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Primary Health Care facility managers’ competency ... file04/05/2016 Primary Health Care...

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  • 04/05/2016

    Primary Health Care facility managers competency

    assessments in South Africa: The refinement of competency

    assessment tools and approaches

    R Madale1, J Dippenaar1, A Cois1 and R English1 1 Health Systems Trust


  • Background

    In 2013, a competency assessments study was conducted with 429 PHC

    managers in ten districts across five provinces.

    The purpose of that study was to:

    Determine public health and general management competencies of health

    facility and local area managers working in selected districts in South

    Africa in order to identify areas that need strengthening in the context of

    the PHC re-engineering

    A set of tools were developed to assess the competencies of these managers.

    This study revealed competency gaps of managers in:


    Operational management

    Public health


  • Conceptualising the project

    Qualitative enquiry to inform the development of tools

    In depth interviews with key experts and PHC managers

    FGDs (FM, LAM, OTL)*

    Stage 1: 2011- 2012

    Development of three pronged competency assessment tools

    Internal & External tool review

    Tools piloting in 1 district

    Stage 2: 2012-2013

    Application of competency assessment tools in ten district, across five provinces

    Stage 3: 2012-2014

    Refinement of tools

    Piloting of tools in four districts

    Development of competency database

    Additional assessments in nine districts

    Stage 4: 2014-2015

    Project summary

    *(FGD) Focus group discussion; (FM) Facility managers; (LAM) Local Area Managers;

    (OTL) Outreach Team Leaders


  • Aim and Objectives

    Overarching Aim

    To assess the public health and general management competencies of health

    facility and local area managers working in selected districts in South Africa in

    order to identify areas that need strengthening in the context of the current PHC


    Specific Objectives for this study

    Further refine competency assessment tools used in previous studies

    Conduct internal and external review of these tools

    Pilot the tools to ensure their validity and reliability

    Modify the tool based on pilot results

    To conduct further assessments with PHC facility and local area managers

    To identify gaps and make recommendations of how to empower these managers in

    their roles as implementers


  • Design: Mixed methods

    Sampling: Purposive sampling used to select PHC managers (FMs, LAM, Sub-district and Out-reach Team Leaders)

    Study site: Four districts in one province

    Data collection: October 2014, at a central point (district offices)

    Data Capturing and Analysis:

    Quantitative data - captured in Microsoft Excel, analysed in STATA Statistical Software for descriptive and multivariate analyses, and MPlus software for factor analysis.

    Focus group discussions data - transcribed and content analysis conducted to develop common themes.



  • Methods: Tool refinement process

    Three types of tools Quantitative self-assessments using

    Likert-scale, where respondents rated

    their confidence and competence


    A practical exercise, where

    respondents were expected to do

    calculations, interpret graphs, display

    policy knowledge and application

    Focus group discussions for sharing

    of experiences including enablers

    and barriers to effective PHC


    1. Literature review

    2. Refinement of existing


    3. Internal & External review

    4. Final tools for piloting


  • Study Results


    Refinement of tools

    Piloting and testing of competency tools

    Demographic characteristics

    Analysis of missing data

    Factor analysis

    Self-administered questionnaire

    Practical exercises

    Focus group discussion results



  • Refinement of tools (pre-pilot)


  • Pre-pilot tool refinement Tool 1: Self- Administered questionnaire

    Components of the previous


    Section A: Demographics and

    training history (listing based on


    Section B: Self- administered


    104 item

    6 controls

    6 dimensions

    16 sub-scale

    Components of the refined tool

    Section A: Demographics and

    training history (checkbox)

    Section B: Self- administered


    136 item

    6 controls

    5 dimensions

    18 sub-scale


  • Self-assessment questionnaire assessment criteria: Five point Likert


    Key: Competence: Adequate training received in skills and knowledge Confidence: Feel comfortable to carry out tasks in your daily practice

    Rating Scale: 5- Fully competent and confident; able to teach others (mentor) 4- Fully Competent; not able to teach other (not able to be a

    mentor) 3- Capable; (partially competent and confident)) 2- Not capable; (not competent and confident)

    1- Not currently in my job description

    1 2 3 4 5


    Do you feel competent and confident to? Develop with your staff an annual facility operational plan, in line with sub-district

    and district health plans to attain the goals and objectives of your facility

    Compile the health profile of your catchment population

    Recognise staff members with compatible work styles and group them to work

    together to achieve related tasks 11

  • Pre-pilot tool refinement Tool 2: Practical Exercises


    Refined tool: 16 items 4 domains Multiple choice, single or multiple responses Graphs Calculations




    1 Calculation of immunization coverage

    2 Calculation of clinic patient load

    3 Calculation of percentage



    5 Interpreting line graph

    14 Interpreting bar graph

    15 Interpreting multiple bar graph



    9 Interpreting a medium size table

    16 Calculation of average case load

    Knowledge of

    policies and


    4 Asset register management

    6 Drug management

    7 Health information management

    8 Patient and data flow maps

    10 PHC strategy

    11 National Core Standards

    12 Staff management

    13 Performance assessment

    Previous tool 07 items 4 domains

  • Pre-pilot tool refinement Tool 3: Focus group discussion guide

    Semi-structured interview guide comprising of 12 probing


    Leadership and


    Operational Planning; Communication; Time management;

    Building effective teams; Change management and Self-




    Management of abseentism; Conflict management and Financial

    planning management

    Quality Quality improvement and drug management



    Health information management and Community and population

    based assessments


  • Pilot: Analysis of missing

    data; factor analysis


  • Results: Data cleaning

    Tools administered to a sample of 348

    15 questionnaires excluded more than 40 % of missing data

    46 questionnaires excluded nurses delegated to represent their facility managers

    Final analysis of data conducted on 287 participants


  • Analysis of self assessment questionnaire - missing and incongruent

    responses (n=287)

    Proportion of missing data was less than 5%

    Analysis of possible contributory factors to missing data

    Participants characteristics

    Easiness or difficulty of questions

    Effects of length of tools (fatigue)

    Level of understanding of the questions (control questions)


  • Job category Age

    Qualification Years in position

    Proportion of missing data by participants characteristics


  • Proportion of missing data in each question (difficulty of questions)

    A few items (indicated in red) showed an especially high proportion of missing data. They are listed in the following table 18

  • Item Code

    Adjusted proportion of missing data (%)

    001 Collaborate with staff and develop a facilitys vision, mission and core values that are in line with the sub-district and district, but specific to the facility 4.8

    023 Use appropriate skills mix for task delegation 3.1

    027 Initiate change processes in the facility 3.3

    028 Demonstrate flexibility and adapt readily and efficiently to the changing demands of the health priorities of the Department of Health 4.3

    064 Interpret and respond to the queries of the district on financial matters 3.2

    116 Implement effective data management systems for the collection and recording of individual, family, and community data in a timely, efficient, and accurate manner 3.2

    128 Compile the burden of disease profile of the catchment population using health indicators and update it annually 3.5

    129 Collaborate with the community using innovative ideas to encourage community ownership of health 3.2

    130 Use listening skills to understand the communitys views and

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