Converging Leadership and Quality in Mozambique

"For sustainability, [leadership and management training] is better for involving people and affecting their own performance. But for actually improving services, [complying with quality standards] is better." -Nerina Jone, Director, Meconta Health Center, Province of Nampula, Mozambique

So goes the great debate engaging healthcare academics and policymakers and executives and financiers from around the world. Does training healthcare professionals how to lead, innovate, and change yield better long-term results than driving change through conforming to best practice standards?

At the core of the debate is the very real question of whether prescriptive quality standards can fully represent evidence-based care and service, but also whether they can capture the hearts and minds of the people who have to live with such standards. On the other hand, can training staff on management and leadership, without clear and agreed standards or objectives, deliver improved care and service?

With funding from the U.S. Agency for International Development (USAID), and working with the Management and Leadership Program of Management Sciences for Health (MSH), a leading international organization based in Cambridge, Massachusetts, the Mozambican Ministry of Health has launched two major change initiatives that represent the aforementioned debate.

The first is the Challenges Program, whereby staff receive training on leadership and management and then, with input from their communities, identify and target their greatest challenges. The intent is to hear the community and empower staff to contribute to improvements, resulting in an infectious "can-do" attitude that generates change at all levels.

The second change initiative is focused on quality achieved through compliance with national standards of care. The Quality Program was imported from Brazil, where it had been wildly successful. It was customized to fit the Mozambican culture and dovetail with the existing work on standards of care.

In July of 2004, the Ministry of Health released a set of 161 nationally recognized standards designed to improve the delivery of care and service. Participating Mozambican health facilities self-assessed against the standards and generated action plans to address their areas of non-compliance.

Currently, both initiatives are generating tangible and measurable results out in the rural provinces of Mozambique-and staff believe they are making a big difference.

Quality standards at work

At the Mossuril health center in the northern province of Nampula, the quality standards have already yielded benefits. At baseline, a team at the health center determined that the center was compliant with 41 of the 161 standards. Three months after mobilizing staff to increase compliance through focused action plans, the center now complies with 55 of the standards. Remarkably, they increased their compliance without any additional resources, just their ingenuity about how to do things differently.

"At first, seeing our compliance created a little anxiety among staff because they saw how far we had to go," says Calisto Maria Sampo, District Director for Mossuril. "Previously, staff saw things that could be done but they couldn't initiate change. Now (with the quality program) they can initiate change. And, as a result, they believe in what they can do, not only in their work but in their personal lives, too."

Not far from Mossuril, in the village of Carapira, the quality program has made an enormous difference. In August of 2004, the health center's baseline compliance was 18 of 161 standards. By November, also with no additional resources, they raised their compliance to 73 of 161 standards.

"It was very hard work, especially to convince staff who hadn't been through the process," says Luísa Manuel Chiporo, a nurse at the Carapira Health Center. "But now it's the way we do things."

However, about 20-30% of the action plans that would raise compliance cannot be implemented without funding.

There are a variety of reasons why authorities like standards. Typically, the reasons include combinations of the following:

• demonstrate control (e.g., governance)
• facilitate consistency in management
• provide a platform for measuring performance
• capture requirements in one source
• drive improvement through third-party oversight
• increase accountability to stakeholders
• disclose expectations and provide internal vision and direction
• improve quality, reduce risk

Depending on how they are designed, standards-based initiatives may or may not achieve any or all of the above objectives.

All challenges are local

Former U.S. Speaker of the House Thomas P. "Tip" O'Neil once said, "all politics is local." In Mozambique, health managers and staff are learning that all performance is local. Through the MSH Challenges Program, health centers in the province of Nampula have learned that it is possible to improve service and health without prescriptive requirements from central government.

The Challenges Program represents a very different belief about the best way to improve health. Where compliance-based initiatives, such as the quality program, believe service and health improve by setting standards and then driving compliance against the standards, the other school of thought is to give frontline staff the permission, tools, and motivation to find out what the local community believes needs to be improved.

Just as the Quality Program has motivated staff to improve service and health in Mossuril and Carapira, the Challenges Program has generated real results as well.

In the village of Lumbo, the community identified hygiene as one of the health center's key challenges. Using the Challenges approach, the health center team developed action plans and criteria to measure against, with respect to hygiene. In one year, from February 2004 to February 2005, the health center improved its performance against hygiene criteria from 20% to 88%. In addition, Lumbo answered a second community challenge by increasing the number of consultations done per month from 1,015 to 1,562 in one year. And it's third community challenge of increasing the percentage of births that are attended by a midwife was improved from 42% to 61% in one year.

Not far from Lumbo, on the Ilha de Moçambique, the health center there has also accomplished a great deal through focusing on challenges. At a community meeting, the center was challenged to improve both hygiene and biosecurity in a physical environment that was dilapidated and ancient.

By engaging staff to respond to the community, the center was able to develop action plans and corresponding criteria against which to measure. Over the course of one year, the center saw its performance against hygiene practices (such as no water on the floor, clean floors, good ventilation, etc.) rise from 11% to 78%-surpassing the goal of 75%. Similarly, the center has seen its performance against biosecurity practices (such as correct use of gloves, proper decontamination, proper labelling, segregation of waste, etc.) increase from 16% to 83% in a year-surpassing the goal of 60%.

By outperforming their goals, "we realized that we can go beyond what we thought we could do," says José Manuel, Director of the Ilha de Moçambique Health Center. "It is important for staff to see the results so they realize they are making a difference. The process is completely known to all our staff."

Adds Licinia Lopes, Chief of Maternal Child Services, "We now have a way of focusing our efforts and targeting resources. And [the challenges program] has created a healthy competition between units to see who can do better."

Clearly, the Challenge Program's aim of fostering management and leadership at all levels has worked. However, the bigger challenge with any decentralized improvement process is keeping the wheels of improvement in motion. Where the currency of the Quality Program is compliance with standards-something that can be compared between facilities-the currency of management and leadership is measured success in improving health.

"We're feeling as if we've gone as far as we can with the quality program, but we also have needs with the challenges program" adds Antonio Novella, outgoing HIV/AIDS coordinator for the Nampula Province. "Where the limiting factor with quality is resources, a limiting factor with challenges is a lack of competency in measurement and indicators."

Where to go from here

While every health center that has participated in both the Challenges and the Quality Programs agree that great value has been derived from both, there is a feeling that health centers will have to make a choice over which one works best for them.

A lot is at stake with the evolution of the Challenges and Quality Programs in Mozambique. First, if health centers have done all they can to raise their level of compliance against the standards without resources, staff could lose heart and interest in the program.

The second risk factor is that standards give politicians, ministers, and policy-makers comfort that everyone is prescribed the same requirements. As a result, non-compliance is transparent and comparing and ranking health centers is easily done by comparing percentage of compliance. In other words, a standards-based compliance initiative makes it easy for politicians and ministers to feel as if they know what's going on.

Conversely, an initiative like the Challenges Program, which does not generate comparative data on a regular basis, can make politicians and ministers feel insecure and uninformed about what is going on. In other words, a decentralized initiative like the Challenges Program, which isn't ideal for macro-measurement and benchmarking, keeps health workers engaged in change and improvement, but gives little comfort to provincial or national leaders.

What might determine the fate of the Quality Program is the availability of resources to drive compliance even further.

In the end, how service delivery performance is driven in Mozambique will boil down to trust. Do the powers-that-be trust that giving health workers permission to respond to community challenges about what they want is the best way to improve healthcare? Or, is it better to centrally decide what communities should require and force all health centers to do the same things to meet those requirements?

"In the future, some health centers will participate in the Challenges Program and some in the Quality Program, and it needs to be decided which is better," says Dr. José Daniel Nihaleque, a medical director with the Nampula Province.

"The big difference [between the Challenges and quality programs] is that the challenges taught us how to consult ourselves and the community," said Mossuril's Sampo. "With the standards, we're taught how to compare ourselves with established norms and standards. The other difference is that with the Challenges, you stop to evaluate your performance. But with Quality, you are constantly evaluating performance because the data (percentage of compliance with standards) are always there in front of you. But both lead to the same result, improving health service delivery."

Clearly, there is room for both programs, and both are bearing fruit from the labor of health workers. As to how to converge or integrate the Challenges and Quality programs to get the best results, that will require continued dialogue between the Ministry of Health and the provinces and districts.

Michael Paskavitz is an independent consultant and author who just returned from Mozambique. From 1999-2003, he consulted with the Department of Health in England, and recently authored a book entitled "Measuring and Communicating Success in Healthcare" (Witherbys, London, 2004). Previously, he founded the Health Care Safety Institute in Boston, and edited the two most widely read subscription publications on healthcare quality & accreditation and safety & risk in the US. He can be reached at mpaskavitz@aol.com.

By Michael Paskavitz

For more information about Management Sciences for Health, please visit: www.msh.org .

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