Leading by doing
An innovative process aimed at unblocking health service delivery by building a strong, united team of health leaders is being piloted in Namibia by a partnership of management and development organisations.
‘I used to think that the Permanent Secretary in Windhoek had to take final responsibility for health. But now I understand that I am the Permanent Secretary of my region and I have to take responsibility,’ says Bertha Katjivena, Regional Health Director of Hardap Region.
For the past 12 months Bertha has been involved in a leadership initiative involving Namibia’s top health leadership.
Driven by Synergos, a global development organization, in partnership with McKinsey & Company and the Presencing Institute, the initiative is aimed at improving productivity and health service delivery in this country. It is based on the premise that a more effective health system can be achieved by enhancing the quality and performance of the health leaders. This is done by aligning their vision, values and commitments and empowering them to design and test new approaches to problem-solving.
Bertha was appointed to her position in October 2007, having moved up the ranks over the past 20 years from her start as a registered nurse. Her region lies south of Windhoek, running in a fat band across the entire width of Namibia. She oversees two hospitals, three health centres and 12 clinics as well as a range of other services including HIV/AIDS programmes, social services and environmental health.
‘I was not sure if what I was doing was right or wrong before the leadership initiative,’ says Bertha. ‘But now I have been empowered to understand my responsibilities and to do my job with confidence.’
Michael Likando is Regional Health Director of Caprivi, a narrow strip of land in the far north east of the country with a very high HIV rate and poor infrastructure. He oversees 25 clinics, three health centres and a district hospital.
‘During seasonal flooding, we cannot access three of our clinics for three or four months. One is on an island and we can only get to it from Botswana,’ says Likanda.
A power cut terminates our telephone conversation and when we resume talking on his mobile phone, Likando laughs: ‘I forgot to mention that poor communication is another challenge. Some of our clinics don’t even have telephones.’
For Likando, who has lived in Caprivi all his life and raised seven children there, it is sometimes easy to feel out on a limb, unconnected to other regions and the distant Health Ministry.
‘In the past, regions had their own plans but they were not well guided by the Ministry,’ says Likando. ‘The ministry didn’t have a strategic plan or a clear vision or mission. But now, with the health leadership initiative, we have developed a strategic plan. We understand where we are, where we want to go and how we have to get there.’
The idea of the African Public Health Leadership Initiative was first mooted over three years ago while Synergos was working with a consortium of management and development partners in India. The Bill & Melinda Gates Foundation agreed to put up $7-million to fund an initiative that could engage leaders in poor countries to work on out-of-the-box ways to unblock health service delivery, and Synergos set about looking for a country to pilot its vision.
Namibian Prime Minister Nahas Angula received the idea enthusiastically when it was introduced to him by civil society leader Len le Roux. Namibian Presindent Hifikepunye Pohamba then met Synergos leaders in the US and the initiative was given wings.
However, it was only when Kahijoro Kahuure was brought into the Health Ministry by Health Minister Dr Richard Kamwi as the new Permanent Secretary two years ago that the initiative began to fly.
‘Within a week of Kahuure being appointed, he gave me the green light to get things going,’ said le Roux, who by then had been recruited by Synergos to drive the initiative.
Kahuure instituted a review of the health sector, while Synergos and McKinsey did a complementary assessment to measure the performance of the Ministry.
The findings were daunting: leadership was weak, structures were dysfunctional. There was no strategic planning, no proper data, no clear targets and the country was slipping behind in reaching key milestones outlined by the Millenium Development Goals (MDGs).
Between 2000 and 2006, maternal mortality had jumped to 449 deaths per 100 000 births, an increase of 178 deaths. Life expectancy was a mere 54 years of age, a six year plunge in as many years, mainly as a result of HIV/AIDS which infects one-fifth of all Namibians. In 2000, the WHO ranked Namibia almost bottom of the class – 189th out of 191 countries – for ‘level of health’, a measure of the ratio between the actual level of health and the potential level if the country’s health system was run efficiently .
Kahuure embraced the help being offered by the Synergos-led initiative and moved swiftly to identify a team of leaders who could be trained to manage the country’s health sector.
Some 25 existing and emerging leaders were identified and the process of equipping them with managerial skills and encouraging them to work out innovative solutions to problems they identified is well underway (see block for more details on the ‘U Theory’ process).
Deputy Permanent Secretary Dr Norbert Forster, brought in by Kahuure to be his deputy, smiles when he describes the novelty of the approach used to build leadership.
‘There was a rigidity in the way that the department worked, with different departments in silos and there was a disconnect between the national level and the 13 regions,’ says Forster, speaking from his humble, paper-filled office behind Windhoek Central Hospital.
‘The Synergos process focused on breaking down barriers through workshops and retreats. People have got to know each other. Through joint visioning, we have developed a cohesive team and have an esprit de corp we didn’t have before,’ he adds.
‘All the core health leaders in the country are now on first name terms. Some are still hesitant about giving up their titles. There are doctors who like to be called ‘doctor’ and nurses who say ‘but I have called you doctor for so long’. But by using first names, people start to see each other as equals and also to ask what they can bring to the process as individuals.
‘By the end of the 30-month process, there will be a major change in organisational culture. In time, this will filter down to the districts, and the hospitals and clinics. We want to develop the team approach, where we understand we are all here to improve the health of people; a team that is bigger than the sum of its parts.’
Improving maternal health has been identified as a priority for the initiative, and a special group has been set up in the Khomas region (around Windhoek) to drive new approaches.
‘Maternal health captured the interest of Cabinet because the high maternal mortality rate is a big worry. The leadership team has endorsed the establishment of a special group to look at improving maternal health in one region,’ says le Roux. (See accompanying article)
By the end of 2010, this group plans to have implemented a number of ideas to improve the lot of the women who are giving birth to Namibia’s future.
Forster believes that the health leadership initiative is working because it has top level support: ‘The project has been able to link to the Prime Minister and the Health Minister. The political leadership is very interested in the process.’
Le Roux agrees: ‘The initiative is attractive to the political leadership as the Namibian Development Plan talks about transformational leaders, and we are delivering on that transformation agenda.’
Not only does the initiative aim to improve the performance of the Namibian healthcare, but it also wants to develop a model that can be used throughout the continent to unblock obstacles to health service delivery ‘ often caused by weak leadership and poor systems.