The success of any organized health program depends upon effective management, but health systems worldwide face a lack of competent management at all levels. Management development for health systems, particularly at the first line of supervision, must be given much higher priority by senior leaders and for investment. Human resource development leaders must be the advocates for making the investment in managerial competence.
"We are treating only a very small faction of the people who are infected ... These countries have very limited infrastructure, so we have been advocating that the Global Fund and other funding sources try to build up a least a rudimentary health care infrastructure, so that patients can be treated ... Even if the drugs were there, free, they wouldn't reach those patients." Dr Jean-Pierre Garnier, Chief Executive Officer, GlaxoSmithKline 
Most discussions about the potential impact of the Global Fund to Fight AIDS, Tuberculosis and Malaria, the pharmaceutical Accelerating Access Initiative, the United States HIV/AIDS initiative and expanding World Bank funding to the health sector end with either "it will outrun absorptive capacity" or "they do not have the infrastructure to use the funds". The observations come from well-informed and well-intentioned people. They are correct. The systems were inadequate before these new resources appeared, so why do we assume that they are adequate now? Not only have they not improved, but also in many countries they are actually weaker than they were a decade ago.
The most fundamental barrier to these new resources reaching the people who need them is the lack of competent management at all levels. Infrastructure is not an organigram; it is not handbooks and procedures, job descriptions, computers, budgets and supply chains. Infrastructure is people. An effective infrastructure is the right people in the right places. Health systems lack people who have and use the managerial competencies that match their responsibilities. In most health systems in developing countries there is an acute shortage of the right people. There is also an acute lack of understanding of the direct link between the lack of "hard" management skills at all levels and the poor outcomes of the health systems.
This lack of competent managers at all levels fosters "vertical" health programs that are narrowly targeted and centrally planned and controlled for maximum accountability for resources and results. Weak management encourages vertical programs because it fosters a lack of confidence, if not distrust, and discourages decentralization, program integration, local participation and initiative. In other words, weak management is the enemy of fundamental public health values.
We promote weak management when we avoid talking about management – as if strong management is not compatible with good public health practice. We also promote weak management by confusing descriptive public health administration education with training in specific managerial competencies. And we promote weak management when we put clinical status ahead of demonstrated managerial competence when we fill jobs at every level. Too often, incompetent management defeats the best intentions of skilled clinicians, encouraging them to find ways to work around or outside of the system.
The HR response
Management competence is the essential precondition for program success. Stories of mismanagement and under-management and observations such as those of Dr Garnier will undermine the will of our supporters. It is the responsibility of human resource development leaders to address the managerial competence gap head-on and do so soon, if the health sector is to avoid a collapse of the hope that the new resources will reach the people.
HR is the advocate for making the investment in managerial competence. To successfully compete for the resources that HR must have to develop managerial competence, HR must start with a solid assessment of the need. Each position, at every level (Ministry of Health, hospitals, health centers, programs, etc.), must be analyzed to identify the specific management competencies required to meet the objectives of the position. The analysis will produce up-to-date position descriptions and identify the skills that need improvement.
HR's advocacy has several targets. Management training is an essential expense of successful enterprises of all kinds. Every application to every donor should include a request for support for management development as a component of every program. Donors will respect and respond to objective assessments of management skill needs that are directly related to achieving the results of the investment. Finance ministries and some donors make a serious mistake when they argue that the country should not borrow for management training. They are setting projects up for failure. Ministries of Health and Finance have to be convinced to include the money in loan and project requests. HR is in the best position to make the case. You will not get what you do not ask for.
Another advocacy target is the regular budget process. HR people know that training, especially for management, is often left out of operating budgets or that it is the first thing to be cut when money gets tight. The needs assessment, tied directly to results, is essential to make the case for support.
Build internal advocacy for management competence development. The experience of several countries demonstrates that health care managers who are well organized are effective advocates for training resources and for improving managerial practice. HR leads by organizing national and regional associations of health care executives and administrators. These professional associations encourage individuals with management responsibilities to take pride in their roles. They can develop credentials and recognitions for outstanding performance, organize courses, create publications that promote self-improvement and share "best practices". Most importantly, professional associations of health care executives are valuable partners of HR in advocating for management training resources.
The essential management competencies
The essential core competencies that must be assessed for every managerial position relate to the control of and accountability for resources, effective management of personnel and assuring results. They are not the same as the public health competencies necessary for program planning and evaluation, or for good clinical practice in the community. General management competence and public health competence are both essential and they are complementary, but they should not be confused. It has been shown over and over again that public health competence without a firm foundation of management skills does not produce successful results.
When assessing competency needs, focus on practical skills that are essential to everyday experience. Avoid the complex, culturally limited concepts of managerial and organizational behavior that dominate contemporary managerial literature and many advanced courses. There is little evidence that they work, and to the extent that they do, there is less evidence that they are transferable from one society to another.
It is useful to think of management competencies in three categories: 1) HR competencies, 2) general management skills and 3) advanced or senior management competencies. A strong HR function or department, and building management throughout the health system, require HR officials who are skilled at their own work. General management skills are the essential tools that enable front-line supervisors to deliver the results for which they are accountable. Advanced management competencies are required at middle and upper positions. Advanced or upper managers must also have general management skills. And clinical and public health training and skills are not the same as and do not substitute for management competencies.
Human resources development competencies
Organizing the HR Department
Assessing Training Needs
Budgeting and Advocacy for Resources
Developing and Using Position Descriptions
Planning and Implementing Training Programs
Building Effective Teamwork
Implementing Labor Law and Personnel Management Regulations
General management competencies
Managing a Budget
Managing Health Professionals
Managing support staff
Developing Staff Competence and Productivity
Planning for Units and Programs
Assessing and Improving the Quality of Services
Oral and Written Communications
Using Computers and Information Systems
Implementing Labor Law and Regulations
Ethical Management Behavior
Managing Facilities and Equipment
Advanced or senior management competencies
Budget Preparation and Management
Human Resource Planning and Management
Leadership in Organizations
Organization of Public Health and Medical Care Services
Principles of Health Economics
National Health Policy
Planning Health Services
Organizing and Implementing Purchasing Systems
Developing and Managing Contracts
Assessing and Improving the Quality of Health Services
Ethical Management Behavior
Working with the Private Sector and Building Coalitions
Where you train for management makes a difference
On the job and with the team. Years of relying upon formal courses have not delivered concrete results because the front-line managers do not have the basic management skills to translate the leaders' directions into day-to-day actions. The courses are important for leadership to develop in-depth knowledge and skills, but that does not reach the operating level without hands-on training at the operating level. The leaders who are trained in expensive courses often do not have anyone to talk to. They cannot use their training in isolation.
Management competencies will be learned most effectively if the training takes place where people work, with the team that works together and when it addresses what they are experiencing as they do their jobs.
No organized health program can achieve its objectives without effective management. Management development for health systems, and particularly at the first line of supervision, must have a much higher priority for the attention of senior leaders and for investment. What must be done is clear. It is the responsibility of HR to carry the message forward.
Health Affairs 2003, 119-127. Publisher Full Text