Assessment of strategic management practice of malaria control in the dangme west district, GhanaArticle submitted to the west african college of nursing for the award of a fellow

doi:10.4236/health.2011.36059

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Vol.3, No.6, 343-356 (2011)

doi:10.4236/health.2011.36059

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.

ABSTRACT

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. INTRODUCTION

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-

nence.

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

A. M. A. Ofei et al. / Health 3 (2011) 343-356

344

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-

tality.

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

improvement.

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

345345

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-

straints.

2. METHODS

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

346

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

indicators

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

environment

(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

(STRATEGY FORMULATION)

Promotion of N MCP objectives

Implementation of planned strategies and activities of malaria control

(STRATEGY IMPLEMENTATION)

Monito ri ng and eva luation of s t rategies and

activities of malaria control

(STRATEGY CONTROL)

Feedback

Figure 1. The conceptual framework.

Openly accessible at

A. M. A. Ofei et al. / Health 3 (2011) 343-356

347347

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

process.

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.

3. RESULTS

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

patient;

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:

A. M. A. Ofei et al. / Health 3 (2011) 343-356

348

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

claimed:

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

remarked:

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-

munities.

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

A. M. A. Ofei et al. / Health 3 (2011) 343-356

349349

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-

ed:

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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350

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-

mands.

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-

tation.

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

(29.4%).

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

shops.

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)

Total

(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)

Total

(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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352

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

women.

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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353353

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.

4. DISCUSSION

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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354

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

environment.

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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355355

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-

laria.

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-

cient.

5. LIMITATIONS OF THE STUDY

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.

6. CONCLUSIONS

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.

7. RECOMMENDATIONS

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

356

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.

Openly accessible at

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