The best reward

Allow me to paraphrase an old Taoist saying: " The best leaders are those the people hardly know exist. The mark of a successful leader is when the team says WE DID IT!"

I have always believed a leader is only as strong as his/ her team. My work has consistently given the opportunity to build the capacity of my team and others involved in my work. The effort you put in to building a team's capacity is directly proportional to the quality output. Now, what is all this talk about leadership, you may ask? Strengthening health systems has a lot to do with leadership. Building the capacity of workforce and the system requires leadership qualities. That is why I sought a doctorate in public health leadership after my medical degree. I am firm believer that leadership is essential to build and strengthen health systems.

So, what is the exact relationship between leadership and health systems strengthening (HSS)? Allow me to give an example. HSS requires a commitment and buy-in from various stake holders, government and non-government players included. Anyone heard of "From silos to systems"? Strong leadership qualities are an absolute necessity in securing these commitments and buy-in. A successful leader will engage all the players and bring them together to build a strong health system. That is what I have always done in my line of work...engage, secure commitments, and obtain buy-in. It is the first and crucial step towards building/ strengthening a health system.

My work in Liberia is a testament to successful leadership. I can proudly say I was responsible for conceptualizing, operationalizing, and initiating the first and only comprehensive HSS/ capacity building framework for a post-conflict country. It would not be possible without the commitment and support from various stakeholders and my staff. Starting from the Liberian Ministry of Health to international donors like USAID and various NGOs, everyone played a role. I am proud to have created and implemented a framework that facilitated the stakeholders to come together and rebuild Liberia.

Besides stakeholder buy-in, a successful leader is also appreciated by his/ her team. It has been almost six months since I left Liberia and I continue to receive messages from my staff and colleagues about the impact I made in their career. The best message is one I received from an ex-staffer which read "Thank you for all that you have done. WE are now able to work towards rebuilding and strengthening our health system". I capitalized the word "we" to emphasize the mark of a successful leader. The message brought a tear to my eye. I am glad the ex-staffer said "we". I never want things to fall apart after I leave, and I am glad my ex-team is following up and making things happen after my departure. I take pride in them and I am blessed to have had the opportunity to build their capacity, which enables them to continue with the work I started.

A latest message from an ex-colleague in Liberia made me think about leadership today. She wrote "good to know that you are working in Kenya. I know you will help people in Kenya like you helped my career". Am I a successful leader? I may not fit the stereotype of a traditional leader, but I possess some leadership qualities. I will, however, say with certainty that I will continue to build the capacity of people and health systems in order to prove myself as a successful leader in my line of work.

While I appreciate every opportunity I have been given, I am particularly appreciative of the fact that my teams always say "WE DID IT!". The sense of camaraderie among the team members and the stakeholder buy-in will continue to be the best reward of my career.

Onwards and upwards!

The first and only comprehensive assessment of capacity of the health system in Liberia - finally!!

Capacity building seems to be the buzz term in Liberia. Everybody and their mother talks about building capacity! I am not even joking when I say everyone from the international donor community to local pen-pen drivers use the term capacity building. Sometimes it feels like people are just using the term because it makes them look "cool". Almost every NGO and donor agency has a line item for capacity building in their work plan. There is even a national capacity building strategy document for Liberia. If I had a nickel for every time someone used the term capacity building! Don't get me wrong! I strongly believe in building capacity. However, I get frustrated sometimes because the term is used very loosely. Many people who are in the business of building capacity in Liberia see it from a very narrow point - the point being training individuals to build workforce capacity. For someone like me who has spent a majority of his professional life strengthening systems, it is a bothersome view. Training workforce is one of the three components of capacity building; it should not be the only focus. An individual functions well in a system that enables her/ him to put their skills to good use. You cannot just train individuals and leave them to work in a system that is not conducive to working efficiently and effectively. Strengthening individual capacity and system has to happen simultaneously if we want to achieve maximum results. Allow me to give you an example. We often hear people being trained in Monitoring and Evaluation (also known as M&E for the geeks in international aid community). I personally know plenty of local workforce that has been trained in M&E as a part of building their capacity. However, the system under which an M&E professional works is not always enabling them to use their training. How can a trained M&E person be productive when s/he is lacking a data collection and reporting system? What kind of functions will a trained person perform when they do not even have a job description? What kind of data analysis can be performed and how is the data used towards decision making when there is no mechanism/ system to analyse data and distribute the findings to key stakeholders? The above example is just one of the numerous instances where a narrow focus on capacity building does not yield intended results. More often than not the NGO and donor community tends to focus narrowly and not see the big picture. While there are situations where a focus on individual capacity takes precedence, one must always keep the institutional and systems perspectives in mind. For example, immediately following conflict there was a great need for qualified workforce in Liberia. Majority of the resources were focused on building workforce capacity, which, at that time, was thoroughly justified. Now that foreign aid is dwindling and Liberia is moving in to a phase of planning for sustainability, the time is ripe for building comprehensive capacity, not just individual capacity. That is exactly why my/ our project's approach towards building capacity is comprehensive. The approach is comprehensive; I/we focus on three levels of building capacity - individual, organization, and system.

A notice pinned on the main notice board of Lofa County Health System announcing our assessment and  "mandating" participation

As mentioned in one of my previous posts, I am following the WHO six building blocks of a health system framework. There are two reasons for this: 1. The Liberian National Health and Social Welfare Policy and Plan (NHSWPP) is designed around the same framework 2. The framework is flexible enough to adapt to various situations and country systems and allows us to assess the health system in a comprehensive manner.

For anyone who has ever designed/ conducted/ participated in a health system assessment, I do not have to reiterate the fact that it is an extremely tedious process. As tedious - and sometimes frustrating - as it might be, it is immensely satisfying for geeks like me. It is very rare that an entire system comes together to assess performance, capacity, and functions. We finished the county level assessments two weeks ago and we just wrapped up our central assessments.

Key respondents and staff conducting the assessment in Lofa County

The county assessments were conducted in three counties - Lofa, Nimba, and Bong. They took place over a period of two weeks - two days for each county assessment + travel time in between. A team of us - from the ministry and our project - traveled to each county to conduct the assessments. I am not ready to share the results of all assessments yet, but I will say there is a lot of work to be done. No surprise there!

We are now moving in to the phase of analyzing our data and writing a report about our findings. I can already tell there are a few areas that we need to focus - performance management, pharmaceutical supply chain management, data use for evidence-based decision making, and organizational restructuring. The last one is going to be interesting to pull off, because people are usually resistant to change, especially when it comes to restructuring. There is vast disconnect between what the central ministry perceived the capacity to be at the county level and the actual capacity. We need to address this disconnect if we have to move forward with strengthening the health system.

I always seek feedback from respondents immediately following an assessment. One of the statements that gives me satisfaction and makes it all worth is when the respondents said (I am paraphrasing here) "many people have come and gone in the name of capacity building assessments...you are the first person who has approached it comprehensively and has a plan". I will share the results once we finalize the report with feedback from the ministry. Until then, I am going to be spending numerous late nights writing the results and a plan of action.

I promise I will write something fun in the next post...food or about animals :)

Service delivery in the bush

Two weeks ago I visited some of our health facilities in the Grand Cape Mount county to observe service delivery and organizational structure. Our project supports many health facilities across the country, I am trying to visit as many as I can. As part of this mission, I visited one health center and two clinics - Sinje health center,  Bo-Waterside Clinic, and Tieni Clinic. Terminology is important because a health center is different from a clinic - type of services, number of staff, catchment population, and other factors play a role in deciding if a particular facility is a health center vs. clinic.

Sinje is a health center. They have a maternal and child health ward, provide family planning and reproductive health services, and even have an in-patient section. Fairly well run. I found a few issues here and there, but what health facility does not have issues, especially in the developing world? Even though I am not their supervisor, I found some areas in health records maintenance that I advised. I noticed that the newly appointed child survival officer was not adequately trained on recording patient data, therefore I took it upon myself to show her what individual columns mean in the ledger and how to record patient data. She was more than happy to listen because she has been looking for someone to show her how to record some of the data. If you look at the size of the book (see pic below), you will realize why training is needed to fill in the data. Our County Coordinator was quick to capture Dr. V in action, resulting in this picture.

Me explaining data collection to the child survival officer. Look at the size of that book!

After visiting the children's ward and talking to various staff, I wanted to visit the maternal health section. Reproductive and family planning services are top priority when it comes to improving Liberian health system. As such, it is very important for us to understand and improve service delivery in these areas. I was greeted by the Certified Midwife, who just finished delivering twins. I had the privilege to visit the children and delivery room. Neatly maintained. I even spoke to a few pregnant women who were waiting for their antenatal care checkup. I inquired patients about their satisfaction with services and the type of services they are receiving. While services are delivered as planned, there is still a lot of room for improvement. That is why I am here, to strengthen service delivery as a part of strengthening the system.

Avoid sex?

One of the posters I noticed on the wall in the maternal section caught my eye. It is a message aimed towards youth. Teenage pregnancy is a big problem in Liberia and there are different campaigns - from USAID, EU, WHO, etc - aimed towards family planning of both youth and adults. This particular poster is not from our project. What particularly caught my attention on the poster is "avoid sex". Technically speaking, the poster is absolutely correct. Abstinence is part of comprehensive family planning. I appreciate the "protect yourself at all times" message.

Following Sinje, I visited Bo-Waterside clinic. Also known as Bo-H2O (waterside = H2O, get it?), the town borders Sierra Leone. We ate lunch at a restaurant situated right at the border. In fact, we waved at the border patrol while eating lunch. Bo-H2O delivers a limited range of services compared to Sinje health center. We talked for an hour with the Officer in charge (OIC), who is a young guy working there for about 6 months. I discovered a lot of issues with the way the system is currently set up and I plan to address them during our interventions. Tieni clinic was the same as Bo-H2O, with limited service delivery and an even smaller facility. 

Pink delivery table

Besides these facilities, I also visited the Gbanway clinic in Lofa County. One of the best clinics I've visited so far, very clean, neatly organized, and all staff were present and busy working on the day I went (I didn't inform them ahead of time of my visit). The major attraction at Gbanway clinic is the pink delivery table. It put a smile on my face. Child birth is a tedious process, a little color in the delivery room might add some pleasant visual. I am so tired of seeing the hospital green and grey delivery tables, pink is a welcome change. I think every clinic should get a pink delivery table.

I can write about each one of the clinics in great detail, but I do not want to bore my non-public health friends with additional details. I have more trips planned and I will post pictures of my visits. I am in the bush all week doing assessments, so I hope to come back with more stories and pictures. 

Professor Moominpappa

Last week was the most professionally fulfilling week since I've been here. Don't get me wrong, I love my job, despite the drama and frustrations. But work is all I was doing since landing in Monrovia more than 3 months ago. I have accomplished a lot (according to USAID), and still felt I am not doing enough for Liberia. Well, now I don't feel lacking anymore.

Some of my friends know I like teaching. I was guest lecturing and assisting my friend/ colleague Christina in teaching a Masters level public health course at UIC before coming to Liberia. I never imagined myself being a professor (even a assistant or associate professor), but I enjoy teaching. Two weeks ago I mentioned to our Chief of Party (COP) that I miss teaching. Our COP is an Americo-Liberian woman, she was a practicing pediatrician in Monrovia before leaving the country many years ago. Besides running the largest US government health project in Liberia, she also teaches at the local university. A day after I mentioned to her that I miss teaching, she asks if I would like to give a guest lecture in her class. Imagine my joy when I resoundingly said yes!

Last week was my guest lecture. I was taken to Cuttington University by our COP. You should see the looks I got when she introduced me as the guest lecturer. I guess the students were expecting someone around our COP's age, not a young(er) professional. However, they were all eager to listen to what I had to say. I was surprised to find one of my staff members in the class. Even though I am her supervisor, I haven't been able to connect much with her (outside of work) because of our schedules. She commented "you are my supervisor and now you are my instructor as well". I hope that's not a bad thing!

Students work in teams to identify risk factors for health problems

The course that our COP teaches is titled "Primary Health". A perfect conduit to teach about public health. Since I don't believe in lecturing for more than 30 minutes, I made a short power point presentation. I then gave an exercise to work that lasted for an hour. I split the class in to teams and each team worked on identifying risk factors for a different health problem. I admire the tenacity of the students. Imagine sitting in a room with no air/ fan in a 100F humid temperature for 2-3 hours for each course. Some of them do it all day when they have back to back classes. I was soaked in sweat within the first 15 minutes of my lecture, I can only imagine how these students do it every day. I took encouragement from the students and kept on with the lecture even though I was dripping buckets of sweat. These students are my inspiration.

The students thoroughly enjoyed the exercise. Each team had arguments and discussions, but they all came to consensus in the end. In fact, when I asked what's the most important lesson of this exercise, their answer was "team work". You have no idea how happy that made me. We all know how important it is to work in teams, but team work has an added significance in a country like Liberia that has been torn apart due to internal differences. They really need team work here, at all levels.

More student teams working on the exercise

I think the best sign of a successful lecture is when students ask you to come back. At the end of the class, when I asked if they have any questions, they all said "we hope you come back!". Yes students, I will be back. I will definitely be back now that I have found my favorite way to contribute to Liberia outside work. Just call me Professor Moominpappa and I will be at your service!

What does it mean to build capacity and strengthen a health system??

The one question I have been trying to get answered, since I've been here. I may finally have an answer by the end of this month. I have to warn my friends reading this post: it is going to be all about work, no personal or fun stuff here.

Plato once said "the beginning is the most important part". I always believe the beginning of a project sets a tone for what's to come. One of the preliminary and major tasks of building capacity in health systems is to "define" what building capacity means for the recipient. Some call it developing a "vision". Whatever terminology you may prefer, the common understanding is that the recipient should be able to "define/ envision" what building capacity means for them.

My priority task, since I've arrived in Monrovia, has been to help/ guide/ persuade the Ministry of Health come up with an idea of what building capacity means for them. Why is this important? I'll give you another quote (I am full of these quotes today). To paraphrase what H. James Harrington wrote in Business Process Improvement:

"In order to strengthen/ change a system you have to control it;
in order to control a system you have to understand it;
in order to understand a system you have to measure it"

In my quest to strengthen/ change the health system in Liberia, I realize the need to measure it. Measurement requires definition. That is why I need the ministry to define building capacity and strengthening the health system. I could do it myself (I am thoroughly capable and competent), but I am not here to tell people what to do. I am not a dictator (although, in my spare time, I pretend to be one wearing a ridiculous crown). I am here to help, enable, and advise. So I proposed a few definitions and helped facilitate a discussion. We are making progress in coming up with a common vision.

Few days ago I delivered a talk to the senior leadership at the Ministry. It was well received, they were engaged in the discussion, and the best outcome - they agreed to finalize the vision for capacity building very soon. I am happy about this development. Now that I am gathering stakeholder participation and support - a vital component of strengthening a system - I am focusing on stakeholders at both central and county/ district level. The central ministry has heard (and got on board) with my strategy to build their capacity and strengthen the system, now it is the county and district health departments to get on board. In order to accomplish this buy-in, I will be traveling to the counties - Lofa, Nimba, and Bong - next week. I will present my strategy, introduce the instruments, and seek feedback.

The framework I am following to strengthen Liberian health system and build capacity is the WHO framework. It describes six building blocks that form the basis of a health system. Building Block 6 - Leadership and Governance - is the one that interests me the most. I strongly believe leadership capacity is the one that guides the other five building blocks. Allow me to share a diagram from the WHO framework

Six building blocks of a health system

As you can see, all building blocks work in unison towards creating/ strengthening a health system, but leadership is the one that guides other building blocks.

I believe we need strong leadership and a capacity to govern fairly in order to have a viable health system. Leadership is something that is lacking in the health system here. There are a few people at the central ministry who understand the importance of leadership and see the big picture, like Deputy Health Minister Yah Zolia, but leadership at county and district level is severely lacking. One of my objectives in building capacity for the ministry is to build their leadership capacity. I will be conducting an assessment of current leadership in the ministry - both at the central and county level - to identify issues that plague leadership. This assessment will help us develop a strategy to build leadership capacity.

Of course leadership is only one of the six building blocks of a health system. There are five other blocks for me to focus...and they will all receive due attention. I am using resources from WHO and CDC to create assessment tools for the Liberian ministry. These tools have been adapted and tested in other countries. I have first hand experience with these tools, having adapted and implemented them to health systems in Israel and India. I do not have to tell you that post-conflict systems are a completely different ball game. There are developed systems (US and most of Europe), emerging systems (India), and then there are post-conflict systems. There are not many frameworks/ instruments that have been developed specifically for post-conflict health systems, and that puts the burden on people like me to adapt existing frameworks to post-conflict settings. I like the burden because I like a good challenge. In the beginning I thought it feels like going back to the drawing board, but I have come to realize it is not even that. It is more like understanding that I need a board and pencils to draw, then embarking on a journey to procure the board and pencils before I begin drawing on a board. That's the level of  system in a post-conflict setting. Needless to say, it is challenging but extremely rewarding.

I have a lot of work ahead. We will start assessing baseline capacity next month and that will lead us to developing a capacity building and health system strengthening strategy. Analyzing the data and developing a strategy will take 2-3 months. We intend to start implementing our activities in June. I see a poetic sense of beginning because June is also the rainy season. To me, rain has always symbolized the beginning of a new adventure. It will be perfect for our adventure to begin in June.

I promise the next post will be not as dry as this one. I will add more personal and fun stuff, perhaps some pictures, for my friends.