Evaluation report of the operations level management project

The project was implemented by the MEDEX Group of the John A. Burns School of Medicine at the University of Hawaii. The core of the project was the application of the MEDEX Group's structured process for reengineering managerial systems for supervision, personnel, transport, drugs/medical supplies, finance, communications, health information, patient records and referral, maintenance, and training. The project recruited and trained Ministry personnel as management analysts, supervised them in the study of the various systems, held decisionmaking workshops to determine the content of the redesigned systems, wrote manuals to document the new systems, and trained district level personnel in the use of the systems. Despite delays, the MEDEX management development process appears to work and to show potential for further development and application in other areas and other countries. The process succeeded reasonably well in Lesotho, but ran into difficulties in Botswana, in part because of problems in interministerial coordination. The project demonstrated that ministry engagement in an analytical and decisionmaking process can result in the redesign of management systems and in the development of manuals to document those systems. On the down side, due to various delays and USAID's shortening of MEDEX's original 5-year project to 4 years, some major objectives were not achieved: putting the revised systems in place at the operations level; installation of an improved supervisory system linked to an ongoing program of inservice training; and full institutionalization of the new process in the target ministries. As a result, there is little evidence that the new systems are helping to improve the delivery of child survival or primary health care services. Lessons learned are as follows. (1) What is important is not just the product, but the MEDEX process itself, including a thorough self-analysis by the host organization. Simply to hand out a manual could short-circuit the process, although well-written manuals can be illustrative. (2) Where systems were non-existent or very weak, the MEDEX process worked well to create or to improve them, and ran into little resistance. Where reasonably well developed systems were already in place, more resistance and delays were encountered. Redesigning systems requires additional criteria, including the potential political volatility or interministerial impact of the change. Addressing less contentious systems first could build skills, experience, and credibility before taking on the more controversial systems. (3) The MEDEX approach focuses specifically on management improvement, creating a critical mass of talent and resources focusing on that goal. Once a ministry has gone through the process under the guidance of MEDEX, it has the skills, methods, and materials to continue the process independently and at relatively low cost. (4) The time, resources, and energy devoted, especially early on, to developing and testing four management improvement technologies (critical events, case study, distance learning, and resource allocation technologies) was a distraction to the main thrust of the project. Only the critical (or management) events technology proved relevant to the core management development process. Case study and distance learning activities could have contributed more, but appear to have been used in relative isolation. (5) "Establishing a Receptive Framework" is not just the first step of the MEDEX process, but an ongoing activity which, if neglected, can seriously compromise the whole process. Commitment to this activity must be constantly renewed, particularly at the central level. (6) The project lacked a carefully articulated plan to install the new systems in the districts through the teaching of specific skills and competencies to operations level personnel. Much more work is needed to design and deliver the competency-based management training program for district-level personnel called for in the project design.