Not long ago, the health clinics in the Aswan governorate, a mostly rural area in Egypt's poorest region, presented a picture that was all too familiar in resource-poor settings. Staff who lacked motivation. Health statistics that were bleak. Clients who were dissatisfied.
This discouraging picture has dramatically changed. Now the doctors and nurses of Aswan governorate are focused on improving health results. Their efforts have proved successful in attracting clients to clinics, as shown by the districts of Aswan, Daraw, and Kom Ombo, which increased the number of new family planning visits by 36%, 68%, and 20%, respectively, compared to the same period last year. Aswan health staff are now strong, enthusiastic leaders. They have instituted "leadership clubs" in which they teach colleagues how to improve teamwork and performance.
What caused this remarkable turnaround? According to Dr. Morsi Monsour, Director of the Leadership Development Program in Egypt the changes were caused by a profound shift in attitude that clinic staff engineered for themselves using the approach pioneered by the Management and Leadership Program of Management Sciences for Health (MSH).
"We worked toward a vision-to have staff who were committed to results in their clinics and who wanted to continuously improve their performance," he said. Dr. Mansour explained that the term "vision" in this context meant "dream plus action plan." "That's how I translated into Arabic this word 'vision' which is a key element of leadership development."
As Projects Coordinator of the Population and Family Planning Sector of Upper Egypt between 2000 and 2002, Dr. Mansour noticed that health managers were sent to numerous training programs. (He recalled one training funded by an international donor that lasted for 70 days!) However, even with courses aimed at improving management, planning, data analysis, monitoring and evaluation, infection control, and other topics-once the staff came back to their workplaces, nothing changed.
"Why did we train them in planning and they didn't use planning? Why did we train them in infection control and they didn't practice infection control? When they came home we could not detect any improvement at the clinic level because service providers were not committed to service quality," said Dr. Mansour.
Undiscouraged, Dr. Mansour kept looking for a formula that would tap into the health staff's creativity. He attended the Implementing Best Practices program sponsored by the United States Agency for International Development (USAID) held in Cairo in 2000, where the presentation by the Management and Leadership (M&L) Program appealed to his sense of practicality. "Here was a down-to-earth definition of leadership: 'Leadership is facing challenges to achieve results in complex conditions.' Leadership is about producing something!"
What's more, said Dr. Mansour, the eight functions of leadership and management outlined in the Leading and Managing Framework seemed logical and simple. He felt it could work with his managers.
Over the next few months, Dr. Mansour led the effort to bring M&L's leadership development program to Aswan. He faced opposition from several quarters, especially from the head of the Aswan governorate health team who said flatly that he saw no benefit from courses funded by international donors and wanted no more of them in his districts.
"He was frustrated," Said Dr. Mansour. "He had no faith in his district teams. I promised that he would have committed staff-people he could depend on." The head of the health team remained skeptical, but allowed the program to go forward.
Health Teams Focus on Results
From June 2002 to June 2003, M&L's Leadership Development Program in Egypt (LDPE) was introduced as a pilot program. Ten teams with a total of 41 members took part. Dr. Joan Galer of M&L worked with Dr. Mansour and local facilitators such as Dr. Barakat, the Aswan Family Planning Director, who assisted in delivering the program in Arabic and trained other facilitators to carry the program forward.
About four months into the program, Dr. Mansour noticed that the nurses were showing a heightened sense of empowerment and confidence. Although, in the beginning, the nurses were mostly silent and deferred to the doctors in leading the teams, "as they participated in the program," recalled Dr. Mansour, "the nurses became highly committed to producing results in their teams. It was the nurses who were the most active in presenting their action plans and they began to speak very fluently about the functions of leadership."
One young nurse, Nagwa Ibrahim Mohamed of Gharb Aswan Hospital, described the change as personal as well as professional. "The program showed us how to work properly and to love and help each other," she said. By the end of the program, even the most junior nurses were unfazed when presenting their findings before large gatherings of senior officials in Cairo.
Dr. Mohammed Sorour, Family Planning Director from Kom Ombo, said that the LDPE gave him and other managers the tools they needed to enable others to raise their performance. "An individual alone is nothing, but if he is in a work group or there is a team helping him, then he can achieve everything. The problem doesn't lie in the quality of work the individual performs, even if it is exceptional, but in helping others perform their work with the same quality. Supervision or no supervision, if one doesn't do his work based on a personal conviction or belief, then the work will not succeed. Leadership is facing challenges to achieve results in complex conditions."
Dr. Abdo Al Swasy, Hospital Director from Kom Ombo, realized that M&L's program was unusual when he observed a preliminary meeting that took place without there being an official notice or a district manager attending. "The people came from Aswan, Kom Ombo, and Daraw. There were no absentees, no official notice, no incentives, no punishments. People came from all over, some crossing the Nile, people from all positions, doctors, and nurses. We gathered because there was love and familiarity in the group. That really affected meto see everyone attend the meeting. This was impossible to happen before the LDPE."
Eleven months after the pilot program began, the Management and Leadership Program conducted an evaluation that showed that all the Aswan teams had achieved better health service results, as measured by increased visits for antenatal and postpartum care and family planning. Three teams achieved notable increases in the average number of antenatal care visits. Postpartum visits went from 0.2 visits to 3.6 visits per client at one health center.
Health centers were able to improve their performance when managers applied the practices of the Leading and Managing Framework to identify and overcome service delivery challenges. The head of health team for the governorate, who had been a reluctant participant, now became a leading proponent of leadership development.
Self-Directed Leaders Take Over
The 12-month pilot program ended in June of 2003. Dr. Mansour told the program participants that they would no longer receive funding. "When I told them there was no more donor support to budget new activities, the graduates of the LDPE told me, 'We don't need donor money. We'll do it ourselves.'"
And that's just what they are doing now. Led by Dr. Al Swasy and Dr. Sorour, the participants decided to continue the program without funding or technical assistance. They established leadership clubs to continue their progress and to transfer the leadership development program to other clinics.
In six months, the self-directed leaders have trained over 60 new participants. New teams have taken up service challenges and the existing teams have taken on new challenges. The clubs are truly self funded. Participants pay for all costs, including travel and meeting space. Dr. Fatima, Family Planning Director from the Aswan district, said that this is the first time a USAID program has continued in a self-sustaining manner beyond its funding period.
The teams continue to use the Leading and Managing Framework practices to achieve results. When health workers in one clinic scanned their environment"scanning the environment" is one of the first leadership practices introduced in the LDPE workshopsparticipants collected information in counseling interviews that revealed that there was false information in the community about religious opposition to family planning. The clinic staff are now working with the local religious leaders to hold talks in the community to clarify the religious point of view on the acceptance of family planning.
Dr. Galer pointed out that these results did not come from an infusion of resources or a change in personnel. "The most outstanding result is the enthusiasm and confidence of the people in Aswan to take on their challenges and find ways to overcome them. Their commitment is inspiring. They are an example of how real development is self development." Dr. Mansour agreed and concluded simply: "This approach is powerful because the participants themselves own it."
M&L's Leading and Managing Framework
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