xii
Conclusion: The management knowledge among hospital managers is poor and there is an
urgent need to organize management trainings for the hospital managers according to
specific needs founded in the study.
1
CHAPTER ONE: INTRODUCTION
1.1 Background
The concepts in health sector reform and the decentralization of health systems has
made considerable progress in developing countries and particularly in Asia.
However, the end user can hardly observe the assumed positive effects of
decentralization. Halbwachs (2001) proposes that the reform process predominantly
concentrate on general policy and strategy development without tackling the more
concrete day-to-day management issues in health service delivery.
Tabish (1998) says the majority of WHO members have felt the need to strengthen
their existing weakness in planning, organization and management of health system
and to achieve Health for All, professionalization in hospital management should to
be introduced. Iimprovement in quality of health care requires strategic development
of training and supervision (Rearing and Sauerborn, 1996).
Like other post-socialist countries, Mongolia developed more it’s social sector in the
certain period of the history. And most historians considered that the health sector had
established specially in this period. As a result of the policy implemented until
recently and that emphasized the hospital service, a number of hospitals were built
throughout the country and trained thousands doctors and health professionals. The
current statistics (NSO, 2001) such as 365 people per doctor, or 27 doctors and 31
nurses per 10000 population and 7.5 hospital beds per 1000 people shows that it’s
higher than even some developed countries.
On the other hand, in developing countries, hospitals absorb more resources than any
other governmental health services. Bold (2001) in his thesis wrote that although the
actual percentage varies from country to country, anywhere from 50-80 per cent of
public sector health resources, in money and trained personnel are used in hospitals.
Reviews of the health sector in many countries suggest that these large recurrent
expenditures on hospitals involve a great waste of resources because of the technical
and managerial inefficiency within hospitals. In order to control hospital expenditure
2
and improve the efficiency, management, and role of hospitals in the health sector,
there is a need to introduce rationalization of hospital service through
professionalization in hospital management.
Since 1990, Mongolia has boldly proceeded with reforms of its system of government,
economic structure, social protection measures and other changes in society. Legal
instruments to assure sustainability have supported these social reforms. In the new
Health Law and in Public Health Policy the public health, preventive and health
promotion activities considered as a priority. Although, the Government implemented
the a number of programs and initiatives which brought some reasonable
achievements during last 10 years, there is a little improvement in hospital service.
Since 2004, the Government have been preparing to initiate the hospital
rationalization program with support from World Bank, Asian Development Bank and
other donor organizations in Mongolia. And the main executors of the program will
be the hospital managers.
During last few years, as a result of the new Public health policy the health managers
have been trained in some official training. A Health Management course has been
established at the HMIEC with the support of the WHO since 1994, and the Faculty of
Public Health Management at the National Medical University since 1990. The
training curriculum includes the general management, public health and project or
program administration as a priority subject and the training conducts for director of
the soum hospitals, officers of the Department of Health in city, aimag and districts,
project or program coordinators who are the administrators in the health sector.
While basic programs in management for physicians have been available for a number
of years, no one-program whish reflected the features of hospital management have
existed. Typically, hospital managers who have assumed administrative positions,
either within the medical staff organization or within the hospital's management
structure, have not received any formals training in management.
3
In December 2002, NCHD had been reorganized to the Directorate of Medical
Service (DMS), which the priority became to support hospital service development.
The Human resource department of the DMS organized 1-2 experimental trainings for
hospital managers in 2003. But today’s circumstances shows there is a growing
awareness of the need to develop new curriculum on Hospital Administration based
on research findings which reflects real practical needs of hospital managers.
Consequently, this study to determine knowledge and skill of hospital managers was
crucial to initiate the extended training program for all hospital managers in Mongolia.
1.2 Justification for the study
The majority of the hospitals owned by the Government are managed by specialist
clinicians by virtue of their seniority and both the quantity and quality of services are
not up to the mark.
A staff-satifactory survey showed some common complaints among health care
workers, (DMS, 2002). The complains can be grouped into 2 broad category, that is,
complaints of doctors and nurses and complaints of managers.
Lack of health management training
Low Management Skill
Doctors & Nurses Managers
Low quality in
Health care services
Figure 1.1. Problems resulting from the lack of health care management training.
The flow-chart above shows that low managerial knowledge can lead to low quality of
health care services in hospitals and centres. According to the flow-chart above, one
4
can see that low quality in health care services is a result of lack of managerial
training. We believe that with adequate knowledge in management among health care
workers that plays a manager’s role in hospitals and centres, health care services will
improve when health care workers are happy with their job. Therefore, management
training is very important in our attempt to further improve health care services in
Mongolia.
Tabish (1998) stressed that there is an urgent felt need to introduce professionalization
into hospital management. Hospitals with 51-100 beds need to have an administrator
who has attended a short-term training course in the specialty. Hospitals with 101-300
beds need managers who have at least a post-graduate diploma in hospital
administration from a recognized institute. Large hospitals (301 beds and above)
should have an administrator with a post-graduate degree in hospital administration.
As an arm of MoH, the NCHD have been organizing short-term management training
courses since 1994. These courses focused only on public health managers and the
programme has trained over 900 managers thus far. However, a few of those trained
were from the hospitals.
A study conducted by NCHD (2001) showed that most health care managers acquire
management knowledge and skills by observing previous managers and from one’s
own experience, that is, “learning by doing”. Out of 62.5 % of health care managers
that responded to this survey stated that they were never exposed to any management
training. 63.3 % of these wrongly answered the basic level of management knowledge
test. Also, 93.8% of respondent feels that they need training in health care
management, and suggested that these training should be organized in two stages:
basic and refresher stage, with 1 to 2 years interval between.
A “Staff- satifactory survey” conducted among health care organizations under the
jurisdiction of Ministry of Health (MOH) Mongolia, showed that the 20% of
respondent answered that they are not satisfied with their job in the organization;
33.8% of them not satisfied with the management of the organization. 38.3% of the
respondents feel that there was no improvement in the health care service and quality
since last year. This survey concluded that there was a dire need to organize training
5
for health care managers and to improve their management skills (Directorate of
Medical Service 2002).
On the other hand, the new government has started the process of decentralization
through newly adopted laws. In 2004, MOH will start the management privatization
of one of the biggest specialized hospital, Shastin’s Memorial hospital. Many other
hospitals are also changing-emphasizing on decentralization of hospital departments.
These changes will lead to increased responsibilities of middle level managers in the
hospitals (NCHD, 2000).
6
CHAPTER TWO: LITERATURE REVIEW
As health care services develop in Mongolia, health care services are going beyond
the traditional boundaries. Clinicians now, need to manage not only their patients, but
also those working under them. Since these clinicians do not have any formal training
in management, most learn it through experience. Managers in health care settings do
not only mean doctors, that’s why this paper focused on clinicians who also play the
managerial role.
Training and development approaches for managers differ from countries to countries.
It appears that more integrative training and development could bring more flexible
approaches, but the need for expertise and specialist are rarely disputed and is evident
in the differences in the range of providers of management education and
development. Therefore, in order to provide better health care services, health care
workers need to have a wide range of expertise. Trainings to better manage human
resource are vital in maintaining the harmony in health care services.
2.1 Do doctors make a ‘good managers’?
Atun (1997) noted there are many views to the issue of doctors being managers.
However, it cannot be denied that in health care settings, doctors make the best
managers, as they have first hand knowledge of the running of a hospital, or any
health care services. Doctors bring
different experiences and perspectives to
management; and this
ensures a balance between the dimensions of patient ethics,
equity,
efficiency, and
choice.
However when a doctor is required to manage organisations, he has to expand his
knowledge and skills beyond this simple analogy. Principles like "management by
objective" will have to be learnt. If management is defined as "the practice of
consciously and continually shaping organizations" as propounded by Stoner,
Freeman and Gilbert (1995), then the doctor-manager has to learn a wide array of
skills. Basically the doctor-manager will have to utilize and practice the basic
management principles in his organization in the health care system, be it a clinic, a
7
hospital, a training centre, a research institute, a faculty of medicine, a ministry of
health etc. He will have to adapt management principles, strategies and methods in the
key areas of organizational management, which used to be simple involving mainly
resources and people, and which traditionally have been reduced to the processes of
planning, organising, coordinating and evaluating. However, in recent years newer
concerns have emerged, such as a change in management, leadership development
and quality management. Many writers simplify these into four key areas, which are
easily adapted in health management: -
i. The management of resources and products
ii. The management of people
iii. The management of change
iv. The management of self
The doctor-manager has to know a lot more compare to just being a doctor.
This is because these skills can have different connotations and implications on the
health care system, and also, because health management has specific scopes
exclusive to the health care sector. Only the doctor’s best understand many of these
specifics. Whether or not an individual doctor makes a good manager is not the
relevant issue here, but the important issue is whether doctors have the relevant
knowledge to be able to become a good manager.
With these realities as a backdrop, i.e. (a) that management involves processes
very much like those in medical practice, and (b) that many decisions in management
of health organizations require the basic knowledge of medicine as a biological
science, then:
(i) Doctors have to consider management as part of their functions,
(ii) Doctors are considered the most fitting for management of the health sector, not
just of the clinical department, but of also health organizations such as those at
district, state, institutional and programme levels, and
(iii) With the appropriate additional training, the doctor, with knowledge in both
medicine and management, makes the best choice for management functions
8
The nature and demands of health management today have become increasingly
complex requiring a broad knowledge rooted in both the biological science of
medicine as well as in management. A lay manager can indeed be made to manage
health organizations, and so can a doctor with no additional training in management.
However it has been seen that the best person to manage and lead health and medical
organizations is the one who has had training and experience in both medicine and
management.
2.2 What is meant by ‘clinicians in management and leadership roles’?
A broad definition of ‘clinician’ was used to include any person with a health
professional training, who is (usually) qualified and have been involved in direct
practice with individuals, groups or communities (Jones et. al. 1999). Below are some
examples of positions or roles with management or leadership responsibilities in
health and/or disability sectors include those in line management (Jones et. al. 1999).
• first-line managers and team leaders at unit or team level, responsible for a
team(single discipline or multi-disciplines) directly involved in service delivery
• middle managers at service or departmental level, accountable for the
performance of a group of first line managers or team leaders
• senior managers at executive level, for example general managers or division
managers (also some Heads of Departments and Clinical Directors who carry
similar responsibilities for service delivery)
• chief executives or general managers (of whole organisations) who carry
ultimate management responsibility for organisational performance
• Board members who accept nomination or are elected to governance roles,
overseeing organisational direction and performance.
All the above roles have formal authority by virtue of the position, yet require
leadership qualities for their effective performance.
9
2.3 Management training for doctors
At the beginning, many doctors are "a little sceptical of the benefits of management
courses", but for most of the participants that have gone through these courses, their
earlier views like, "I think this is a waste of time" changed into "may be something in
it". Not all will be converted but most of the 250 doctors who have participated in the
North Western RHA programmes over the last five years, have said that these
trainings have improved their understanding of the management system and principles
and provided them with valuable insights into daily management situations (Horsley
S, 1994).
For any doctor wanting to make a service more efficient and effective, management
training is a worthwhile investment. It is doubtful if any doctor's views of the
management of the NHS remain the same after some involvement in management,
such as being a clinical director (Barnes, P 1991). Indeed, there may be a danger of
creating a "two-tier NHS" with a serious division developing between those doctors
not involved in management and those doctors who are involved in management and
believe in it.
As managers have strived to bring doctors closer into the management structure, some
doctors have become managers, at least part-time (although management is definitely
a minority interest and not for all doctors). So doctors increasingly are likely to
become the senior managers. In some trusts now there are only doctors as line
managers between the chief executive and the business manager of the clinical
directorates. Many of these business managers have had only a few years' experience.
Where are many of the future chief executives to come from, but from the medical
directors and clinical directors?
David (1995) argued that obviously what the future holds depends partly on what the
chief executive appointment committees want and they might decide that they prefer
to appoint non-medical managers. What happens depends partly on what consultants
do and want. If doctors find that management is not for them and decide not to enter
the competition or if medical managers are not successful, for one reason or another,
then medical managers will not make the breakthrough, but given the continued
10
interest of doctors in management and the success of at least some, I would not be
surprised if in ten years' time most chief executives are medically qualified.
As it is now, most health care organization are managed by their own professionals,
and not by "lay" managers (Lupton, 1988). This opens up a variety of challenges for
management development as well as opportunities for doctors and must be for the
better of the Service if those who have the greatest influence on how the resources are
used are a mainstay of the management of the Service.
Jones, Boyd and Raymont in a report titled “An analysis of learning needs and an
overview of learning strategies and resources” for CLANZ wrote that learning
programmes rated well by adults have the following characteristics:
1. Environments and relationship/s are such that participants feel safe and are
interactive and involved. Abilities and life achievements are acknowledged and
respected (faculty members often comment that they learn as much from their
students as the students learn from them).
2. Intellectual challenge and creative thinking are encouraged. Work experiences are
related to theory. One respondent commented
“…Use small groups of 20 or so. This facilitates presentation of the data and the
time to discuss. It’s important that clinician managers are able to present their
own case studies from their own work. That is, if they study finance one week, then
observe their own setting and note how what they have learned is applied or not
and present to the class at the following session. The putting to work and
reporting was key”.
3. People are challenged just beyond their present level of ability. Respondents noted
that
“…talking down to well qualified clinicians is a problem when it occurs...these
folks can assimilate quickly so you can throw a lot at them...assuming they are not
quick spells disaster”
11
“ …Use of real case studies worked very well”.
No matter the country or context, clinicians find that the transition to a management
or leadership role brings new perspectives and challenges, which in turn require new
skills:
“I now see management as enormously creative. It may be difficult, demanding,
complex and exhausting -- but it offers an opportunity to achieve with others far more
than you could ever hope to achieve on your own. No matter how clever you are you
cannot hope to introduce a new service into a hospital, raise the quality of asthma
care within a health centre, or reduce premature deaths from heart disease in a
region without understanding something of the techniques of management” sad one
clinician after completion of the management training programme (Simpson, 1991).
And finally David (1995) concluded that there are many opportunities for doctors to
play their part in management. Doctors need training to meet these opportunities and
to show them that good management is as intellectually challenging as good medicine.
What doctors or anyone else does in management is not fixed. Participation in
management programmes empowers doctors to develop their role in management and
to change what they do. So there is an organizational development benefit.
Management training is not only to help doctors to manage better, but also most
importantly is to help them do a better job.
2.4 The diversity of management education and development
According to Vivien Martin (Open University Business School, UK, 1999) the
literature on management education and development indicates that there are
distinctly different approaches, which appear to arise from different conceptions of
"management". These can be grouped as clusters of approaches, which relate to
different views of managers as learners:
• The education view which relates to the view of a manager as one who thinks,
who engages intellect to address all aspects of management. The manager is
seen as a learner and sometimes referred to as a student.
• The workplace view which relates to the view of a manager as one who "does",
whose prime role is to ensure that work is planned and carried out in order to
12
contribute to effective organisational activities. The manager is seen as a
worker who needs to be trained to respond to new performance requirements.
• The personal development view which relates to the view of a manager as an
individual "'being" who engages in work as one of life's experiences. The
manager is seen as an adult with all the characteristics of any adult learner but
with particular personal development requirements and needs which relate to
their role as a manager.
In each of these clusters there are a variety of approaches to management education
and development, each with different traditions and underlying philosophies. The
differences between developers in each of these clusters can lead to difficulty in
collaboration when practitioners work together to address management learning from
more than one perspective. It is important to recognise these differences because
although they contribute to barriers being retained they are often essential differences
if the strengths of diversity are to be retained.
In Figure 2.1 these dimensions are set out in diagrammatic form showing how
the three clusters of viewpoints relate to managers in a development environment. It is
important to note that this offers a summary of viewpoints and is not a proposal that
all practitioners in each of these groups hold identical viewpoints but that the three
different perspectives are characteristic of the potential range of viewpoints in each
cluster.
Figure 2.1. Different views of managers as learners
13
The cluster of workplace training and development is shown as having a prime
concern for planning and carrying out the work of the organisation effectively. In
order to achieve this, organizations train staff, including managers, to achieve
standards of performance, which are recognized by the organization as being
ffective. The emphasis is on "doing" activities although these might be identified as
out work.
ept that everyone will interpret the management role and its
imensions differently. The view accepts that working in the role of manager is only
manager as "being" in the situation of manager, implying their wholeness as a
more coherent way.
e
competences or skills.
The cluster of viewpoints from the educational perspective incorporates higher
education and business schools, which have traditions of universities and the more
vocationally oriented former polytechnics. These all have strong traditions of the
teacher as an expert in a disciplinary area and view the student as a learner although
this may include recognition of adult learning perspectives. Managers are seen as
learning to engage intellect to apply to all areas of their work. The emphasis is on the
"thinking" aspects of management work rather than on the practical activity of
carrying
The cluster with a focus on personal development is more diffuse and represents the
viewpoints, which approach management development in terms of the person at the
centre of any intervention. The emphasis is on the person who is in the role of leader
or manager and the issues that this raises for development of that person in the context
of his or her setting, relationships and biographical development. Practitioners taking
this perspective acc
d
one aspect of the life of any individual. This cluster is shown in the diagram as seeing
a
person.
There is considerable diversity within management education and development as
each of the clusters of approaches includes a wide range of different specialization
and interests. If the strengths and opportunities of such diversity are to be used
effectively it is important to find ways in which developers might work effectively
together and ways in which participants might experience management learning in a
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