Building Resilient Health Systems in Africa through Improved Leadership, Management, and Governance: An evaluation of Niger's Ministry of Health Transformative Training Program

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Building Resilient Health Systems in Africa through Improved Leadership, Management, and Governance: An evaluation of Niger's Ministry of Health Transformative Training Program

https://doi.org/10.21203/rs.3.rs-5183135/v1

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Background

Effective leadership within the healthcare sector is imperative to address the evolving challenges faced by Africa, including climate change, pandemics, resource constraints, and a growing population. Moving beyond traditional supervisory roles, transformative leadership, with its focus on empowering and motivating others, is essential. To address this need, the Office of the World Health Organization (WHO) in Niger conducted a transformative training for leadership in health targeting senior officials of the Ministry of Health.

Objective

In this evaluation study, assessed the impact of the training program, particularly its influence on managing and leading health organizations, teams, and programs, promoting self-leadership, and fostering staff cohesion and solidarity through virtual and face-to-face sessions.

Methods

This was a descriptive study that used each component of the Leadership for Health Transformation training in Niger from November 2 to 5, 2022.

Results

Out of 28 participating managers and senior executives, the majority reported a better understanding of their leadership weaknesses and acquired tools to enhance their leadership effectiveness. Notable areas of improvement included listening skills, self-control, self-confidence, feedback exchange, objective clarification, peer coaching, change management, innovation for health transformation, negotiation skills, and a win-win approach.

Conclusion

Given the crucial role of this leadership training in transforming healthcare in Niger and across Africa, additional training programs are judged necessary in the future to strengthen this sector.

Leadership for Transformation

health system

Niger

Africa

The quality of leadership in the health sector must be strengthened in order to respond to Africa's changing environment, particularly climate change, fatal pandemics, and resource constraints and growing population. Leadership is widely recognized to be a critical component of an effective health system (Johnson et al., 2021; World Health Organization, 2007). Good leadership has a wide-ranging and catalytic impact across the health system, from increasing health staff performance and retention to ensuring the fair distribution and effective use of the health budget and the preservation of health infrastructure (Swanson et al., 2010). In the absence of highly structured health governance systems, where clinical and operational decision-making may be less thoroughly regulated, the need for leadership in health system functioning and ordinary clinical practice may be felt much more acutely (Johnson et al., 2021). Many Sub-Saharan African countries, for example, lack a health management cadre and consequently rely on individual health professionals to manage day-to-day operations at the facility, district, or national levels (World Health Organization, 2010).

The Africa Health Transformation Agenda is the strategic framework that guides the contribution of the World Health Organization (WHO) to the sustainable development of Africa, as presented in the document “Africa Health Transformation Agenda 2015-2020 – A vision for universal health coverage”(World Health Organization, 2015). It builds on the transformation agenda, which aims to strengthen and reorient the capacities and activities of WHO in the African Region to respond to regional and national priorities through a more effective, efficient and focused approach (World Health Organization, 2015). Traditional health-care delivery methods must be reconsidered. To respond to this changing environment in Africa, it is vital to improve the quality of leaders in the health care. Indeed, Africa should pass through a transition from a traditional style of leadership focused on team supervision, organization, and performance to a transformational leadership that emphasizes the leader's ability to provide others with the means and motivation needed to work more effectively while feeling invested in a mission.

The evolving landscape in Africa presents unprecedented prospects for transforming countries, including Niger, towards achieving universal health coverage (UHC) and tangible milestones for improved health outcomes across the continent. Niger, with the support of WHO and the European Union, is actively participating in this transformative process, focusing on equipping its senior executives and managers with the essential leadership skills needed to effectively implement its national health policy and Health Development Plan, ultimately realizing UHC objectives (Abdou Illou and Codjia, 2018). To facilitate this endeavor, the WHO Niger office, with backing from the WHO Regional Office for Africa and the European Union delegation in Niger, provided Ministry of Health officials with the opportunity to partake in the "Pathways to Leadership for Health Transformation" training. The program fosters transformational leadership, promoting innovative thinking, interdisciplinary collaboration, and the embracement of novel ideas. Central to this leadership approach are continuous improvement and accountability, empowering employees, embracing change, and striking a balance between tradition and innovation (Organisation Mondiale de la Santé, 2021).

This study is driven by a critical imperative to bolster healthcare leadership in Africa, particularly within the context of Niger's pursuit of UHC. Amidst the unprecedented challenges posed by the COVID-19 pandemic and enduring regional conflicts, the significance of transformative leadership becomes undeniable in shaping meaningful change within the healthcare sector. Through the assessment of the "Pathways to Leadership for Health Transformation" training's impact, valuable insights will be gained regarding the effectiveness of equipping senior executives and managers with the essential skills to spearhead the implementation of the country's national health policy and achieve UHC objectives, thus fostering improved health outcomes for the African population.

To examine the impact of the transformative training aimed at enhancing leadership, management, and governance for resilient health systems in Niger, the study utilized specific variables as indicators. These variables encompassed enhancements in managing and leading health organizations, reinforcement of team management, cultivation of self-leadership, and promotion of staff cohesion and solidarity. Ultimately, the training yielded the acquisition of leadership skills geared towards facilitating Health Transformation in Niger. This was a descriptive study that used each component of the Leadership for Health Transformation training in Niger.

2.1. Theoretical Foundations of the Training Offered

“A transformational leader is like a role model, a thinker who thinks outside the box, who ensures collaboration across disciplines and teams, and who welcomes new ideas. Continuous improvement and accountability are fundamental elements of his leadership. Transformational leaders are mentors; they engage staff and build their capacity. They embrace the old and the new and are agile and resilient champions of change”. Studies have shown that transformational leadership has a positive impact on employees' creativity and their attitudes towards work (Aboramadan and Kundi, 2020; Al Harbi et al., 2019; Jun and Lee, 2023; Walumbwa et al., 2005). Transformational leadership as a practice also has a positive impact on leadership effectiveness, leading to positive outcomes such as extra effort, efficiency, and satisfaction (Aboramadan and Kundi, 2020; Walumbwa et al., 2005). Using real-world examples, participants reflected on how they might implement initiatives in their own countries and communities. The Transformational leadership theory states that people will follow a leader who inspires them through vision, passion and enthusiasm (Kumar and Khiljee, 2016). This is through the nine dimensions of healthcare leadership model which include leading with care, sharing the vision, Engaging the team, influencing for results, evaluating information, inspiring shared purpose, connecting our service, developing capability and Holding to account (Kumar and Khiljee, 2016). This is the basic foundations of training of Managers and Senior Executives on the paths towards Leadership for Health Transformation.

2.2. Training Objectives:

The overarching goal of the "Leadership Pathways for Health Transformation in Africa" was to enhance the personal and interpersonal awareness of Ministry of Health employees in Niger. The specific objectives aimed to equip participants with a range of skills, including identifying their leadership strengths, utilizing systems thinking to address management challenges, applying appreciative leadership for driving change, fostering teamwork strategies, improving communication and coaching abilities, systematically addressing staff performance challenges, honing negotiation skills, and applying effective negotiation strategies across diverse work scenarios.

2.3. Design of the Training Program:

The training program was designed as a spaced blended learning approach, combining virtual sessions and face-to-face training. The virtual sessions, conducted by international experts in public health leadership, focused on change management, health transformation innovation, and successful negotiation. The subsequent four-day face-to-face training in Niamey, Niger's capital city, from November 02 to 05, 2022, further engaged participants through presentations, group work, case studies, role plays, and simulations, enabling them to exchange experiences and deepen their understanding of various subjects. Experienced professional trainers also provided personalized sessions to support individual progress.

During the face-to-face workshop, participants delved into subjects such as appreciative leadership, systems thinking, team performance, giving and receiving feedback, emotional intelligence, and personal leadership vision. The workshop was organized into four phases: Introduction, Discovery, Application (including coaching, three virtual sessions, and supervision), and Conclusion (Figure 1). Throughout the program, participants filled out satisfaction questionnaires to provide feedback on their experiences with the Leadership for Health Transformation in Africa training.

2.3.1. Introduction Phase:

In the Introduction phase, the trainers acquainted the participants with the course content and facilitated a thorough assessment of their learning needs. Through reading selected leadership articles/documents, undergoing a 360° feedback process, and taking the Emotional Intelligence test, participants received valuable insights into their leadership skills and incorporated feedback into action projects aimed at enhancing their leadership capabilities. The Introduction phase was completed prior to the session, while the Emotional Intelligence test provided learners with behavioral guidance based on their results.

2.3.2. Application Phase:

The Application phase encompassed coaching, virtual sessions, and fieldwork. Coaching sessions allowed participants to analyze their 360-degree feedback results, enabling the identification of areas for leadership improvement and the development of personalized action plans. During virtual sessions, trainers and learners engaged in discussions covering diverse leadership topics, including successful negotiation, coaching, team performance management, innovation integration, change management, and delegation of authority (Figure 1).

2.3.3. Field Phase:

In the Field phase, learners were observed in their leadership roles during the poliomyelitis vaccine campaign activities. Supervisors highlighted positive aspects and areas for improvement. Positive findings included participants' utilization of participatory leadership, effective communication, clear goal-setting, support for individual expression, feedback-seeking behavior, and a culture of trust and appreciation. Areas for improvement included limited control over time management and results.

2.3.4. Conclusion Phase:

During the Conclusion phase, the final session focused on achieving specific goals: identifying major program outcomes, sharing best practices and lessons learned, discussing action plans, and enhancing future sessions. The training's impact on participants' job performance was noteworthy, as evidenced by increased commitment among team members, improved accountability, reduced workload through task delegation, enhanced team performance, and greater team autonomy in carrying out activities even in the leader's absence (Figure 1).

[Figure 1](World Health Organization, 2023b)

The training was designed to ensure an engaging experience, even during the virtual phase. Participants were encouraged to find a quiet room with a closed door for the session and to close all other programs on their computer to minimize distractions. The Participant Guide provided detailed instructions for connecting to the meeting room, facilitating a smooth start to using the Zoom platform.

The following tools were necessary to ensure a successful virtual training experience: headset with USB port connection, Webcam, fast WI-FI connection or Ethernet cable to Internet source are part of the hardware/physical system, lamp or natural light (to allow participants to see your face in the video), private room in a peaceful location where you will not be disturbed, Software including an operating system (XP, Vista, or Windows 7), processor (Intel Core2 Duo or similar / RAM: 4MB minimum), Java, Flash, and Chrome. Internet-enabled ActiveX with a Broadband Internet connection (DSL, cable modem, ISDN, or T1) and a computer with a loudspeaker/microphone were also important.

The training results are consistent with the WHO regional office's evaluation of the program. According to the training report, all registered participants attended the face-to-face session, but the virtual sessions had low attendance ranging from 10.7% to 53.7% (Figure 2). Coaching sessions were attended by 45.2% more people than virtual theoretical sessions, with an average of 45.2% and 20.2%, respectively (Figure 2). The summary shows that the participation rate for virtual sessions is 20.2%, 45.2% for coaching sessions, and 32% for overall success (Figure 3). Indeed, during the course's closing session, nine participants who had followed the program confirmed a significant improvement in the way they led their teams. They also mentioned more commitment from members of the structures' teams in achieving collective results, better individual and collective accountability, an improvement in team performance with the production of more results, a workload for leaders due to task delegation, and empowerment of teams so that activities could be carried out even in the absence of the leader.

[ Figure 2]

[Figure 3]

The use of practical examples applied on Leadership for Health Transformation in Africa is regarded as one of the best training approaches by managers and senior executives at the Niger Ministry of Health. In terms of leadership learning, participants acknowledged that the training allowed them to identify their leadership weaknesses. Participants also acquired tools to better exercise their leadership. These included listening skills, self-control, self-confidence, taking into account the opinions of others, the ability to give and ask for feedback, the need to clarify the objectives and roles of team members, team, peer coaching, management of Change, Innovation in the service of health transformation, being a competent negotiator and a win-win concept (Figure 4).

[Figure 4]

This evaluation study emphasized the results of a program that aimed to increase the personal and interpersonal awareness of Niger Ministry of Health staffs, refine their analytical abilities, and better comprehend the difficulties and challenges confronting today's managers and leaders in Africa. This study showed that managers and senior executives of the Ministry of Health have enough knowledge and practical on health leadership for health transformation in Niger in particular and Africa in general. This is a useful tool as Africa is facing multiple health challenges that need leadership for health transformation as shown in multiple examples from WHO.

An illustrative example can be found at the WHO level, where the Global Transformation Assessment in 2021 revealed notable improvements. Within the WHO African Region, more staff members expressed feeling valued, heard, and accountable for their results. Additionally, staff motivation showed a significant increase, rising from 43% in 2017 to 54%. These investments in staff, coupled with support from partners, have contributed to a more responsive WHO, attuned to the needs of the African Region. For instance, outbreak detection has seen a substantial enhancement, reducing from 17 days in 2015 to just four days in 2020. Furthermore, outbreak containment has also displayed remarkable progress, reducing from 418 days in 2016 to 40 days in 2020. Additionally, WHO has dedicated efforts to improve the quality of support to Member States by establishing flagship programs aimed at strengthening national emergency response capacities, enhancing the health of adolescents and children, combating neglected tropical diseases, and promoting universal health coverage, health financing, and consideration of the social determinants of health (World Health Organization, 2023b). This improvement in the quality of support to Member States begins with building the capacity of WHO staff on transformational leadership, which most of the senior executive representatives in the region have already benefited from. The last example is that the quality of family and reproductive health care has also improved, and maternal, infant and neonatal mortality rates have dropped significantly in the Region. Thus, in 2015, WHO embarked on this transformation process and defined the WHO Africa Health Transformation Agenda as the strategic framework to guide WHO's contribution to the implementation of the Platform for Sustainable Development in Africa (Organisation Mondiale de la Santé, 2018, 2021). This program has a vision for health and development that seeks to address the unacceptable inequalities and inequities that cause the WHO African Region (AFRO) to lag far behind others in terms of health and enjoyment of the highest possible standard of living. For WHO and its partners, strengthening the leadership capacities of key health sector actors to ensure better leadership and optimal management of local health systems is a key strategy to ensure the implementation of reforms. of the health sector by governments (World Health Organization, 2023a).

In Niger, leadership for health transformation has shown its strengths in the framework activities have been implemented to use COVID-19 resources and strengthen health systems to ensure the continuity of essential services through several projects: i) project funded by the Union European "COVID-19 surveillance and resilience of the health system" (construction of boreholes to ensure the supply of drinking water to 18 health facilities in the target area); ii) project financed by the World Bank "Capacity building for the response to COVID-19 and the resilience of the Health System in Niger" (acquisition of medical and laboratory materials and equipment to expand the supply of services to the populations) ; iii) implementation of the project "Support for improving the health of women and children in the regions of Dosso, Agadez, Tahoua and Tillabéry in the context of COVID-19", the main objective of which is to contribute to the reduction of maternal and infant morbidity and mortality, as well as the fight against infectious diseases including COVID-19, through capacity building of health personnel, community awareness and improvement of the access of target populations to quality maternal and child health services (World Health Organization, 2023d). This includes rehabilitating health centers and equipping them with medico-technical equipment (World Health Organization, 2023d). To strengthen the leadership of the Minister of Public Health, Population and Social Affairs (MSP/P/AS) in Niger, an institutional assessment was conducted and a number of points were identified, including raising the deficit of leadership to steer and support changes brought about by health system reforms(UN-Niger, 2022).

Leadership for health transformation training also is part of the development of governance and leadership within the Ministry of Public Health of Niger and includes 13 sub-programs, including: management, dialogue and coordination of activities and partners of the MSP /NOT; sector reform, including decentralization; management, audit and general review of services; public participation; planning, monitoring and evaluation. It includes: financing of the health sector (increase and management); management of physical resources; Human resources management; building, repairing and equipping administrative and educational infrastructure; regulation and standardization; health information; promoting health research; communication (internal and external); documentation and preservation (MINISTERE DE LA SANTE PUBLIQUE-NIGER, 2016). The results of a study on building leadership and management skills in health care found that it could be useful for educators, practitioners and government officials looking to strengthen the performance of health programs, as well as to African policy makers and partners looking to invest in evidence-based management and leadership development models (Ineza et al., 2022). It is a multi-faceted program that aims to increase the capacity of senior officers to lead people and improve the delivery of health services strategically in Africa in general and in Niger in particular (World Health Organization, 2023c). The universality of leadership concepts and frameworks for health workers remains an open question. Further training is needed to determine if there are distinctive characteristics of leadership roles, health system context and broader socio-cultural characteristics in Sub-Saharan Africa in general and Niger in particular (Johnson et al., 2021).

However, the development of the leadership for health transformation training should be an ongoing process implying more training as possible of leaders involved in health sector. Given the low participation rates shown in the results, it is important to assess lessons learned, challenges encountered and future training plans in order to increase participation in future trainings. Among the lessons learned, challenges experienced, and future plans, the training noted that participation in the training was low because only 9 of an initial enrolment of 28 learners were able to attend all of the sessions conscientiously and qualify. The difficulties encountered by this program are related to poor internet access and quality for participants from regional directorates and districts; for participants from the central level, participation in activities outside of Niamey and Niger contributed to their low participation. The main lesson learned is that strengthening the skills of health system management executives in leadership for health transformation allows for better intervention organization and management, leading to a new vision of managing and governing teams and health services with the goal of building team spirit, accountability, and improving quality and better health outcomes. The following suggestions are critical for integrating what has been learned: Persistence in implementing action project solutions Consolidation of technical knowledge through reading and utilizing materials, fostering a culture of transformational leadership within teams, requesting assistance from course coaches as needed Coaching improvement for the benefit of his team members, Participants' experiences are shared, and regular use of systems thinking and communication improvement. In terms of perspective, it is vital to organize the training of another cohort by implementing practical steps and precautions to ensure excellent participant attendance.

Managers and senior executives of the Niger Ministry of Health highly value the practical examples utilized in the Leadership for Health Transformation in Africa study, considering it one of the most effective training methods. Their satisfaction with the leadership development aspect is evident, as they reported gaining a deeper understanding of their leadership weaknesses and acquiring tools to enhance their leadership effectiveness. Noteworthy areas of improvement encompassed listening skills, self-control, self-confidence, feedback exchange, team collaboration, peer coaching, change management, innovation for health transformation, negotiation prowess, and embracing a win-win approach. However, the training attendance rates were adversely affected by various challenges, particularly limited internet connectivity. Given the critical importance of this leadership training in transforming healthcare in Niger and across Africa, further training initiatives are deemed necessary to strengthen the sector in the future.

Contributions: M.D., A.G., F.Z., and B.M.: conception. M.D., A.G., F.Z., B.M., J.L.T. and P.D.M.C.K.:study design.M.D., A.G., F.Z., B.M., J.L.T. and P.D.M.C.K.: study design: data generation and analysis. Writing original draft: M.D., A.G., F.Z., B.M., J.L.T. and P.D.M.C.K. Editing:E.K.I., O.T.M., B.O., M.S.K., G.A.D., A.M.C., S.M., K.B., J.T., H.H., H.M., N.K., J.L.T., P.D.M.C.K, D.E.N., C.S.W., and B.P.M.A.

Availability of data and materials: The datasets and materials collected and/or analyzed during this study are owned by WHO-Niger and hence not publicly available. However, the relevant author can get the data and resources with authorization from the WHO-Niger(Dr. Batouré Oumarou, email: [email protected]).

Ethics approval and consent to participate: The Niger Ministry of Public Health's Institutional Review Board provided ethical clearance. The Directorate for Surveillance and Response to Epidemics granted permission to conduct the research. All subjects provided written informed consent after being explained the goal of the study. The security of the participants' information was safeguarded by assigning each participant a code number and password-protecting the data in the closet and computer.

Competing interests: The authors declare that they have no competing interests.

Funding: We would like to acknowledge the publication fee funding support from the World Health Organization.

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No competing interests reported.

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Building Resilient Health Systems in Africa through Improved Leadership, Management, and Governance: An evaluation of Niger's Ministry of Health Transformative Training Program

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Abstract

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1. Introduction

2. Methods

3. Recommendation for virtual training to enhance participation

4. Evaluation of the Training Program: Results

5. Discussion

6. Conclusion

Declarations

References

Additional Declarations

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