TOWARDS HOSPITAL AUTONOMYDECENTRALIZATION KATHs PERSPECTIVES

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TOWARDS HOSPITAL AUTONOMY/DECENTRALIZATION
KATHs PERSPECTIVES
DR. ANTHONY NSIAH-ASARE (CEO) KOMFO ANOKYE
TEACHING HOSPITAL KUMASI

• Roundtable Conference on Human Resource for
  Health
• 11th 12th June 2008

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PRESENTATION LAYOUT

• Autonomy/Decentralization
• Decentralization, focus on devolution
• Autonomy managing item 1 budget HR
  considerations
• Benefits and challenges

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WHAT IS AUTONOMY?

• Decentralization of decision-making from the
  Central Bureaucracy to the Periphery
• The degree of independence that managers have in
  decision-making
• Taking certain actions without seeking approval
  from higher levels

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FORMS OF DECENTRALIZATION OF HEALTH FACILITIES

• Deconcentration - administrative
  decentralization, describes the transfer of
  limited functions - remain dependent (often
  financially) on the central government WE ARE
  HERE
• Delegation - attribution of certain specific
  functions to semi-autonomous para-statal
  organizations no direct responsibility to
  either local or central government institutions.
• Devolution - transfer of specific functions to
  local authorities together with the legal basis,
  capacity for the generation of material and human
  resources and discretionary decision power -
  little reliance on central government - PREFERRED
• Privatization - complete and final transfer of a
  package of government services to private
  for-profit or not-for-profit organizations.

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WHY DECENTRALIZATION IN THE HEALTH SECTOR

• Trends worldwide - realization that development
  should not be a top down process - decision
  making power needs to be in the hands of local
  governments and local populations to affect their
  own development.
• Centralization of the planning and allocation of
  resources for health has led to only limited
  flows of resources to the peripheral levels.
• Pressure by donors to improve the delivery of
  health services in terms of responsiveness,
  effectiveness and efficiency through
  decentralization

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WHY IS OUR DECENTRALIZATION DECONCENTRATION?

• Ghanas stated objective is to devolve health
  delivery responsibilities to local governments.
  MoH has begun to deconcentrate its resources in
  the context of a sector-wide approach.
• Planning and budgeting have been decentralized
  (BMCs -1998), central level maintains control
  over the overall allocation of resources,
  standard setting, employment of health workers
  and procurement of essential drugs and supplies.

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FOCUS ON DEVOLUTION KATH (I)

• KATHs experience with autonomy dates back to the
  1980s. Hitherto no central policies on financial
  management no standardized accounting
  procedures existed
• The Hospitals Administration Law (PNDC Law 209,
  1988) then provided the legal backing
• To address the shortcomings in PNDC Law 209, Act
  525 of 1996 was enacted.

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FOCUS ON DEVOLUTION KATH (II)

• Teaching hospitals should be able to act
  under their own authority to achieve their
  primary goals and objectives as provided by
  legislation - sharing some characteristics of
  private organizations in order to be more
  efficient. Devolution allows for local controls
  over
• Governance ( KATHs Board has substantial powers
  to govern with some continued government control)
• Operations and Management (Decentralized to
  Directorates)
• Financial, HR, Supply Chain Management

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FOCUS ON DEVOLUTION KATH (III)

• This legal delegation of authority is not
  absolute but controlled through
• Central Policy and Planning Controls
• National Quality Assurance Programmes
• Limits over Resource Management

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AUTONOMY MANAGING ITEM 1 BUDGET HR
CONSIDERATIONS (I)

• One measure of autonomy or devolutionary autonomy
  is the right to receive from central Govt.,
  generate manage ones own income and be
  accountable.
• Budget Management Centres (BMC) concept in 1998
  aimed at decentralizing financial management and
  enhancing resource management.

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AUTONOMY MANAGING ITEM 1 BUDGET HR
CONSIDERATIONS (II)

• Current drive is to decentralize PE budget
• Less burden on CAGD but more pressure on local HR
  and accounts departments.\
• Difficulties may arise if unexpected expenditure
  such as salary increments occur after budgetary
  allocation
• Efficiency in managing funds from central as well
  as IGF.
• Control of Human resource
• Possibility of initiating performance based
  contracts (PBCs).

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CONSIDERATIONS FOR PBCs (I)

• Potential benefits of PBCs
• Applicability of performance indicators and
  models.
• Experience to date with performance contracts.
• Budget are funds available to pay for such
  contracts?
• What will go into developing the performance
  standards

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CONSIDERATIONS FOR PBCs (II)

• Internal Equity and Market rate what are other
  employees in the same title earning? How similar
  is their performance? Experience? Skills?
  Knowledge? Assignments?
• Bargaining Contract in some cases, specific
  salary increases might be mandated by contractual
  agreement.
• Employee considerations knowledge, skills, or
  an employees overall performance (details
  overleaf)

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CONSIDERATIONS FOR PBCs (III)

• More details on employee considerations include
• Nature or type of work performed
• Level of responsibility
• Impact of position on the unit or directorate
• Reporting relationships
• Scope of duties
• Complexity of work
• Creativity/innovation
• Supervision received
• Supervision exercised
• Knowledge and skills required to perform duties

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CONSIDERATIONS FOR PBCs (IV)

• Less important employee considerations
  include
• Past performance and longevity
• Unusual qualifications eg. Doctor Law degree
• Personality
• Financial needs

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BE CAREFUL IT DOES NOT ALL BECOME ONLY PAPER-WORK!
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EXPECTED BENEFITS OF AUTONOMY AND PBCs (I)

• The focus will be placed on higher level outcomes
  and satisfaction of those who access teaching
  hospital services. I.e. a shift to the right in
  the employment contract continuum a progressive
  increase in the value achieved.

The employment contract continuum
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EXPECTED BENEFITS OF AUTONOMY AND PBCs (II)

• Salary decisions will be based on appropriate
  equity and budget considerations.
• The link between performance and pay will be
  clearly defined, hence employees will be
  motivated to work and innovate.
• Better value for money efficiency gains
• Reduced central administrative costs
• Increased sense of ownership and clearer
  accountability
• Risk of having ghost names on the register will
  be reduced.

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EXPECTED CHALLENGES OF AUTONOMY AND PBCs

• Creation of inappropriate performance measures
• Reduced ability to deal with budgetary changes
• Potential loss of control by central Govt.
  Absolute autonomyanarchy
• Lack of experience in the initial stages and
  human resource challenges monthly inputs
  variance issues
• If the process occurs too quickly, the
  organizational structures, roles and
  responsibilities of management may be
  inadequately defined, creating structural
  imbalances in the health system as a whole.

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PBCs ARE NOT SIMPLY HOOPS THROUGH WHICH WE WANT
PEOPLE TO JUMP
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CONLCUSION INTERNATIONAL SUPPORT FOR PBCs

• First-ever joint guidelines on incentives for the
  retention and recruitment of health
  professionals.
• Commissioned by the Global Health Workforce
  Alliance (GHWA) English PDF (44p.) 1.2 Mb at
  http//www.who.int/workforcealliance/documents/Inc
  entives_Guidelines20EN.pdf

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THANK YOU!