-
tion within th e district h ealth system. Benchmark ing was
a novelty and w as sparing ly used b y the HCMs pr obably
because of its uncertainties in practice as stated by
Macmillan and Tampoe [24] or its comparative nature as
planning was basically informal. Community assessment
was fairly utilized by all the HCMs; simple on-going
conversation and informal gathering of local leaders
were most favoured method.
Common strengthens among the HCFs were av ailabil-
ity of recommended anti-malarias, charging of moderate
fees and promotion of the tenets of NMCP. Attitude of
healthcare providers were particularly good because of
the indigenous nature of the district. HCMs readily ac-
cepted that due to the rural nature of the district, most
professionals refused postings to the area hence, inade-
quate quality and quantity of healthcare providers was a
major weakness to almost all the HCFs (GHS). Inade-
quate resources, no definite plans for the program, in-
adequate motiv ation of staff, insensitive attitude of some
staff, infrequent in-service training for staff, and lack of
privacy were some weaknesses identified with the HCFs.
Analysis of all the above data set the pace for effective
planning though there w ere no formal plans in almost all
the HCFs just as Botchie [2] confirmed this to be very
common in public services in Gh ana.
Planning for malaria control activities in the district
was much more informal than formal. HCMs were more
interested in the day-to-day management of their facili-
ties due to the homogenous nature of district. Planning in
such an environment according to Duncan et al. [10] can
be mostly informal especially with smaller entities such
as the HCFs found in the district. Though almost all the
healthcare managers used either informal or combined
planning process relevant to the situation, there was con-
sistency in decision making, and management of malaria
control within the HCFs was relatively effective. Duncan
et al. [10] reiterated that when there is an increase either
in the level of competition or changes in environmental
factors, the need for a formal planning process appreci-
ates. The attitude of the HCMs therefore, was due to
doing business in an uncompetitive and relatively stable
As discovered by Hussin et al. [18] the general prac-
tice of HCFs was more towards short-term than long
term, and the duration ranged between one to five years
with an average of 1.5 years. Generally, it can be con-
cluded that strategic orientation did not exist in the dis-
trict and so was strategic thinking since plans were
mostly informal or combined with short-term duration.
This was not unforeseen ; the districts are the operational
level and normally are implementers of plans orches-
trated either by the regional or national levels of GHS.
Frequency of planning meetings ranged between quar-
terly and monthly meetings though, many preferred con-
tingency planning meetings to bridge up gap on trends of
malaria control with colleagues.
Ensuring access to basic quality healthcare services
was a key strategic objective of the health sector [27]
and since various studies [7,15] have observed relation-
ship between user-perception of quality of care and
healthcare seeking behaviour for malaria and other ill-
nesses, clients were assured of prompt attention for all
treatment being given at the facility and more impor-
tantly improved attitude of healthcare providers. As
Wyss rightly put it a well-functioning health system de-
pended on motivated workforce, much more was being
done both at the district and national level to help moti-
vate healthcare providers to give off their best. The use
of performance appraisal has always been a thorny issue
in the GHS and there have been several attempts in re-
viewing its use. Only a quarter of the healthcare provid-
ers admitted to using the tool although, it is very effi-
cient and effective in identifying weaknesses in terms of
knowledge, skills and attitudes for further training. It is
an open secret that this important management tool is
used just for promotional purposes and its contents were
never analyzed for developmental gains. Monitoring of
client’s concern is an essential way of assessing clients’
perception on quality healthcare delivery and improving
performance based on user perspective which would
ultimately guide healthcare providers in satisfying cli-
ents’ needs. Although the DHD has recommended the
use of suggestion boxes to formalize concerns, like the
proverbial African, concerns were still generated through
informal means. This again is of great concern since
clients could be victimized and/or ignored through this
process. HCMs need to be encouraged to have sugges-
tion boxes installed in all HCFs so as to generate i mpar-
tial perceptions of their output or impact from the gen-
eral public which would ultimately improve performance
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and attitude of staff.
In maintaining competitive edge HCMs naively u s ed a
combination of approaches suggested by Macmillan and
Tampoe [24]. Time based approach was significantly
used to avoid client frustration and maximize satisfac-
tion; this appro ach couldn’t be well executed at the pub-
lic facilities where work load was almost always high.
Healthcare delivery being a professional service was
undoubtedly a knowledge-intensive enterprise thus; de-
velopment of knowledge have been a strategy in sus-
taining commitment, competencies, and confidence of
the workforce to g uarantee delivery of qu ality healthcare
to clients in the district as confirmed in all these studies
[14,21,25,33]. Hence, in carrying out most of their man-
date, knowledge and technology generated from research
[28] were used in curbing the ascendancy of severe ma-
With the upsurge of morbidity and mortality, streng-
thening of programme evaluatio n was essential to en sure
effectiveness and efficiency of malaria control [4].
HCMs in evaluating malaria control activities mostly
studied, analyzed and evaluated outcomes; taking imme-
diate steps to make amends where necessary. They again
organized frequent staff durbars to discuss achievements
and the way forward. Thus, HCMs used both outcome-
based and impact-based approach in their evaluation and
extensively involved their colleagues which encouraged
commitment to the ideals of malaria control.
An effective feedback system provides the workforce
with the opportunity to reflect on their past performance
and improve upon it, thereby enhancing performance.
Feedback again promotes commitment among staff,
strengthening competence and confidence. The study
acknowledged that HCMs used more informal ap-
proaches such as conversation than the formal appro-
aches. This was seen more with the HCFs, where con-
versation appeared to be the favourite of the healthcare
managers. Chemical sellers appeared not to be bothered
about this approach and never really patronized it. It is
however; important to note that giving constructive
feedback is very essential in management as stated by
Mary Parker Follet that management is “working
through people to achieve organizational goals”. Feed-
back always have the magic of ensuring that individuals’
creative ability is accessed jointly as a team to boost
competitive edge, achieving organizational goals and
ensuring that workforce becomes committed, competent
and confidence. Partnership in malaria control was very
important and was maintained by effective communica-
tion. Partners involved in the control process were the
DHD, HRU, NGOs and the wider society. These partners
had roles in planning, sometimes implementation and
even evaluation; they assisted wherever necessary to
ensure that malaria control remained effective and effi-
The approach used for data collection was both quan-
titative and qualitative b ut generally due to the technical
nature of management and the educational background
of most of the respondents especially the HCMs, most
questions had to be explained vividly before they could
complete the data collection tools. This may perhaps
have affected some of the responses that were generated.
The study generally identified many elements of the
practice of SM in the district. However, these elements
were not being managed holistically thu s, construing the
main tenets of the systems’ theory, on which the SM
theory was developed; that is the whole is greater than
the sum of its part. Thus, though the status of key ma-
laria control indicators was remarkable, this would have
been further enhanced if SM had been holistically prac-
ticed in the district.
The diverse findings identified presents implications
for public health practice, education, research, and pol-
icy formulation. The In-Service Training of GHS should
endeavour to develop SM as a taught course for senior
managers using the experiential teaching method to give
it a practical approach. HCMs who have had the advan-
tage of being at GIMPA and exposed to the SM course
should be encouraged to make use of knowledge ac-
quired through training to enrich malaria control and
other health issues of public health con cern. BCC should
be encouraged within the district and more effort is still
needed to extend community participation. This will
enhance acknowledgment of health programmes and
usage of basic tools developed to improve health. DHD
should persuade HCMs to have continuous BCC, taking
advantage of local nuances so as to increase knowledge
and acceptance of new health trends and issues. The in-
volvement of CBAs in healthcare delivery is very com-
mendable and this should be encouraged to ensure that
all pregnant women attend ANC and caretakers improve
their skills on home-based care of malaria.
The DHD should organize workshops and seminars
on the principles of business management especially,
customer care and work ethics. HCMs should be en-
couraged to have formal plans for their HCFs. Finally,
HCMs should focus on persistent upgrading of knowl-
edge, skills and attitudes of their staff to ensure sustain-
able delivery of quality healthcare. The DHD should
A. M. A. Ofei et al. / Health 3 (2011) 343-356
Copyright © 2011 SciRes. http://www.scirp.org/journal/HEALTH/
align themselves with the chemical shops to supervise
their activities, to ensure that they at least record malaria
or febrile cases handled and also to ensure that they fol-
low regulations promulgated by the Pharmacy Council.
This would at least help in the assessment of actual in-
cidence and prevalence of malaria because lots of chemi-
cal sellers are selling and dispensing drugs wrongly to
unsuspected healthcare consumers. There should be a
firm grip on the chemical sellers within the district since
the Pharmacy Council is too remote and their infrequ ent
visits are not helping much.
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